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THE

AMERICAN YEAR-BOOK

MEDICINE AND SURGERY

A Yearly Digest of Scientific Progress and Authoritative
Opinion in all Branches of Medicine and Surgery
drawn from Journals, Monographs, and Text-
Books of the Leading American and Foreign
Authors and Investigators

COLLECTED AND ARRANGED

WITH CRITICAL EDITORIAL COMMENTS

J. M. BALDY, M.D., VIRGIL P. GIBNEY, M.D.,

SAMUEL HORTON BROWN, M.D., C. A. HAMANN, M.D.,

J. CHALMERS DaCOSTA, M.D., BARTON COOKE HIRST, M.D.

W. A. NEWMAN DORLAND, M.D., D. BRADEN KYLE, M.D.,

GEORGE FETTEROLF, M.D., WALTER L. PYLE, M.D.,

JOHN H. GIBBON, M.D., J. HII.T0N WATERMAN, M.D.

UNDER THE GENERAL EDITORIAL CHARGE Of'

GEORGE M. GOULD, M.D.

RGERY

PHILADELPHIA. NEW YORK, LONDON

W. B. SAUNDERS & COMPANY
1904

CONTRIBUTORS.

J. MONTGOMERY BALDY, M.D., Philadelphia, Pa.

Professor of Gynecology, Philadelphia Polyclinic; Surgeon to the Gynecean Hos-
pital, Philadelphia.

SAMUEL HORTON BROWN, M.D., Philadelphia, Pa.

JOHN CHALMERS DaCOSTA, M.D., Philadelphia, Pa.

Professor of the Principles of Surgery and of Clinical Surgery, .Tefferson Medical
College, Philadelphia: Surgeon to the Philadelphia Hospital and to St. Joseph's Hos-
pital, Philadelphia.

W. A. NEWMAN BORLAND, A.M., M.D., Philadelphia, Pa.

Associate in Gynecology, Philadelphia Polyclinic ; Assistant Obstetrician to the Hos-
pital of the University of Pennsylvania, etc.

GEORGE FETTEROLF, A.B., M.D., Philadelphia, Pa.

Laryngologist to the Methodist Episcopal Hospital of Philadel])hia; Fellow of the
American Laryngological, Rhinological, ancl Otological Society; Assistant Demonstrator
of Anatomy, University of Pennsylvania.

JOHN H. GIBBON, M.D., Philadelphia, Pa.

Surgeon to the Pennsylvania Hospital and the Bryn Mawr Hospital.

VIRGIL P. GIBNEY, M.D., LL.D., New York City.

Surgeon-in-Chief to the Hospital for Ruptured and Crippled, New York City; Clinical
Professor of Orthopedic Surgery, College of Physicians and Surgeons, New York City.

C. A. HAMANN, M.D., Cleveland, Ohio.

Professor of Anatomy, Medical College of the Western Reserve University; Visiting
Surgeon to Charity and City Hospitals, Cleveland, Ohio.

BARTON COOKE HIRST, M.D., Philadelphia, Pa.

Professor of Obstetrics in the University of Pennsylvania ; (Jynecologist to the
Howard, the Orthopaedic, and the Philadelphia Hospitals, etc.

D. BRADEN KYLE, • Philadelphia, Pa.

Clinical Professor of Laryngology and Rhinology, Jeiferson Medical College; Consult-
ing Laryngologist, Rhinologist and Otologist, St. Agnes' Hospital; Bacteriologi-st to the
Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, etc.

WALTER L. PYLE, A.M., M.D., Philadelphia, Pa.

Assistant Surgeon to Wills Eye Hospital, Philadelphia.

J. HILTON WATERMAN, M.D., New York City.

Assistant Surgeon to the nos])ital for Ruptured and Crippled, New York City ; Lecturer
on General Surgery, and Instructor in Operative Surgery, in New York Polyclinic.

PREFACE.

In the department of Pediatrics the subscriber will be glad to find
that Dr. J. P. Crozer Griffith and Dr. J. Claxton Gittings have
consented to serve as editors. They succeed Dr. Louis Starr and
Dr. Alfred Hand, Jr., who have resigned. Drs. H. F. Hansell and
Wendell Reber have found it impossible to continue in charge of the
department of Ophthalmology, and Dr. Walter L. Pyle and Dr. Samuel
Horton Brown have undertaken the editorship. I am also happy to
have the aid of Dr. John Marshall and Dr. John H. W. Rhein in editing
the literature of Legal Medicine. These new editors of departments
are so well known as masters in their respective specialties that the
reader will feel assured of the best workmanship and judgment. Grate-
ful acknowledgment of indebtedness is due to the previous editors for
their zeal and the excellence of their work; I regret that other duties
have made their resignations necessary. We also regret the resignation
of Dr. M. B. Hartzell from the section on Cutaneous Medicine and Syphilis.
This department remains under the sole charge of Dr. Louis A. Duhring.

A special endeavor has been made this year, and will be continued in
the future, to place at the head of each chapter a summary of the more
noteworthy advances and discoveries made during the year. These,
we are assured, will prove of use to the reader in fixing in the attention
the special trends of progress in such a vast mass of literature as appears
each year in every branch of medical science. The ever-increasing
difficulty of gathering this to a focus has its compensation in the con-
tinued and increasing success of the Year-Book, despite many formid-
able rivals.

GEORGE M. GOULD.

Philadelphia, January, 1904.

CONTENTS.

PAGE

GENERAL SURGERY 9

By J. Chalmers DaCosta, M.D., and John H. Gibbon, M.D., Phila-
delphia, Pa.

OBSTOTRICS 338

By Barton Cooke Hirst, M.D., and W. A. Newman Dori.and, M.D.,
Philadelphia, Pa.

GYNECOLOGY 421

By J. Montgomery Baldy, M.D., and W. A. Newman Dorland, M.D.,
Philadelphia, Pa.

ORTHOPEDIC SURGERY 505

By ViUGiT. P. GiBNEY, M.D., and J. Hilton Waterman, M.D., New-
York City.

OPHTHALMOLOGY 522

By Walter L. Pyle, M.D., and Samuel Horton Brown, M.D., Phila-
delphia, Pa.

DISEASES OF THE NOSE, THROAT, AND EAR 573

By D. Braden Kyi-e, M.D,, and George Fetterolf, M.D., Philadel-
phia, Pa.

ANATOMY 033

By C. A. Hamann, M.D., Cleveland, Ohio.

GENERAL SURGERY.

By J. CHALMERS DaCOSTA, M,D., and JOHN H. GIBBON, M.D.,

OF PHILADELPHIA.

SURGICAL TECHNIC.

Senn^ describes the preparation of catgut by the Claudius method,

stating his satisfaction in the use of gut so prepared. The commercial
raw catgut is soaked in a 1 % solution of iodin for 7 days. It is claimed
that this makes the catgut aseptic and also imparts to it antiseptic
qualities. The practical results obtained from the use of iodised catgut
show that no irritation of the tissues results from its presence, probably
because the iodin is converted into potassium and sodium iodids by
chemical combinations formed with the salts of the tissues. To those
surgeons so situated that they cannot properly sterilize the catgut by
the more complicated methods this procedure is especially recommended.
The author states that the results of experiments being conducted in
the Rush Medical College for determining the bactericidal power of
iodin will be published later.

A. W. Mayo Robson^ describes a simple and effectual method of
sterilizing catgut, which consists in placing the ordinary commercial
formalin catgut of desired size and strength in metal cylinders of requisite
size and which are furnished with impervious screw covers, and filling
the remaining space with xylol. The cylinder is then boiled for half
an hour, which is sufficient to thoroughly sterilize the material. After
this treatment the catgut is stored in a 5 % carbolic acid solution in
methylated spirit. Catgut prepared in this way keeps indefinitely.
Robson uses the gut out of the -jV carbolized spirit.

Edgar R. McCJuire^ reports from the surgical clinic of Dr. Roswell
Park a careful experimental study to determine the best method
of hand sterilization, and particularly to estimate the value of anti-
septics in hand disinfection. His conclusions, based upon his experi-
ments, are as follows: " (1) Absolute sterility of the hands is impossible
"by any method. (2) There is no royal road to sterilizing the skin —
nothing takes the place of long and vigorous mechanical scrubbing.
(3) The longer the hands are scrubbed under aseptic precautions, the
nearer the approach to sterility. (4) The use of antiseptics on the skin
is, at least, questionable; under the usual conditions it is distinctly
harmful. (5) When the true value of antiseptics is understood we will

' Jour. Am. Med. Assoc, Marcli 28, 1903

^ Brit. Med. Jour., Sept. 27, 1902. ^ Amer. Med., Feb. 28, 1903.

2S . 9

10 GENERAL SURGERY.

have cleaner hands, due to more conscientious scrubbing. (6) The use
of rubber gloves, while not ideal, is the nearest approach to it. (7) The
operator whose hands perspire freely ought to wear gloves in every
case, regardless- of all objections to them."

Robert T. Morris^ discusses rubber gloves in surgery, and thinks
that the advantages of using them have been greatly exaggerated. He
believes that wounds are frequently infected from the atmosphere, and
therefore urges rapid work and smaU incisions. He believes that the
use of rubber gloves interferes with the tactile sense and consequently
with the work of the surgeon. Rubber gloves distinctly have their
place in surgery and should be used in cases of diabetes and whenever
the hands have been seriously infected.

Nancrede and Hutchings^ present a further study regarding the
sterilization of catheters, and offer a modification of their former
conclusions. [See Year-Book op Surgery, 1903.] They present the
following, based upon additional experiments : " (1) Although the wash-
ing with warm soapsuds is an absolute prerequisite to most methods
of chemical sterilization and is an excellent precaution, in the method
of employing caloric we recommend, it is not necessary, as shown by
Experiments 84 to 91, where no difference was observed in the time and
thoroughness of sterilization when this precaution was omitted, when
compared with Experiments 78 to 83, where previous washing was done.
(2) One of the chief obstacles in the way of catheter sterilization has always
been the oily lubricants. The boiling temperature promptly liquefies
the vaselin usually employed, which will be seen floating upon the sur-
face of the fluid mechanically carrying away with it numerous germs
mingled or adherent to the cold, semi-solid lubricant. (3) In our first
paper we showed that the English catheter was more readily sterilized
than the soft-rubber instruments, and, what is of greater importance,
can be repeatedly boiled without material damage, if proper precautions
are taken. (4) Experiment 65 (first paper) shows that the English
web catheter can be boiled for any length of time without damage in a
saturated solution of ammonium sulfate. As this boils at 104° G. it is
superior to plain water, but subsequent washing in sterilized water is
requisite to remove the crystals of the salt which are deposited on cool-
ing. (5) The only precautions requisite in boiling English catheters
in plain water are those necessary to prevent their coming directly in
contact with the bottom of the vessel in which they are boiled — this
can be done by enveloping them in gauze or a towel. (6) Finally, these
numerous experiments incontestably prove that caloric can be success-
fully employed for all varieties of catheters with the exception of the
soft French instrument, provided all air is expelled from the interior;
that this essential having been secured, although in a great majority
of cases 5 minutes' immersion in water which is actually boiling will
suffice, 10 minutes of actual ebullition should be employed, especially
for the smaller calibered instruments; and that a previous cleansing
with warm soapsuds is desirable, although not essential, reducing as it

» N. Y. Med. Jour., Nov. 22, 1902. ^ Med. News, Jan. 10, 1903

SURGICAL TECHNIC.

does the time of exposure requisite to sterilize the instruments. As
pre\dously stated, the employment of a saturated solution of ammonium
sulfate is desirable for English catheters, but is not essential, and de-
tracts from the simplicity of the method."

Stewart McGuire,^ in considering drainage after abdominal sec-
tion, describes an original method of drainage which combines the
advantages of the Penrose and the Fowler drains. It consists of a
soft-gum tube surrounded by numerous strands of cordine, both en-
closed in a thin rubber protective. The rubber protective does not
extend so far as the cordine and the cordine does not extend so far as

Fig. 1.— Various drains used after nbdoiuinal section : 1, Mikulicz's ; 2. Penrose's ; 3, McGuire's ; 4, Fow-
ler's ; 5, Koeberle's (McGuire, in Virginia Med. Serai-Montlily, Nov. 21, 1902).

the gum tube. It is small in size and hence does not interfere with the
closure of the wound. It is also soft and flexible and does not become
adherent. The cordine gives the maximum capillary drainage and can
be removed in part or wholly without taking out the entire drain.

John W. Keefe^ has employed Downes' electrothermic angiotribe
(Fig. 2) for the purpose of producing hemostasis in 50 operations,
mostly abdominal, and states that since November, 1902, he has not
used a ligature in the abdominal cases operated upon in his gynecologic
service. He is greatly impressed with the utility of the instrument,
and thinks it will largely take the place of the ligature. In none of the
cases in which it was used was there any secondary hemorrhage. One

1 Virginia Med. Semi-Monthly, Nov. 21, 1902.
=> Boston M. and S. Jour., June 18, 1903.

GENERAL SURGERY.

of the operations was an amputation of the thigh, and the control of
the femoral after the use of the instrument was perfect. The instrument
was used also in operations upon the stomach and intestinal tract. Its
greatest advantage is that it does away with the use of the ligature
and minimizes the dangers of infection.

The accompanying illustration (Fig. 4) represents a hot-water mat-
tress designed by George W. Crile^ for the purpose of keeping a patient

Fig. 2, — Downes' electrothermic angiotribe (Keefe, iu Bostou M. aud S. Jour., June 18, 1903).

Fig. 3.— Alternating current traus/ormer (Keefe, iu Bostou M. and S. Jour., June 18, 1903).

warm during an operation. The mattress is placed upon the operating-
table and hot water is allowed to flow through it for half an hour before
the patient is placed upon the table. It is unnecessary longer to continue
the passage of the hot water, as after the mattress and table have been
thoroughly warmed they will remain so for an hour or more.

Pollard^ describes a short rubber drainage-tube for drainage of
1 Ann. of Surg., June, 1903. ^ Lancet, Oct. 18, 1902.

AMPUTATIONS.

the pleural cavity. The tube is just long enough to penetrate the
cavity and is held in place by two flanges— a narrow one on the inner

Fig. 4.— Hot-water mattress for operating-table (Crile, in Ann. of Surg., June, 1903).

extremity to prevent the tube from coming out, and a much larger one
on the outside to prevent its going into the pleural cavity. These tubes
are made in a number of different sizes. The accompanj-ing illustration
(Fig. 5) renders more elaborate description
unnecessary.

AMPUTATIONS.

Estes^ presents a further contribution
to the study of modern amputations, add-
ing to his former talkie o.*" 340 major amputa-
tions, 194 additional ones performed during
the past 8 years. His experience in this
second series has strengthened his conviction
that whenever there is the least possible
chance of preserving a useful limb or a part

of a limb which may be of service, careful antisepsis should be practised,
hemostasis assured, and the operation be deferred for from 30 to 40
hours, at which time all doubt regarding the preservation of the part
will be removed. Conservative excisions and ligations should be prac-
tised rather than amputations when at all applicable. Estes states that
1 Amer. Med., Nov. 29, 1902.

Fig. 5. — Rubber tube for drain-
age of the pleural cavity (Pollard, in
Lancet, Oct. 18, 1902).

14 GENERAL SURGERY.

he has seen numerous limbs which would have been classed as hopeless,
preserved and recover almost complete usefulness after a conservative
plan of treatment. The chief points in regard to saving life after severe
injuries which require amputation are the control of the bloodvessels
and the practice of careful disinfection. Practically all of the ampu-
tations which Estes has done have been for injury, and in most of these
cases the damage was of the worst character. After severe crushes
of the lower extremity he has found that amputations in the upper
third of the thigh are almost as fatal as hip- joint amputations. In
hip- joint amputation he practises the dissection method.

A. W. Morton^ reports a case of hip- joint amputation under
medullary narcosis. The method proved entirely satisfactory, the
patient suffering no pain.

The avoidance of shock in major amputations by cocainization
of large nerve-trunks preliminary to their division, with observa-
tions on blood-pressure changes in surgical cases, is the subject of an
interesting paper by Harvey Gushing.^ The mechanism of shock and
its prevention are discussed at some length, and may be briefly summar-
ized in the three following paragraphs, which form the preface to the
article :

"1. By common usage the term 'shock' has come to represent a
peculiar state of depression of the normal activities of the central nervous
system. Such a condition is ordinarily brought about by traumatism,
of one sort or another, to peripheral afferent nerves. In order to produce
shock, the impulses resulting from this traumatism must have acted
refiexly upon the vasomotor mechanism in the medulla in such a way
as to occasion a marked fall in blood-pressure. This diminution of
arterial tension is the most characteristic symptom of shock.

"2. Under ordinary circumstances injuries of only moderate severity
to peripheral nerves cause a rise in blood-pressure. If, on the other
hand, these injuries are extensive or frequently repeated, or if they are
complicated by certain primary or secondary anemias, they are com-
monly productive of a fall in blood-pressure, indicating a state of shock.
Shock consequently need not be occasioned even in most extensive
surgical procedures on the extremities, provided due regard is given to
perfect hemostasis. In operations of considerable magnitude, however,
during which the division of many large nerve-trimks becomes necessary,
or in operating upon such traumatic cases as have been already com-
plicated by extensive injury to peripheral sensory nerves, so-called
operative shock is rarely avoided. When, therefore, any condition is
existent which predisposes to shock, such as loss of blood, prolonged anes-
thesia, etc., or when a certain degree of shock is already present before
operation, especial risk is attendant upon the division of important sen-
sory nerve- trunks.

"3. Cocain injected into a nerve- trunk effectually blocks the trans-
mission of all centripetal or sensory impulses. Cocainization, therefore,
of main trunks of nerves central to the proposed site of their division
1 Pacific Med. Jour., Feb., 1903 ^ Ann. of Surg., Sept., 1902.

AMPUTATIONS. 15

in a major amputation, prevents the conduction of those impulses result-
ing from the traumatic insult which otherwise, by acting reflexly through
the medullary centers, might become the chief factors in the production
of shock."

Illustrating the principle put forth in the foregoing paragraphs,
Gushing relates 2 cases of interscapulothoracic amputation, one of which
was done without cocainization of the large nerve-roots and the other
done after antecedent cocainization of the nerves. In both instances
hemostasis was thorough. Except for the difference in the operative
technic, the cases were in every respect similar. Two charts recording
the pulse-rate are here reproduced (Figs. 6 and 7) which show distinctly
the point which Gushing wishes to emphasize, namely, that in the case
in which the nerves were divided without cocainization there was a
marked increase in pulse-rate, indicating shock, whereas in the other
case in which the nerves were cocainized there was a fall of pulse-rate
after the division of the nerves. Gushing also calls attention to the
fact that in extensive operations where no large nerve-trunks are divided,
shock may be avoided by careful hemostasis, and refers, as an illustration
of this statement, to the performance of the complete Halsted operation
for carcinoma of the breast. Although this is one of the most extensive
operations of present-day surgery, providing there is no loss of blood
shock is rarely occasioned. In operative cases, however, in which it
becomes necessary to divide large bundles of nerves, precautions other
than the avoidance of the loss of blood seem to be demanded. To Grile
is given the credit of bringing the attention of the profession to the
method of blocking the efferent impulses by the intraneural injection
of cocain. This method has been extensively employed to produce
regional anesthesia in operations upon the extremities and in hernia.
The method advised by Grile in amputations precludes, of course, the
possibility of employing the time-honored methods of amputating,
necessitating, as it does, the employment of gradual dissection. The
author states that "the tourniquet and long amputating-knives are
practically relegated to disuse." Regarding the employment of the
tourniquet, it is said : " Should the tourniquet be used in amputations, I
believe that its application distal to the site of amputation has more
rationale than the usual proximal method of employing it. It may
thus be applied as an Esmarch bandage either after the ligation of the
main arterial vessel or before beginning the operation, its purpose being
to prevent the loss of blood into the extremity." Regarding ampu-
tations for traumatism, it is stated that these principles apply in a
degree almost greater than in pathologic cases. " Here a state of shock
may already be present, and the attendant ordinarily is advised to wait
for some hours, during which time a readjustment of conditions is ex-
pected to take place and the severity of shock to diminish. As a matter
of fact, the very conditions are present which tend to perpetuate or
to increase the already existent degree of shock. Such an increase is
brought about by a continuation of afferent sensory impulses. The
tourniquet itself, which has been applied at the time of the accident,

GENERAL SURGERY.

although controlling the loss of blood, constantly adds, from pain, an
increment to the shock of the original injury. The dragging of the

TIME

IHOUR

2 HOURS

45 50

Pulse

190

180

170

■£

160

-.~

ISO

P A

„

130

120

■

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''■

■i

-,i

■^

ino

■

■I

£!

-rl

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■5

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Resp.

—

Fig. 6. — Chart recording pulse-rate during operation on Case I, December 26, 1899 (Gushing, in Ann. of

Surg., Sept., 1902).

TIME lOJOi

IHOUR

2H0URS

Plll.SP

lao

170

IfiO

150

140

P,i

-Yff

■2

-5

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'=«:

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Resp

Fig. 7.— Ether chart recording pulse-rate kept during the operation on Case II (Gushing, in Ann. of

Surg., Sept., 1902).

helpless or mangled limb on the great sensory nerve-trunks, which are
rarely severed, gives impulses of pain with every movement of the often
restless patient, — impulses which in such a state cause reflexly a further

AMPUTATIONS. 17

lowering of blood-pressure. Strychnin, intravenous infusion, even though
there may have been but slight loss of blood, and delay, are the usual
measures advocated for such states. I believe they are, if not actually
harmful, certainly not helpful. The real indication is to rid the patient
of the centripetal impulses, originating in the crushed member, hv
cocainization ■ and division of the large nerves, so often exposed in a
mangled limb, by ligation of vessels if necessary, and the earliest possible
removal of the painful tourniquet. Under proper management, with
possible strapping of the abdomen to hold up the blood-pressure, with
morphin in small amounts to control restlessness, and with a proper
avoidance of those conditions which during the operation would increase
shock, I believe that it is no heresy to advocate ether anesthesia (never
chloroform) and early operation for most cases of severe traumatism of
the extremities." Although the pulse-rate is an index to the blood-
pressure, it is not an accurate index, and when the blood-pressure is to
be definitely recorded an apparatus should be employed. By the use
of this apparatus in the operating-room Gushing states that he has been
able to anticipate and to avoid profound states of shock and collapse.
The latter portion of his paper is devoted to the records of the variations
in blood-pressure occurring during the performance of certain operations,
and is illustrated by the reproduction of a number of charts.

A case of interscapulothoracic amputation for sarcoma of the
brachial plexus is reported by Lund.^ Before resorting to amputation
in this case Lund attempted to remove the growth by dissection, but be-
cause of the involvement of the axillary vessels, especially the vein, which
was torn, the operation had to be abandoned. The vein was repaired by
sutures and its caliber restored. Some time later, when the growth had
greatly increased in size and the patient had made up his mind to accept
the operation, the entire upper extremity was removed. Lund employed
the plan of removing about 2^ inches of the middle of the clavicle with a
chain-saw in order to expose and tie the subclavian vessels. Each cord
of the brachial plexus was also injected with 10 minims of a 0.25 % solu-
tion of cocain, as suggested by Crile, and divided. The pulse was un-
affected by this procedure. The operation was then completed without
hemorrhage or other difficulty. The author states that after the ligation
of the subclavian artery and vein, which sliould be carefully done and in
the order named, the operation is simple enough. This case is interesting,
aside from the operation, in that there was a close relationship between
the development of the tumor and the injury to the arm. The early
paralysis of the median nerve and the fact that this nerve and the cords
which form it were actually involved in the growth, while the other nerves
of the brachial plexus were affected simply by pressure, point probably
to the tumor as of primary origin in the median nerve.
' Boston M. and S. Jour., April 16, 1903.

18 GENERAL SURGERY.

TETANUS, SEPTICEMIA, GANGRENE, ETC.

Luckett^ reports 2 cases of tetanus successfully treated by the
subarachnoid injection of antitetanic serum. The conclusions of
his article are as follows : " (1) As no attempt was made to maintain an
equation between the amount of spinal fluid withdrawn and the amount
of serum injected, that the shock or collapse so often observed following
spinal subarachnoid injection of cocain for anesthesia is not due to an up-
setting of the equilibrium of the pressure in the spinal canal, as is claimed
by the advocates of this method of producing anesthesia, but is due solely
to the physiologic action of the cocain. (2) Given a wound infected with
tetanus, I am by no means positive that the anatomic seat of the wound
does not play an important role in the production of the constitutional
symptoms of tetanus, for, again accepting the present view of the patho-
genesis of tetanus, any wound infected with tetanus near a large nerve
will be more likely followed by constitutional effects of the infection than
a wound anatomically remotely removed from the seat of a large nerve.
It is possible, therefore, that the space in the palm of the hand, between
the first and second metacarpal bone, is a favorable point for an infection
of tetanus to produce constitutional effects, because the median nerve
in the hand becomes flattened out and much larger at this point ; it there-
fore offers an increased surface with greater facilities for gathering and
conveying the toxins to the cord. (3) While I recognize the absurdity
in trying to draw conclusions from 2 cases, the reaction after each injec-
tion was so prompt, And improvement so positive, and followed by final
cure in both grave cases, that I am constrained to state that I believe in
the spinal subarachnoid injection of the tetanus antitoxin, preceded by
the withdrawal of the active, concentrated, highly toxic spinal fluid,
supplemented by forced nutrition and proper cate of wound, we have at
least the promise of a method of treatment of tetanus by means of which
we can offer more hope in this fatal and rightly most dreaded disease than
we have been able to, heretofore."

Gideon Wells^ presents a statistical article on Fourth of July tetanus
which shows that in a number of large cities the number of cases occurring
in July as compared with other months is enormous. The high mortality
of this disease throughout the country at this season is also shown by the
figures presented. It is urged that the physician undertaking the treat-
ment of the blank cartridge wound should look upon it as a most dangerous
injury, and remember that when properly treated at the beginning it is
almost without danger. Therefore the responsibility for bad results lies
with the man who first treats the wound. The prohibition of the sale
and use of explosives is the proper solution of the problem.

Wynter^ reports a case of tetanus occurring in a man 40 years of age,
in whom the symptoms developed 10 days after a punctured wound of
the foot, and which resulted in recovery under the combined treatment

1 Med. News, April 18, 1903. ^ Amer. Med., June 13, 1903.

' Lancet, Nov. 15, 1902.

TETANUS, SEPTICEMIA, GANGRENE, ETC, * 19

of antitetanic serum, bromids, chloral, physostigma, and morphin. The
symptoms in this case became well marked, the patient suffering from
frequent and severe convulsions, and the temperature reaching 102.6°.
The morphin produced considerable rest, and the patient began to improve
10 days after the onset of symptoms. The patient developed an antitoxin
rash. It is noticeable that there was an absence of prolonged spasm or
fixation of the respiratory muscles or glottis. Sixty doses of antitoxin,
of 10 cc. each, were given during the course of treatment.

F. L. Taylor^ writes on prophylactic injections of tetanus anti-
toxin in cases of wounds from toy pistols. It is difficult to establish
the value of these prophylactic injections because, of the comparative
rarity of tetanus, even among patients receiving dirty wounds. This
fact does not, therefore, warrant the conclusion that prophylactic in-
jections are absolutely prophylactic. Their use, however, in large num-
bers of cases will prove or disprove their efficacy. During the past 3
years Taylor employed this treatment in 72 cases of toy pistol wounds.
In 57 other cases of the same injury the injection was not used. But
one case in this series developed tetanus. The disease was fatal in this
instance in which no prophylactic injection had been employed, but
Taylor is not satisfied that the local treatment of the wound in this case
was as thorough as it should have been. The statement is made that by
the immediate and thorough cleansing and cauterization of the wound
with carbohc acid and the prophylactic injection of antitoxin the Hudson
Street Hospital has been rid of tetanus in cases of wounds from toy
pistols. The action of the carboUc in these cases has been limited with
alcohol. Some pains in the joints and rashes occur occasionally after
the use of tetanus antitoxin, but these are transitory and usually cause
but slight inconvenience. The dose employed was 10 cc. of the tetanus
antitoxin.

Vallas" deals with the treatment of tetanus at considerable length,
and concludes by stating that the antitoxin treatment stands far above
any other. He also advocates the use of the remedy as a preventive agent.
Chloral and carbolic may be used as auxiliary agents. Chloral is more
useful because it is less dangerous. The local treatment of the wound is
also of great importance. The greatest stress is laid on the prophylactic
power of the tetanus antitoxin.

The treatment of acute septicemia by the intravenous infusion
of a solution of formaldehyd has been brought before the profession
by an article on the subject by C. C. Barrows.^ The author refers to the
work done by Maguire, of London, in determining by experiments upon
animals and upon himself the amount of formalin which may with safety
be injected into the circulation. After numerous injections of the solu-
tion into his own arm he determined that the maximum strength of
formaldehyd solution to be injected was 1: 2000, which is equal to a
solution of 1 : 800 formalin', and that the maximum quantity was 50 cc.

* N. Y. Med. Jour., June 27, 1903.

' Gaz. Hebdom. de M6d. et de Chir., Oct. 5, 1902.

' N. Y. Med. Jour., Jan. 31, 1903.

20 GENERAL SURGERY.

for an adult. Reference is also made to the work of Ewing, of Cornell
University, in injecting the formalin solution into the circulation of rab-
bits. The basis of Bari:ows' paper is a case of severe sepsis occurring
in the Bellevue Hospital in a negro woman 26 years of age. The sepsis
followed the delivery of a macerated, decomposed fetus at 6 months.
Sepsis developed on the second day after her admission, when she had
a chill. The examination of the blood showed an absence of malarial
organisms and a leukocytosis of 18,000. Six days later a blood-culture
was made which gave a pure culture of streptococcus. At this time the
patient was first seen by Barrows, who found her with a temperature of
108°, pulse 150 to 160, and respiration 38. She was in a low muttering
delirium. There were no local signs or symptoms. The patient was
given 500 cc. of a 1 : 5000 aqueous solution of formalin. In 3 hours her
temperature had fallen to 105°, and in 6 hours it had fallen to 101°, her
pulse being 104 and her respiration 28. For 3 hours the temperature
remained at 101°, when it gradually began to rise until it reached 103°,
her pulse having risen to 120. It remained at 103° for 3 hours, when
it plunged downward, until in 3 hours the thermometer registered by the
rectum only 95°. The pulse had then fallen to 86 and the respiration to
22. In 12 hours the temperature had reached 102°, and the pulse 110.
It then dropped to normal, but rapidly rose to 103°, although the pulse
did not go higher than 112. Although a second blood-culture had been
taken, there had not been time for a report, so it was decided to give her
a second infusion, 750 cc. of the same solution being then given her.
There was a slight chill without a further rise of temperature, which in
the course of 12 hours fell to normal, where it has practically been since.
The woman is up and about the ward, and from all appearances is entirely
well. A number of blood-cultures were made since the first infusion,
but none have shown any streptococci. Numerous microscopic ex-
aminations have also been made and no changes have been noted in the
red corpuscles. Albumin, which was present in the urine before the in-
fusion, disappeared and no blood occurred in the secretion. The author
warns the profession against the indiscriminate use of this remedy when
proper blood-cultures have not been made, and of course it must not be
considered a substitute for the proper surgical measures which may be
indicated in each individual case.

Wm. L. Baner^ discusses Barrows' paper on the intravenous injec-
tion of formaldehyd and reports a case very similar to that of Bar-
rows, in which the drug was employed without any good result. [Clinical
experience with the use of formalin injections in cases of septicemia has
been entirely too limited to render conclusions regarding its efficacy
possible, and until the remedy has been used in a number of carefully
watched and recorded cases it is hardly to be generally recommended.]

After detailing his experiments upon a number of animals to ascertain
the value of intravascular antisepsis, Fortescue-Brickdale^ writes the
following conclusions: "Generally, then, it may be said that at present
there is no experimental evidence which would warrant the assumption

1 N. Y. Med. Jour., March 21, 1903. ^ Lancet, Jan. 10, 1903.

CYSTS AND TUMORS. 21

that the course of a septicemia in animals can be influenced favorably by
the intravenous injection of the antiseptic substances, and that the only
result to be obtained by pressing such a treatment beyond the maximum
nontoxic dose is to hasten the death of the animal. In view of the results
described in this paper and those obtained by former investigators, it
seems useless to continue trying to apply clinically a method which,
while by no means free from special daggers and difficulties, is at present
unsupported by any experimental evidence, either as to its present ad-
vantages or future prospects."

Juhen and Tellier^ discuss septicemia of buccal or dental origin,
and base their remarks on 8 cases. The prognosis of this condition is
always grave and most of the patients die. It is stated that the gravity
of this condition in its early or chronic stages is frequently overlooked
by both physicians and dentists. These patients require the most care-
ful watching and treatment.

In the treatment of traumatic gangrene of the extremities a
circular amputation of all structures, soft parts and bone together, just
above the line of apparent demarcation is recommended by Knott. ^
Later, when the patient's condition is improved, a second operation,
which consists in a higher division of the bone and approximation of
the soft parts, is done. His reasons for advising this are that the cutting
of the flaps and the introduction of the sutures tend to produce a gan-
grene of this structure, the circulation of which is already bad. He
has practised the method advised 4 times, — once in the upper third of
the thigh, once in the middle third of the forearm, and twice in the upper
third of the leg, — with vmiformly good results.

CYSTS AND TUMORS.

Henry Morris opened the discussion of the Surgical Section of the
British Medical Association^ on the treatment of inoperable cancer.
Under the term cancer he includes all malignant growths, and under
the term inoperable he includes disease which cannot be entirely eradi-
cated by any operative procedure, but does not imply by this term that
the disease is of constitutional as distinct from local origin. The author
discusses the various methods of treating inoperable cancer which have
been brought forth in late years, deals with them most fairly, and
reaches the following conclusions: "(1) That the bacterial treatment of
malignant disease is not of the slightest use in carcinoma; that not one-
half of the cases of spindle-celled sarcoma disappear under treatment
with Coley's fluid; that in cases of sarcoma, other than the spindle-
celled, Coley's fluid is not of value; that the treatment by Colev's fluid has
many dangers, and should never be employed except in absolutely in-
operable cases. (2) That Beatson's treatment is limited in its action to
cases of mammary carcinoma, and the local and glandular recurrences
after mammary carcinoma ; and that even in these cases only a small pro-

1 Lyon M^d., Feb. 1.5, 1903. ^ Jour. Am. Med. Assoc, April 11 1903.

=• Brit. Med. Jour., Oct. 25, 1902.

22 GENERAL SURGERY.

portion are influenced by the treatment, while neither as a cure nor as a
palliative can it be relied upon in any given case. (3) That rodent ulcer
has in Finsen's light and in the rc-rays its most successful treatment, so
far as we at present know; and that this is true not onl}'- of cases otherwise
inoperable, but also of operable cases, because of their excellent cosmetic
results, and of their effect upon insidious and nonevident foci. There
are, nevertheless, cases of rodent ulcer which resist the light, and others
which resist the x-ray treatment, and some of these cases are success-
fully treated by excision and caustics. (4) That sarcoma, epithelioma,
and the other forms of carcinoma are best treated, whenever possible,
by early excision; and that all forms of treatment hitherto tried in
inoperable cancers of these kinds are uncertain and inconstant in their
effects, and unreliable as to the durability of the results they produce.
In the vast majority of cases they are quite without palliative influence
of any kind, except possibly in relieving pain. (5) That the boundary-
line between what are considered operable and inoperable cases needs
revision from time to time; that the tendency to extend the limits of
operable cases needs in some instances to be restricted, and in others
there may prove room for further extension. (6) That it is open to
question whether some of the operations performed for relief or pro-
longation of life in inoperable cases of malignant disease should not be
abandoned, and whether in other cases palliative operations ought not
to be more often performed. (7) That investigations into both the
cause and nature of cancer are of the first importance, as being more
likely to ultimately lead to cure than any treatment at present known.
(8) That, with few exceptions, the attempts to cure cancer by means
other than early and free operations have been hitherto almost invariably
futile." [Our experience with the a;-rays indicates that superficial malig-
nant growths are apt to disappear when so treated, but are very prone
to recur, and that the x-rays should be used only when operation is
contraindicated or refused. In surface carcinoma the x-rays usually re-
tard growth and relieve pain. Deeply seated growths are practically
uninfluenced. Dawbarn's operation of bilateral extirpation of the exter-
nal carotids and their branches is very valuable when employed for
inoperable malignant growths fed by these vessels.]

Beatson, in continuing the discussion opened by Morris, speaks
particularly about the operation of oophorectomy for inoperable
cancer of the breast. In many of the cases the effects of this pro-
cedure on the local manifestations are transient, and fresh nodules
appear. Notwithstanding this, there has been in a large number of
cases an improvement in the general health with the relief of pain. In
a smaller number of cases the disease has disappeared and the patients
have remained well for some years after the oophorectomy. In the
present state of our knowledge of cancer this operation is not justified
as a substitute for free and early removal by the knife, but Beatson
maintains that there are inoperable cases of mammary cancer where it
is of service in prolonging life and alleviating suffering. The author
has never claimed for it any curative quality.

CYSTS AND TUMORS. -' 23

A. F. Meredith Powell^ relates his experience in the treatment of
inoperable cancer with applications of formalin solution, referring
to a number of cases coming under his care. He states that when a
solution of formalin from 1.5 % to 2 % is applied to the cancerous growth,
the foul-smelling discharges cease ^dthin from 24 to 48 hours; that
within from 3 to 7 days the cancer mass begins to detach itself and that
healthy granulations spring up in its place. The process of separation
is aided by snipping with scissors the fibrous bands which connect the
growth mth deeper structures. If weaker solutions than this are em-
ployed, the hardening process does not take place so promptly or so
satisfactorily; and if stronger solutions are used, the application is
painful. Absorbent lint is soaked in 2 % formahn solution and laid
on the tumor. This is changed every 6 hours. After a few days the
use of the formalin is painless and separation takes place as before de-
scribed. [Sufficient time has not elapsed since the use of this treatment,
nor has it been employed in a sufficient number of cases, to warrant
its use in any other than in absolutely inoperable cases, and it is in these
cases alone that Powell recommends it.]

J. Chalmers DaCosta^ reports 2 cases of carcinomatous change
in an area of chronic ulceration, or Marjohn's ulcer, and discusses
the malignant changes taking place in superficial chronic ulceration.
Both of the cases reported occurred in women, and represented epi-
theliomatous change developing in chronic varicose ulcers of the leg.
In both cases amputation was declined' and in each the diagnosis was
verified by microscopic examination. DaCosta approves characterizing
these conditions as Marjolin's ulcer, since this investigator carefully
studied and accurately described the condition over 50 years ago. "A
great many hold that in such cases as those reported the ulcer is not
directly converted into a cancer, but that the chronic irritation in the
ulcerated area simply allows of the admission and favors the destructive
action of some cancer germ. It is certainly not proved, at the present
time, that cancer is due to a germ, although many of the ablest students
and observers are of the opinion that it is. There is no theory as
to the cause that is really capable of explaining all the phenomena
of cancer. Besides the fact that regions that are irritated or in-
jured are particularly prone to develop cancer, the parasitic theory
has gained support from the observation that metastases take place;
and that it may be possible to inoculate the growth into the lower
animals, or that an accidental inoculation may take place in man.
When a cancer arises from an ulcer, it is not to be supposed that the
connective tissue of the ulcer has been converted into, epithelium. The
proliferating epithelium of a cancer must spring from preexisting epi-
thelium; hence, it sometimes comes from epithelial elements, such as
sweat-glands or hair-follicles, that lie undestroyed among the granu-
lations of the ulcer, or, what is more common, from the edges of the
ulcer itself." The fact that malignant growth can follow chronic irrita-
tion is not proof positive that the irritation is its direct cause. DaCosta
1 Brit. Med. Jour., May 30, 1903. * Ann. of Surg., April, 1903.

24 GENERAL SURGERY.

does not accept readily the views of Gaylord and others who maintain
that protozoa are the cause of cancer. The existence of metastases
seems, at first glance, to be strongly suggestive of a parasitic influence.
These secondary tumors are, however, not due to the proUferation of
lymphatic structure in that region, as would be the case in an ordinary
infection; but they are the result of the transfer of epithelial cells from
the primary focus, the deposition of these cells in the lymphatic tissue,
and their multiplication in this tissue. In view of the possibility that
an ulcer of the cutaneous surface may become malignant, it becomes
highly important that every chronic ulcer should be subjected to a
thorough study for the purpose of making a careful diagnosis. As
previously stated, in any chronic ulcer mahgnant change is most apt to
appear at the edges, and persistent and increasing induration should
excite suspicion. When a carcinomatous change takes place in a chronic
ulcer, induration usually begins at a portion of the margin and spreads
slowly, progressively, and inexorably ; although, even after it has existed
for a considerable time, we may find but one-third or one-half of the
margin of the ulcer to be malignant, the balance of its edge being non-
malignant. In fact, it is extremely rarely that the entire margin of a
large ulcer is converted into malignant disease; it requires a long time
to effect this. An important fact to remember is that, while very chronic
simple ulcers are rarely tender or painful, in malignant disease there
is both induration and pain. When cancerous changes take place in
a chronic ulcer, the discharge is increased in amount, becomes ichorous,
and bleeding may occur. At some time or other the anatomically related
lymph-glands are bound to enlarge; although this seems, as a rule, to
be late, probably because the previous induration has blocked up the
lymph-channels. The most difficult case in which to make a diagnosis
is one in which there has been great preexisting induration of a chronic
ulcer, and the knobby induration of the cancerous change is not appre-
ciated and differentiated for a considerable time. In every doubtful
case of chronic ulcer, portions should be removed from the margins and
be studied by a skilled pathologist. When the surgeon removes a bit
of growth for microscopic investigation, it should be large enough to
make many sections, and should include not only a portion of the obvious
growth, but also a portion of the adjacent and apparently healthy tissue.
Infiltration of the apparently healthy tissue with embryonic epithelium
demonstrates the existence of carcinoma. Having clearly reached a
diagnosis of cancer, amputation is the proper treatment, and the inguinal
glands should be removed at the same time. a;-Ray treatment has
proved a cure for some of these cases, and should always be tried in case
operation is refused.

In connection with the above report, the following case reported by
MartinelU^ is interesting, as it illustrates the development of cancer
on old cicatrix. The patient was a man aged 45, who 20 years pre-
viously received an extensive laceration of the thigh, requiring several
months to heal. Some months before coming under MartineUi's treat-
' Giorn. dell Assoc. Napol. di Med. e Nat., Sept. and Oct., 1903.

CYSTS AND TUMORS. 25

merit the patient received a large lacerated wound through the site of
the old scar. The wound did' not heal, in spite of treatment there re-
maining a large square-shaped ulcer. The upper half of the ulcer was
concave and the lower markedly convex, with exuberant granulations
which bled readily. The margins were infiltrated with numerous nodules
and the inguinal glands were enlarged. A diagnosis of epithelioma was
made and the leg amputated. The diagnosis was confirmed by micro-
scopic examination. The glands of the groin were also removed at
the time of the amputation. Twenty months after operation the patient
was in excellent health, with no evidence of return of the disease. Mar-
tinelli discusses the literature of this subject and shows the frequency
with which cancer develops in cicatrices and ulcers.

A note upon the possible relationship between carcinoma and
nerve or trophic areas is presented by Cheatle.^ It is maintained,
first, that there is in some cases a marked relationship between the
spread of the primary focus and the distribution of nervous and trophic
areas. Deduced from this observation is the practical conclusion that
the extent of these areas should be taken into consideration in marking
out incisions when removal of cancer is contemplated. The author does
not wish to detract from the importance now attaching to the lymph-
atic pathways of distribution, but desires to point out another factor.
He also states that there is reason for thinking that the incidence of
cancer within a nerve area is not a fortuitous circumstance, but that
it may be due to direct or indirect nervous influence upon that area.
In justification of these views Cheatle presents numerous illustrations
of superficial maUgnant disease of the head and neck which show marked
liinitation to certain trophic areas. He does not claim to have enunciated
a new theory of cancer, but does assert that there is reason to justify
us in taking into consideration the possibility that the genesis and spread
of cancer, even when considered apart, may be connected directly and
indirectly with the nerve influences which persist over the areas affected.

Stanley Boyd and Unwin^ present a personal series of cases of cancer
of the tongue occurring during the past 12 years, and in 27 of these cases
some part of the tongue other than the frenum was the primary seat of
the disease; in 7 the frenum seemed to be first affected. As one of these
cases was recurrent and could not be traced, it is not included in these
statistics. The cases are divided into two classes, those in which the
primary disease was situated in the tongue and those in which it was
situated in the frenum. Of the 26 cases in which the tongue was involved,
1 patient is alive and well (11 years) ; 2 died — 6 and 4^ years after opera-
tion free from obvious cancer ; 2 are free from obvious cancer at the time
of writing — one 8^ years after removal of a cancer on the right tongue
and more than 2 years from a second operation for a cancer on the left
side of the mouth; in the other 11 months only have elapsed since the
operation; in 2 cases life seemed to be considerably and usefully pro-
longed,— 4 and 5 years, — but one is dying of certain recurrence in glands
low in the neck, and the other most prt)bably had some intrathoracic

* Brit. Med. Jour., April 18, 1903. ' Practitioner, May, 1903.

3 S

26 GENERAL SURGERY.

and possibly hepatic recurrence. Five patients died ; 4 soon after opera-
tion— 1 apparently from septicemia, 1 from "exhaustion" (?), 1 from em-
pyema, 1 from bronchopneumonia. The fifth patient died of broncho-
pneumonia from a foul mouth after a gland operation only. In the 14
remaining cases the disease recurred quickly ; in only 1 of them did a year
elapse between the first operation and recurrence. Under this heading of
recurrences, ultimately proving fatal, must of course be placed the two
cases already dealt with, making a total of 16 cases in which the disease
recurred and was not successfully dealt with. Of the 7 frenal cases
operated upon, 1 patient remained free for 3| years and then the disease
recurred ; 1 is at present sound, 2 years and 4 months from operation ; 3
died ; 2 had recurrences. A table of these cases is presented, giving a brief
history of each case, and the fatal ones are considered at some length in the
text. The authors believe, though they admit that it is difficult to prove
it, that some recurrences have been due to direct inoculation of raw sur-
faces from the growth as it was dragged past them. But the great majority
of recurrences are due, in loco, to the removal of an insufficiently wide mar-
gin of apparently healthy tissue round about the primary growth ; or, in
glands, to a too limited operation upon the gland-area in connection with
that growth. A disease that is so difficult to arrest as this is, certainly
justifies the freest excision. In operating the authors most commonly
employed Langenbeck's section of the jaw in front of the ramus, with
wide separation of the two parts. It has been their endeavor to remove
the growth in a capsule of apparently healthy tissue which is nowhere
less than half an inch in thickness, and which is double this, if possible,
behind and beneath the growth. Section of the muscles above the
hyoid bone is the most certain way of obtaining this. There is probably
most danger of recurrence in these two directions. As the lymphatics
from the anterior part of the tongue and floor of the mouth are said to
pass through the mylohyoid muscle on their way to the submaxillary
glands, a careful examination, at least, of this muscle should be made
in cancer of these parts; and removal of it and the anterior belly of the
digastric is advisable in advanced cases. Cases in which it may be
justifiable to omit removing associated glands are very exceptional. The
question of the extent to which these operations should be carried is
still a matter of opinion. The cases recorded will show that the magni-
tude of the operation has been steadily extended. In early cases, whether
in the anterior or middle third of the tongue, the submaxillary glands
and aU glands beneath the sternomastoid muscle, parotid gland, and
posterior belly of the digastric muscle down to the bifurcation of the
carotid artery and backward as far as can be reached along the eleventh
nerve, should be removed, together with as much connective tissue as
can be readily taken away with them. If the history shows that an
epithelioma has existed for more than 2 months, especially in the middle
and posterior thirds, it will be wise to add an incision along the anterior
edge of the sternomastoid to the clavicle and to remove the deep cervical
glands as far as can be done without dividing muscles. If the mid-line
of the tongue or the floor of the mouth is crossed by a growth a gland-

CYSTS AND TUMORS. 27

operation should be done upon both sides. So should it in most, if not
all, cases of cancer of the posterior third of the tongue. If a gland is
adherent to a muscle or to a vein, a good portion of that structure should
be removed with the gland. After describing the preliminary preparation
of the patient, particular attention being paid to the teeth, the following
is the technic practised by the authors : " The mouth is cleansed and the
surface of the growth cauterized. The gland-operation is first carried
out and the wound is closed, if it is certain that the tongue-wound will
not open into it; if there is any doubt about this, it is left open. In either
case it is 'guarded.' Then the growth in the mouth is removed. The
head is generally turned toward the same side as the disease; but some-
times, especially when the jaw is sawed, toward the opposite side. In
either case the dependent side of the nasopharynx and cheek are arranged
so as to form a ' well ' for blood below the level of the glottis ; with this
position it is rare to hear the slightest rattle. A head-light or hand
search-light is used. Tracheotomy is performed only for dyspnea. If
the jaw is to be divided anywhere, the lip and chin are always divided
in the mid-line, and the cheek and Kocher's submaxillary flap are raised
to the proper extent. The paralysis of the lower lip which resulted from
Langenbeck's cut down from the angle of the mouth is thus avoided.
After the removal of the growth, every endeavor is made to cover over
the raw surface in the mouth with mucous membrane, and to leave a
mobile tip to any tongue that remains. Extensive early healing may
thus often be brought about, and discharge into the mouth is propor-
tionately diminished. If the wounds in the mouth and neck communi-
cate or even come close to one another, the latter is freely drained with a
gauze plug. The mouth-wound is painted with Whitehead's varnish.
Until the patient has recovered consciousness and any shock has passed
off, he is kept lying on the sound side, with the angle of the mouth low,,
and is well looked after by a nurse. After a few hours he is set upright
against a bed-rest, and remains in this position ; fluids tend to run out of
the mouth, the patient is more easily assisted to get rid of mucus; he
breathes, spits, and coughs more effectively. His mouth is frequently
cleaned with 'dabs' moistened with soda-solution. Twice a day mouth,
teeth, and tongue are carefully gone over, and after one of these cleanings
Whitehead's varnish is applied to the dried surface. The patient rinses
his mouth frequently, and always before and after food. He is fed at
first by the rectum, and, if necessary, by stomach- tube ; these means of
feeding are abandoned as he becomes able to swallow. Little or no
stimulant is required." The advantage of a two-stage operation is not
great, and when it is resorted to it is suggested that the gland-operation
should be done first and that the lingual arteries should be ligated.

Jonathan Hutchinson, Jr.,^ presents the follo^^dng facts as showing
the difficulties met with in diagnosticating epithelioma of the mouth
from tertiary syphilitic and other lesions : " (1) From at least 30 %
of patients with epithelioma of the tongue a history of former syphilis
can be obtained. (2) In perhaps 20 % epithelioma supervenes on tongues

1 Practitioner, May, 1903.

28 GENERAL SURGERY.

that have been the site of chronic syphilitic inflammation; superficial
glossitis may be actually present when epithelioma develops. Thus
syphilis of the mouth predisposes to, and often passes directly into,
cancer. (3) While in the majority of cases an accurate diagnosis can be
made of any indi\'idual ulcer or lump on the tongue, lips, etc., in a certain
number it is quite impossible to tell until microscopic examination of
sections has been completed. (4) The 'therapeutic test' is often falla-
cious ; that is to say, when iodids are given for epithelioma of the tongue
it is quite common for the condition to appear to improve, especially as
the hygiene of the mouth will probably be attended to at the same time
and alcoholic stimulants left off. The patient may also lose his pain
under iodids for some little time, just as he will under the a;-rays. (5)
Epithelial cancer of the mouth has no uniform characters, its origin and
progress vary greatl3^ In 19 cases out of 20 it presents itself as ' a growth ' ;
there is a raised hard edge to it, often a papillomatous projection. Yet
now and then, so far from there being any growth, the affected tongue
slowly and steadily shrinks, just as the breast does in atrophic cancer.
The common forms of epithelial cancer of the tongue and lips are the
hard-edged ulcer, the warty or papillomatous projection, the indurated
plaque, and the bossy or nodular induration. In all the three last forms
cancer may exist for some time, and infect lymphatic glands, before any
ulceration occurs. The time-honored distinction, 'cancer of the tongue
is an ulcer which indurates, while tertiary syphilis causes an induration
which ulcerates,' is even less true than the majority of such axioms in
surger3^" The site of the condition is one of the best aids to diagnosis;
gummatous ulcers being frequent on the palate, the back of the pharynx,
and the dorsum of the tongue. On the free border of the lips, the sides
of the tongue, and the floor of the mouth gummas are rare, and here
cancers are frequent. If an ulcer exists, the induration and projection
of its edges are greatest in cancer. Shooting pain, especially that re-
ferred to the ear, is a symptom which should excite the gravest appre-
hension in a case of doubtful ulcer of the tongue. The examination of
the scraping from the floor of an ulcer (a test introduced by Mr. Butlin)
is of undoubted value, but it should be carried out with great care. The
floor of the ulcer must first be thoroughly cleansed of all extraneous
matter or discharge; the scraping then made should be stained with
methyl-violet or blue, placed in glycerin or distilled water, and examined
under a microscope of medium power. The age of the person is not
the slightest help in diagnosis. The author refers to a girl, 19 years of
age, under his care for an epithehoma of the tongue. The age and sex
of this case make it unique. Hutchinson regrets the frequent enumera-
tion of the late symptoms of cancer, stating that when these develop
the merest tyro can make a diagnosis, but it will be made too late for
relief to be given to the patient. He states that far too much has been
made in the textbooks of diagnosticating epithelioma of the mouth by
the presence of hard, swollen glands in the neck. "To expect these en-
larged glands in every case of cancer of the mouth, when it first comes
under care, is folly; to delay operative treatment until they can easily

CYSTS AND TUMORS. 29

be felt is a crime." The lymphatic glands draining a malignant area
should always be removed, whether they can be felt or not. The time
at which the first operation is done is the surgeon's opportunity; if he
delays to deal with the glands until they are easily palpated, the patient's
chance is practically gone. Attention is also called to the fact that septic,
syphilitic, or tuberculous ulcers of the mouth frequently cause glandular
enlargement in the neck; hence in the differential diagnosis of cancer re-
liance on this symptom must be entirely fallacious. Hutchinson states
that leukoplakia linguae will practically in all instances develop into
epithehoma. Whenever the opportunity presents of excising part of
the tongue for epithehoma supervening on leukoplakia, the white patches
should be freely removed with scissors at the same time as the part
affected with the cancer. "A chronic hard-edged ulcer of the tongue
opposite a sharp or carious tooth must always be regarded with suspicion.
If the removal of the exciting cause be not followed by healing of the
ulcer, it is usually best to treat the latter as a commencing epithelioma
and to excise it freely. Here, as in the case of persistent hard ulcers of
the hps, the microscope may fail to confirm the diagnosis of cancer, but
the patient is rid of a grave risk at the expense of a small operation.
Mistakes in diagnosis are far more frequent in the direction of overlooking
cancer of the mouth than in urging operation for an innocent lesion.
The microscope, moreover, is not infallible, and the earliest or 'pre-
cancerous' stage can hardly be certified by its aid. It is by prompt
excision of suspicious ulcers or papillomatous growths, whether of the
tongue or lips, that a hope is held out of diminishing the terrible mor-
tality from true cancer of these regions."

Excision of the tongue for cancer is discussed by Walter White-
head.^ The author calls attention to the fact that in order to arrive at
a correct conclusion as to the direct risks resulting from operation for
cancer of the tongue, those cases in which the tongue alone is involved
should be separated in our tables from those in which the adjacent struc-
tures are also the seat of disease. Whitehead has excised the tongue
with scissors for disease limited to this organ 116 times with but 3 deaths.
One of these patients died from rupture of an abscess of the lung on the
second day; a second died on the twelfth day from syncope; and the
third, a man of 70, died on the fourteenth day, from exhaustion. In
these cases the whole tongue was removed with the scissors without
any external incision, prehminary ligation of the arteries, or a previous
tracheotomy. Operation for malignancy cannot be performed too early,
and the associated glandular area of the tongue ought to be explored
either at the time of operation or subsequently, indeixnidently of there
being any evidence of glandular enlargement. Whitehead does not
approve of division of the jaw, the use of the ecraseur, preliminary trache-
otomy, or preliminary ligation of the lingual arteries. Regarding the
tracheotomy, he maintains that a greater mortality follows this operation
than need result from excision of the tongue. As an operating-table
Whitehead prefers to use an ordinary rocking-chair, and describes a

' Practitioner, May, 1903-

30 GENERAL SURGERY.

method of supporting the patient in it by means of a figure-of-eight ban-
dage about the chest. The entire operation as described by Whitehead
is performed with scissors. The technic of the operation is as follows:
"(1) When the patient is narcotized, gag the mouth on the opposite side
to the one intended to be operated upon; but if it is contemplated to
remove the whole tongue, use two gags — one on each side. (2) Seize
the tip of the tongue with a pair of forceps ; pull it forward, and when it
is in this position, pass through it a strong ligature for the purpose of
forward and upward traction during the operation. This is a most im-
portant matter, as the traction not only controls to a large extent the
main arteries, but it makes all the subsequent stages of the operation
much easier. (3) With this Ugature in his left hand, the operator draws
the tongue forward and upward to the fullest extent, and commences
the excision by freely dividing the frenum by means of a pair of scissors.
The lower blade of the scissors is slipped under the mucous membrane
on one side of the tongue and run along this side as far back as the an-
terior pillar of the fauces. By closing the scissors the attachment of
the mucous membrane to the jaw is severed. After dividing the anterior
pillar of the fauces he finally liberates the lateral attachments. As a
rule, after dividing the frenum, a finger can be easily run under the
mucous membrane, and be made to act as a guide for the scissors. The
same proceeding is of course repeated on the other side, when the whole
tongue is going to be excised. If these incisions be completely accom-
plished, it will be found that nearly the whole of the tongue can be pulled
out of the mouth, making the remainder of the operation almost extra-
oral — at any rate, so much so that there need be little fear of any blood
getting into the air-passages. Now the more critical part of the opera-
tion commences — the one most dreaded by the inexperienced. Having
proceeded so far in separating the tongue with scissors, the timid surgeon
need make no further use of a cutting instrument, if he wishes to avoid
any risk of unintentionally dividing the arteries. The tissues can be
ruthlessly broken down and torn asunder. With a dry dissector he can
break down the remainder of the friable tongue, and expose the arteries
and the nerves as cleanly as if he were making a dissection. Nothing
is then easier than seizing each artery separately by forceps, snipping
the distal end, and gently twisting the stump of the vessel. The greatest
confidence may be established by the almost universal certainty that if,
after the forceps are removed, no immediate bleeding of that artery takes
place, no subsequent hemorrhage need be feared. This, in my opinion,
is an unanswerable argument in favor of torsion as against the use of
the ligature, which some surgeons use in preference. Having twisted
each artery, it is desirable, in my opinion, before proceeding further to
place a loop of a strong ligature through the under and attached part or
stump of the tongue, to prevent the stump falling back when the tongue
is finally removed. That this is an advantage is denied by Sir Frederick
Treves; but I still maintain that a ligature should be passed through
the glossoepiglottidean fold for the purpose of traction after the tongue
has been excised, should secondary hemorrhage occur — a very remote

CYSTS AND TUMORS. 31

contingency. In private practice it certainly affords the attendant
nurse an element of confidence. In hospital practice the precaution is
perhaps unnecessary. The final separation can be completed by either
snipping through the remaining muscular fibers, or deliberately twisting
the stump until the tongue becomes completely detached." After the
tongue is removed the floor of the mouth and base of the tongue are cov-
ered with a special varnish. As an ordinary routine, it is desirable to
prop the patient up in bed and prevent his reclining during the night.
The next day he should be encouraged to get out of bed and sit up : and
on the second day, if the weather is congenial, there is no disadvantage
in allowing the patient to go out-of-doors. In closing. Whitehead refeis
to a number of patients operated upon for cancer of the tongue and well
after many years. In one case 13 years have elapsed and in another 11.
Butlin,^ in a clinical lecture, discusses unsuccessful operations for
cancer of the tongue and the early diagnosis of this disease. Elimi-
nating all cases that were in the slightest degree questionable, 28 absolute
successes are reported out of 113 operations. Twelve cases died from
some other disease than cancer of the tongue within 3 years and 14 died
of the operation. Twenty-nine patients died of recurrence in the mouth.
The disease recurred in most of them very quickly, and all of the patients
went through the same stage of suffering before death through which
they would have passed had no operation been performed. Therefore
these cases must be regarded as absolutely unsuccessful. Forty-one
patients died from secondary growths in the lymphatics without recur-
rence in the mouth. The results here presented when looked at alone
are discouraging, but when compared A\ith previous statistics they are
encouraging. The author points out very clearly that early diagnosis
of cancer of the tongue is easy, and lays great stress upon the fact that
the greatest care should be given to those conditions which may be looked
upon as predisposing causes to cancer of the tongue, since about 90 %
of the cases have been the subject of one of these predisposing conditions.
Any chronic superficial inflammation of the tongue, especially if accom-
panied by cracks and fissures, or chronic ulcers, predisposes to cancer.
Other conditions are spoken of as pre-cancerous ; that is, those which
may be looked upon as certainly to be followed by cancer itself. Among
these are warty growths ; flat ulcer due to irritation which does not heal
after the cause of the irritation is removed ; and leukoplakia. Excellent
illustrations of each of these conditions accompany Butlin's article. The
author states that old chronic ulcerations of the tongue are not nearly so
dangerous as the white thick plaques, or as the indolent ulcer, which makes
steady progress in the course of a few weeks or months. In order to illus-
trate the effect upon speech of the removal of the tongue, Butlin refers to
a number of patients upon whom he has operated and who speak with
practically no difficulty. The author closes his lecture with the advice that
all warts or warty growths should be removed as soon as discovered, and
that indolent ulcers upon the surface or under-border of the tongue which
are ascribed to the rubbing of the teeth should be treated first by the
' Brit. Med. Jour., Feb. 14, 1903.

32 GENERAL SURGERY.

removal of the caus'e of the irritation, and later, if persistent, by excision.
The operation is trivial and may save the patient from great misery. If
white patches or plaques become thicker or if they become a little more
prominent, and particularly if they show a tendency to break down in the
center or soften, let them be removed with as little delay as possible.
Of late years it has been the author's practice to go further than this and
advise patients suffering from bad superficial glossitis, where the tongue is
constantly irritated and where the patient consequently is always suffering
and always in dread and danger of cancer, to have that portion of the
tongue removed, even when there is no sign of cancer or of a precancerous
condition. [A recent case impressed us with the necessity of clearing
out the lymphatic glands from both sides of the neck. The left half of
the tongue was removed for cancer of the left edge of that structure,
and the lymphatics were removed from the left side of the neck. Eight
months later the tongue w^as sound, there was no growth in the left
side of the neck, but the right side of the neck presented irremovable
lymphatic involvement.]

Sir Thornley Stoker^ presents an interesting discussion on cancer
of the lips. It is the author's belief that heredity plays little part
in the etiology of cancer. "Like epitheliomas in other superficial situa-
tions, cancer of the lips, when it occurs at or after middle age, is often
preceded and accompanied by a general papillomatous condition of the
skin, or by the alUed state in which there is a hyperplasia of the cuticle
in scaly masses. This condition is distributed over various regions of
the surface, and is usually best marked on the face, neck, and front of
the chest. It is so frequent that it should be regarded as a warning
of graver trouble to come, and as confirmation of the diagnosis of an
otherwise doubtful case of epithelioma. It bears the same relation to
epithelioma of the skin that leukoplakia does to cancer of the tongue.
Warts on the lip, if the}^ have been irritated by treatment, or subjected
to much handling or other irritation, often undergo a change to the
heteroplastic condition and become malignant. '^ The use of the clay
pipe is the exciting cause of lip cancer in almost every case. The disease
is rarely found in non-smokers. In all cases of cancer of the lip which
Stoker has met with in women the patients were addicted to the use
of the pipe. It is stated that it is doubtful whether syphilis is an im-
portant predisposing cause of cancer of the lip. Out of 350 cases operated
upon by Stoker, only 3 of the patients were women, these 3 being Irish
peasants who smoked assiduously. The author has only seen the upper
lip involved in 4 cases. "The progress of a lip cancer, when not checked,
is tolerably definite in its direction. It proceeds to infect the lymphatic
glands below the jaw, and, later on, down the neck. The submaxillary
salivary glands do not become affected until extensive infection of the
lymph-glands has taken place. Next the lower jaw becomes involved,
and, lastly, the floor of the mouth." Secondary cancer, in the shape
of deposits in remote organs, may be looked upon as practically un-
known. The patient dies before it can occur. Death usually results from

' Practitioner, May, 1903.

Plate i.

CYSTS AND TUMORS. 33

exhaustion, septic disease of the hmgs, or hemorrhage. It is gratifying
to observe that the use of caustics and pastes of all kinds for cancer
of the Up has practically been abandoned. When the disease is limited,
operation is both simple and successful, and is rarely followed by recur-
rence. "But when the lower jaw has become diseased, a condition
always accompanied by more or less extensive cancer of the chin, and
perhaps of the lower part of the cheeks, operation assumes a different
aspect, and should rarely be undertaken." Removal of the submaxillary
glands is suggested in all cases. [No matter how early operation is per-
formed the submaxillary lymph-glands should be removed. In a case of
10 weeks' duration the microscope showed involvement. The submaxil-
lary gland of the diseased side must also be taken away. As a rule,
carcinoma begins at the mucocutaneous junction of the lower lip. If it
begins distinctly on the mucous surface, it is more malignant.]

Abbott and Shattock, of St. Thomas's Hospital, London/ report an
interesting and rare case of neurofibromatosis of the nerves of the
tongue (macroglossia neurofibromatosa) and of certain other
nerves of the head and neck. Clinically the disease would be classified
under the head of macroglossia, but it has nothing in common with
the ordinary lymphangiomatous or hemangiomatous forms of the dis-
ease; therefore, the author suggests the name of macroglossia neuro-
fibromatosa. Although in this case there were other nerves than those
of the tongue involved in the disease, the tongue was the most prominent
feature and renders the case unique. The patient was a female child,
4 years of age; except the present ailment the child was perfectly well
mentally and physically. The accompanying illustration (Plate 1, Fig. 1)
represents very well the condition at the time of admission to the hos-
pital. The enlargement of the left ear was noticed at birth, but that
of the tongue was not observed until the child was 2 months of age.
The tongue steadily increased in size, and when the child was H years
old began to protrude from the mouth, which was more or less con-
stantly kept open. There has also been a gradual increase in the size
of the left side of the face, and a constantly increasing tumor of the
submaxillary region. At the time of admission the tongue was kept
protruded from the mouth during all the day and nearly always when
the child was asleep; it could, however, be withdrawn into the mouth.
The involvement of the tongue was found to be entirely confined to the
left side. The tumors of the submaxillary region and ear are well shown
in the accompanying cut (Plate 1, Fig. 2). The right side of the face
and neck was absolutely normal. The child si)oke with some difficulty,
but could be easily understood; when she cried or got into a temper,
there was a definite bright flush over the whole left side of the face.
This had been present from infancy and was not accompanied l^y uni-
lateral sweating. In September, 1900, Abbott removed nearly the
entire left side of the tongue, and about 3 weeks later the tumor from
the submaxillary region. The latter "consisted of worm-hke coils of
semitransparent white cords, inextricably twisted, and with knots in
1 Ann. of Surg., March, 1903.

34 GENERAL SURGERY.

places. These cords varied much in size, from extremely small and
thread-like ones to others the size of a No. 3 catheter." There was
little bleeding from the tongue, but the mass in the neck was separated
from surrounding structures with difficulty. The child made a good
recovery except for facial palsy due to the involvement and consequent
injury of the left facial nerve. Examination of the child on May 6,
1902, showed that the facial palsy had greatly improved, that she was
able to use the tongue freely, and that it lay entirely within the mouth,
which was naturally kept shut at this time. There was a recur-
rence in the tongue about the size of a small almond. The general
appearance of the face was much improved. Mr, Shattock's report upon
the portion of the tongue removed shows "in a highly pronounced
degree the condition of fibromatosis of the nerves or plexiform neuro-
fibroma. Every nerve, as shown by dissection, is enlarged from the
disease, even to those terminating in the divided mucosa along the
lower side of the organ. The nerve most enlarged, the trunk of the
lingual, measures 0.5 centimeter in diameter. All the nerves are re-
markably increased in length as well as in thickness so as to lie in serpen-
tine or short transverse folds, with the result that in many situations
a compact plexus has been produced. Toward the middle line of the
organ such a plexus quite exceeds the distal portion of the enlarged
trunk already referred to." In removing the mass from the neck it was
found necessary also to remove the submaxillary salivary and lymphatic
glands, and the nerves supplying these were found involved. The
following nerves were found involved in the tumors: "Among motor
nerves, the hypoglossal, facial, and motor branch of the third division
of the fifth nerve. Among sensory nerves, the glossopharyngeal, the
lingual and auriculotemporal branches of the third division of the fifth
nerve, and the transverse cervical, suprasternal, and supraclavicular
descending branches of the cervical plexus." The only suggestion the
authors have to make regarding the unilateral flushing is that it was
possibly due to some involvement of the cervical sympathetic.

A case of generalized unilateral neurofibromatosis (von Reckling-
hausen's disease) under the care of Mr. Heaton is reported by Nuthall
and Billington.^ The patient was a man 38 years of age who was ad-
mitted to the hospital because of severe neuralgic pain in the right jaw
and of difficulty in swallowing. The right cheek was greatly swollen.
The patient stated that when 3 years of age he fell and cut his right
cheek, and that 2 years later a lump developed which slowly increased
and was removed when he was 1 1 years of age. Increase, however, con-
tinued progressively after the operation. A second operation was per-
formed when the patient was 23 years of age and a number of superficial
fibrous masses were removed from the right cheek. On admission all
of the soft parts of the right side of the face below the eye were greatly
thickened by what appeared to be a chronic hypertrophy or lymphatic
edema. Scattered over the chest, abdomen and back, thighs and arms,
were many swellings varying in size. The small nodules were cutaneous

' Lancet, Dec. 27, 1902.

CYSTS AND TUMORS.

and the large ones were subcutaneous. These tumors were for the most
part painless and did not appear to interfere with the functions of the
nerves on which they occurred, except in the case of a large tumor on the
left musculospiral nerve near the'elbow. Considerable relief followed neu-
rotomy of the lingual and inferior dental nerves, and the mass situated
on the musculospiral was removed. An attempt to remove a tumor
within the mouth and which necessitated the ligation of the common
carotid artery resulted in death a few hours after the operation. At
the necropsy a tumor near the lower extremity of the spinal cord was
also found. This report is numerously illustrated with drawings of
various neurofibromas from different parts of the body.

The accompan5dng illustrations (Figs. 8, 9, and 10) represent a case of
probable myxofibroma
of the nose, which is
briefly reported by Sea-
bury W. Allen, ^ who,
however, had very little
opportunity to carefully
study the case. The pa-
tient was 34 years of age
and of unusual intelli-
gence. The condition be-
gan 22 years previous.
Allen employed 7 x-ray
exposures, which greatly
diminished the odor and
the amount of discharge.
Because of fear of hemor-
rhage the patient and his
family would not permit
a section of the growth
to be taken for examina-
tion.

John A. Wyetli^ re-
ports good results from
the injection of water at

a high temperature into vascular tumors. The author is careful not to
claim that this treatment will cure every case or to say that it is absolutely
without danger. Results have, however, warranted him in recommend-
ing its employment in the treatment of all subcutaneous vascular tumors.
Before employing it in the human being Wyeth discovered that the in-
jection of boiling water into the iliac artery of dogs resulted in the im-
mediate occlusion of the vessel and all its branches. He has employed
it in the case of a young woman suffering from a large angioma involving
the chin, neck, and a portion of the submucous tissues of the mouth.
Previous to this treatment Hunter McGuire and Wyeth had each at-

* Boston M. and S. Jour., Nov. 13, 1902.
= Jour. Am. Med. Assoc, June 27, 1903.

Fig. 8. — Allen's onse of probable iiiyxofibroina of tlie nose.
T.'iken sliglitly from the right, side; neither eye woiiUl have
shown in a full-face view (Boston M. and S. Jour., Nov. la,
1902).

GENERAL SURGERY.

lig. 9.— Allen's case of probable nivxofibroiua of the nose.
Upper arrow points to slough, lower arrow to month. Left eye
has lost its sight (Boston M. and S. Jour., Nov. 13 1902).

tempted operation, but had been obliged to desist because of hemor-
rhage. The patient was etherized, peripheral compression was applied,

and about one-third of
the tumor was injected
with from 2 to 3 ounces
of boiling water. Not-
withstanding the great
heat there was no necro-
sis of the mucous mem-
brane. The operation
lasted about 10 minutes,
and after it the patient
suffered no pain and
there was no elevation
of temperature. Within

2 weeks after the first
injection the area in-
jected diminished, be-
coming less than half its
former size. Altogether,

3 injections were made,
resulting in the entire
obliteration of the tumor.
Two other cases are also
reported in which the re-
sults were equally satis-
factory; one of these was a very extensive cirsoid aneurysm covering about
one-half of the left side

of the scalp, measuring
about 5 by 6 inches, and
being elevated above the
normal scalp by a half-
inch or an inch. Numer-
ous ineffectual attempts
had been made to arrest
the growth of this tumor
when it was small. The
tumor was supplied by 5
arteries which could be
distinctly located. In
this second case the
needle was introduced
along the course of the
arteries supplying the
tumor and a quantity of
boiling water sufficient
to coagulate its vessels
was injected. Following
the operation edema of the face and neck developed. In another case

I'jg. 10.— Allen's ease of probable myxofibroma of the nose.
Arrow shows discharging mucus (Boston M. andS. Jour.. Kov
13, 1902).

CYSTS AND TUMORS. 37

of this kind Wyeth stated that he would not attempt obliteration of the
whole tumor at one operation, although the author has successfully em-
ployed that method in a number of cases of capillar}^ angioma. He
stated that on account of their superficial character some sloughing is
apt to result unless the greatest care is taken. The weakened tissues
in these cases do not offer the resistance of the normal skin which overlies
the venous and arterial angiomas, and may break down under the hot
water. Care should be taken in these cases to inject the water beneath
the tumor and not directly into it. Wyeth states that he should not
hesitate to employ this method in certain fistulas and ranula. He does
not think the method applicable in the treatment of uterine fibromas.
Dr. William J. Mayo, in discussing this paper of Wyeth's, referred to a
case of very large venous angioma of the cheek which he had treated
successfully with the injection of boiling water.

Fred. Griffith^ presents a brief history of a case of nevus of the scalp
and nose treated i3y hot water injections, as suggested by Wyeth. The
patient was an infant girl 7 months of age. In the case of the scalp a
number of injections varying from 10 drops to 1 fluid dram were employed.
But 3 injections, however, were required in the case of the nose. The
results obtained were very satisfactory.

In a clinical lecture J. Chalmers DaCosta^ describes a case of en-
dothelioma of the mammary gland on which he operated. The patient
was a woman 31 years of age who presented no history of injur}^ abscess,
or inflammation of the breast. The tumor had only been known to exist
for 3 months, during which time it had made rapid progress. The patient
complained of a dull, aching pain. The tumor was irregular in outhne,
being indistinct at the margins, and its center was hard and nodular. It
appeared to lie directly beneath the skin and the aureola. Before re-
moving the growth it was incised, and its vascular character led DaCosta
to believe that he was dealing with a sarcoma. A microscopic ex-
amination of the growth, however, showed it to be a hemangioendo-
thelioma.

Three cases of inoperable cancer of the breast treated by oophorec-
tomy are briefly reported by Power. ^ In 2 instances the patients had
passed the menopause, and in these the operation was attended with no
benefit. In the third case, however, in which the menopause had not been
passed, the operation Avas followed by an arrest and apparently a re-
trocession of the cancerous process.

Taylor and Waterman* report an interesting case of subdural cer-
vical carcinoma secondary to carcinoma of the breast. The develop-
ment of symptoms began about 2 years before the patient's death, when
there were observed both sensory and motor disturbances in the left arm,
which in the course of 21 months progressed to a practically complete
motor paralysis. This was followed by similar disturbances in the left
leg, and finally involvement of the right arm and leg. The beginning
of these cord symptoms antedated the discovery of the breast tumor by

1 N. Y. Med. Jour., May 2, 1903. ' Amer. Med., June 27, 1903.

^ Lancet, Oct. 4, 1902. * Boston M. and S. Jour., Feb. 12, 1903.

38 GENERAL SURGERY.

1 year, though it was not thought that they existed prior to the growth
in the breast. The severity of the cord symptoms, and particularly the
final paralysis of the leg, with involvement of the sphincters, were out of
proportion to the lesions discovered in and about the cord. The points
of interest in this case are : " A growth of long standing in the immediate
neighborhood, but with slight involvement of the cord ; limitation of the
new growth essentially to the subdural space; extensive motor and sen-
sory paralyses from involvement of nerve-roots alone; absence of pain
attributable to invasion of sensory roots."

W. B. Bell^ reports a case of carcinoma of the male breast occur-
ring in a man 56 years of age. A small lump the size of a pea had been
noticed behind the nipple 4^ years previous to the date on which the
patient came under Bell's care. The growth was removed, but recurred
about a year later in the upper portion of the pectoralis major which had
been left. The patient died 1 year and 9 months after the removal of
the primary growth, with deposits in the liver and elsewhere.

Two cases of carcinoma of the male breast are reported by Frank
C. Hammond. ^ The first patient was a man 75 years of age. The growth
in this case was successfully removed, but the patient died about 2 years
later from apoplexy. The second case was that of a man 50 years of age.
The growth in this case was also excised.

Another case of cancer of the male breast is reported by Ballock.^
The patient in this instance was a colored man 66 j^ears of age. The
duration of the disease was given as 3 years. When the enlargement
was first noticed there was a discharge of milky fluid from the breast,
which did not last long. There was never any bleeding and no historj'-
of injury. The growth was thoroughly removed, together with the glands
and adjacent tissue.

A case of congenital periosteal sarcoma in an infant is reported
by H. J. Curtis.* The growth involved the acromion process of the left
scapula. The patient was a male infant 5f months old. The growth at
birth was the size of a small hen's egg, and there was no history of
injury, the child having been born without the aid of instruments. At
the time of the operation the growth was the size of a large orange, ex-
tending from below and in front of the left clavicle to just above the
lobule of the left ear. It was movable, except at the outer end of the
clavicle, to which it was apparently attached. There were a number
of nodules varying in size, some of which fluctuated. The skin over the
tumor contained a number of large veins, and there was a small but dis-
tinct nevus over the prominent part of the swelling. The child was
anesthetized and the growth easily removed, together with 3 small glands
which were above the tumor. There was comparatively little hemor-
rhage during the operation, but later the child was very much shocked
and required vigorous stimulation. The wound healed promptly. About
3 weeks after the operation the child developed fever and presented an
enlarged gland in each groin. Within 2 weeks, however, these glands

' Brit. Med. Jour., Feb. 14, 1903 ^ Amer. Med., Nov. 22, 1902.

» Amer. Med., April 1, 1903. ^ Lancet, April 11, 1903.

CYSTS AND TUMORS. 39

had returned to the normal size, and the child was apparently well. The
growth proved to be typical mixed small-celled, spindle-celled, and round-
celled sarcoma. There was evidence of the growth in the enlarged
glands, which were removed. It sprang from the periosteum covering
the acromion process.

Wagner^ reports a case of probable secondary sarcomatous growths
in the femur following primary sarcoma of the thyroid gland. The
patient was a woman 48 years of age. She had had a goiter since she was
a child, but it had given her Httle trouble until recently. Six weeks
before coming under Wagner's care the patient began to suffer from pain
in the left hip and thigh. The leg was held in a position of sHght flexion,
adduction, and internal rotation. The inguinal glands were enlarged
but not tender; active movements produced pain, but passive move-
ments produced none. There was a small resistant mass felt just above
Poupart's ligament. The whole thigh was tender to pressure, especially
the lower portion. The goiter was about the size of a large fist, firm and
symmetric. It increased in size, the patient's general condition became
worse, and she died 2 months after admission. The thyroid gland at
necropsy was found to contain a spindle-celled sarcoma with a large num-
ber of giant cells. The neck of the femur broke during its removal, and
on division it showed a tumor penetrating into the substance of the bone
and 3 small masses in the medullary portion. These growths all presented
the same appearances as that of the thyroid. The fact that there were
no other secondary growths in the thyroid, and the frequency with which
primary growths in this gland produced secondary growths in bones, and
other points in the history, point in all likelihood to the thyroid tumor
as primary and those in the femur as secondary.

An interesting case of lipoma of the cecum is reported by John
O'Conor.^ The patient was a woman 45 years of age who presented
symptoms suggesting pyloric obstruction. A sensitive mass could be
felt one inch below and to the right of the umbilicus. When the abdomen
was opened, the mass which had been felt proved to be a distended cecum
which was freely movable. The cecum was opened and a large fatty tumor
embedded between the mucous and muscular coats was discovered. The
mucous membrane covering it was gangrenous. The tumor was removed,
the intestine was irrigated, and the bowel closed. The patient made a
satisfactory recovery.

Leonard^ states that there is no method so potent in relie^^ing in-
operable cancer or in the treatment of recurrent cancer as the x-rays.
It has been shown that this agent has an alterative and destructive action
upon malignant tissue, producing retrograde changes that vary in their
degree and intensity. These degenerative and destructive effects may be
so great that in large subcutaneous malignant growths of low vitality
such a rapid destruction may take place as to flood the system with toxins
and result in a fatal autointoxication or septicemia. The harmful effect
which has been noted as a stimulation of the growth of the tumor is prob-

* Munch, med. Woch., Sept. 2, 1902. ^ Lancet, June 27, 1903.

3 Phila. Med. Jour., Feb. 14, 1903.

40 GENERAL SURGERY.

ably due to this cause or to a real stimulation by too weak a dosage.
When the dosage shall be determined for the various manifestations of
malignant disease, this agent will undoubtedly prove to be one of the
most potent. Until then it must follow operative intervention as a sup-
plement to that method, operation removing the macroscopic malignant
tumor, the subsequent Rontgen treatment dealing with the microscopic
residual disease that has escaped the knife. Such a combination is both
curative and prophylactic. It destroys any foci that remain and pre-
vents recurrence. It gives the patient the benefit of the two most potent
methods of combating mahgnant disease. As a primary method of treat-
ment it has no place, except when operation is contraindicated or when
more cosmetic results can be produced, in cases in which life is not threat-
ened by delay, or in which the disease is already inoperable. This agent
must be employed with as great care as any other possessing such marked
alterative properties. The harmful effects must be noted and guarded
against by adapting the dosage to the individual patient and watching
mth care the systemic effects. Stimulation of the disease is the result
of too weak a dose, autointoxication by the rapid destruction of large
areas is the result of too large a dose.

Wilham B. Coley^ discusses the present status of the x-ray treat-
ment of malignant tumors, setting forth the subject carefully and report-
ing briefly a number of cases.- His conclusions are as follows: "We find
abundant evidence that the a;-rays have an inhibitory action on all forms
of malignant tumors. Yet the number of cases is insufficient to enable
us to state what particular varieties are most susceptible to this influence.
So far it would seem that sarcomas primary in the lymph-glands yield
most readily to the treatment. Superficial epitheliomas might be placed
in the same category. Several cases of recurrent carcinoma of the breast
have been observed in which the growths have entirely disappeared after
prolonged exposures of the a;-rays. Yet all these cases have been too
recent to be classed as cured. In fact, sufficient time has not yet elapsed
in a single case of cancer treated with the x-ray to justify us in regarding
it as cured. While this should, on the one hand, prevent us from reporting
patients as cured in whom the tumors have merely disappeared under
treatment, it should not, on the other hand, lead us to minimize the im-
portance of these immediate results, even be they no more than a pro-
longation of life or an alleviation of suffering. One cannot witness the
marvelous melting away or disappearance of an undoubtedly malignant
tumor under a few weeks' or months' treatment with the x-rays, without
feeling that we have a new and powerful addition to our hitherto scanty
means of attacking this disease. The knowledge of this new agent is so
slight that there is added hope in our very ignorance. For by deeper
insight into its nature, gained by further experience, we may hope to
better utilize its power, and thus accomplish greater results."

T. A. Groover^ discusses briefly the treatment of cancer with the

x-rays, reports a number of cases, and reaches the following conclusions :

" The x-ray is a form of energy capable of producing a profound influence

1 Med. Rec, March 21, 1903. ^ Virginia Med. Semi-Monthly, March 13, 1903.

CYSTS AND TUMORS. 41

on cell activity. The changes induced are trophic in character. The
a;-ray has a marked beneficial effect upon malignant growths, in some
cases apparently effecting a cure. In the slow-growing epitheliomas,
situated in accessible regions, the x-ray treatment should have precedence
over all others. In advanced cases of malignant diseases, the a;-ray is
the best palliative measure at our command. From the nature of the
problems which confront us a number of years must necessarily elapse
before the status of the x-ray in the treatment of cancer can be accurately
determined."

Grubbe^ also deals with the x-ray treatment of cancer and other
malignant diseases and reaches the following conclusions: "(1) The
x-ray is the most remarkable therapeutic agent of the last decade. (2)
In properly selected cases of so-called ' incurable conditions ' the x-ray has
brought about remarkable results. (3) Relief from pain is one of the
most prominent features of the treatment. (4) Retrogressive changes
are noticed in all primary cancer or tuberculous growths. (5) The x-ray
has a pronounced effect upon internal cancers. (6) The greatest value
of the x-ray is obtained in treating post-operative cases to prevent re-
currences. (7) The proportion of clinical cures by this treatment is
greater than that obtainable by any other method of treatment. (8)
We are positively justified in assuming an idiosyncrasy to x-rays. (9)
The peculiarities of each case must be studied in order to get the best
results, i. e., no strict rules for treatment can be laid down. (10) Der-
matitis, if properly produced, is within certain limits a desirable feature
of x-ray treatment. (11) Since the vacuum of an ordinary x-ray tube
changes constantly, such tubes are useless for radiotherapeutic work,
and onljr tubes which allow of perfect control of vacuum should be used.
(12) The x-ray has a selective influence upon cells of the body; abnormal
cells being affected more readily than the normal. (13) Hemorrhages and
discharges are decidedly lessened and, ultimately, cease in the majority of
cases. (14) Even in the hopeless, inoperable cases, the x-ray prolongs
life, makes the patient comfortable, and the last hours free from pain."

Rodman and Pf abler ^ deal with the present status of the treatment
of superficial carcinoma and tuberculosis by means of the x-ray, and
arrive at the following conclusions: "(1) The length of time required
for the cure of epitheliomas is longer than by surgical or caustic treatment,
while the cosmetic results are better. The dangers are proportionate to
the urgency of the treatment, as indicated by the degree of malignancy.
It should only be recommended in cases that are inoperable either be-
cause of the extent of the growth or its location. (2) It is absolutely
the best means at our command for the treatment of superficial tuber-
culosis, and it gives better cosmetic results. (3) It should follow all
operations for malignant disease or tuberculosis, with the twofold object
of stimulating the healing process and of preventing a recurrence. In
some cases it may be of advantage to give a course of treatment before
operation, to destroy the outlying portions of the growth and make such
operation of a less formidable nature."

' Med. Rec, Nov. 1, 1902 * Phila Med. Jour., June 13, 1903.

42 GENERAL SURGERY,

ANESTHETICS.

The management and preparation of the patient for general
anesthesia is interestingly and instructively dealt with by W. J. Mc-
Cardie/ This address will prove particularly useful to those unfamiliar
with the administration of anesthetics. Much stress is laid upon the
moral as well as the physical condition of the patient, and especially on
the psychic factor of fear, to which sufficient importance, it is asserted,
has not been attached. Reference is made to a number of cases in which
patients have died from simple fright just before the administration of an
anesthetic. It is shown that fear may not only result fatally before the
actual administration begins, but that it is sometimes productive of fatal
shock in the early stage of anesthesia, especially when chloroform is used.
The chief element of danger in cases in which fear is a factor is profound
disturbance of the circulation, which may commence some days before
the operation, and may persist till the patient is well under the influence
of the anesthetic. In the worst cases Ballard has shown that there are
signs of serious embarrassment of the right side of the heart, and in 2
cases he has observed an undoubtful temporary tricuspid regurgitation,
quite physiologic, no doubt, but none the less dangerous, for when the
patient is still conscious, is struggling and holding his breath, the greatest
strain is laid upon the heart, and sudden syncope is most feared. In
such a case McCardie would hesitate to give chloroform. A heart free
from murmurs may develop them when the patient is greatly excited by
fear, just as it may after marked exertion. One repeatedly observes the
increased roughness of a hemic mvirmur after the administration of an
anesthetic. Pure fear without exertion seems to have the same effect
as severe physical work on the heart, as Ballard points out; that is, it
tends to dilate its cavities, especially the right cavities, to weaken the
cardiac muscles, and produce a quick and feeble beat. Ether is safer
than chloroform if the patient is badly frightened — at least is safer at the
commencement of the administration. Fear, like chloroform, is a strong
cardiac depressant. Fear and chloroform together double the danger.
If to their effects surgical shock be added, the total effect may be very
dangerous. It is argued that death just previous to the administration
of chloroform is not due to fright, because similar accidents do not take
place preceding the administration of nitrous oxid. McCardie thinks,
however, that it is a realization on the patient's part of the respective
dangers of the two anesthetics which makes him fear chloroform and yet
take nitrous oxid with impunity. It is also shown that nitrous oxid
markedly raises the blood-pressure and does not depress the heart until
the asphyxial feature has been in evidence for some time. The latter
part of the address describes the anesthetization of certain groups of cases
and the method of moving patients while under the influence of anes-
thetics. The greatest stress is laid upon the necessity of employing tact
in approaching a patient, and upon the method of keeping him perfectly

> Birni. Mod. "Rev., March, 1903.

ANESTHETICS. 43

quiet and free from all disturbances, such as the sight of instruments
and the presence of friends. One of the great objects is to reassure the
patient, for just as he is when he "goes under" so will he continue to be-
have; that is, quiet induction generally means quiet narcosis. This
applies particularly to chloroform. Reference is made to the work of
Hess, who has shown that ether is excreted from the blood into the stom-
ach and there acts as an irritant, causing vomiting. McCardie believes
that ether, being excreted by the stomach-cells, produces acute gastritis,
and that large quantities of ether vapor administered to animals will
cause well-marked renal lesions. Hess, therefore, advises the administra-
tion of water just before anesthesia. Le"v\dn advises, for the mechanical
protection of the stomach against the action of chloroform, the administra-
tion of mucilaginous substances which will for some time adhere to the
stomach. The most suitable mixture consists of 1 part of gum arable
to 2 parts each of water and tragacanth. The patient should take a dose
of this 3 or 4 hours before, and another dose immediately before opera-
tion. McCardie closes with a suggestion regarding the therapeutics of
atropin, which he thinks has not been sufficiently taken advantage of
before and during chloroform-anesthesia. Atropin, as we know, para-
lyzes the ends of the vagi in the heart, and besides removing the drag of
these nerves, it directly stimulates the heart and in moderate doses keeps
up the force of its systole. It stimulates the vasomotor center and raises
the blood-pressure. Thus, stimulation of the vagus, by chloroform or
other means, can be entirely prevented by a proper dose of atropin. It
has been found that dogs, under the influence of atropin, are decidedly
more difficult to kill with chloroform than animals not so treated. Many
continental anesthetists regularly inject atropin with morphin before
beginning the administration of chloroform. [It is a matter of daily
observation that emotion profoundly affects the circulation. During
fear the heart becomes more rapid and frequent. The practical obser-
vations on this point in McCardie's paper are of much importance. Fear
produces respiratory oppression, which is most marked in children ; pallor
of the face; tremor; vesical irritability; sweating. We know sudden
death may occur from terror, and it seems certain that fear may so depress
the nerve-centers that a few whiffs of chloroform may arrest the heart
or respiration. Dr. A. Hobart Hare has for years insisted on the value of
atropin, and we have long been convinced of the truth of his claim by
ample clinical observation.]

Bad and difficult subjects for anesthetization are described by
Hewitt^ in two lectures. He deals first with those patients whose re-
spiratory tract is in some way encroached upon or whose respiration is
hampered by pathologic or other conditions. It is stated that it is more
important, as a rule, to test the freedom of a patient's respiration, par-
ticularly through the nose, than to listen to the heart before giving an
anesthetic. In these cases asphyxiating anesthetics or asphyxiation
methods of administration should be avoided. For instance, pure nitrous
oxid administered to a patient with angina Ludovici might act as a direct

' Lancet, Jan. 17, 1903.

44 GENERAL SURGERY.

poison. Generally speaking, chloroform or a mixture of chloroform and
ether should be given to patients in this group, but in exceptional cases
ether may be preferable. In cases of goiter, chloroform is the only permis-
sible anesthetic. In certain cases of bronchitis and empyema, in which
cyanosis and respiratory distress exist before anesthetization, the com-
bination of oxygen with ether is a good one. These patients should be
anesthetized in the posture in which respiration is most comfortable, and
as little movement as possible should take place during the operation.
If chloroform is carefully and gradually given in cases of bronchitis and
empyema, anesthesia is, as a rule, attended with no great difficulty.
Lengthy administration of an anesthetic in these cases is bad. Patients
who have been confined to bed for a considerable time, owing to some
constitutional disease, are not, as a rule, bad subjects for anesthetization.
In cases of advanced heart-disease Hewitt considers the administration
of pure nitrous oxygen to be contraindicated. Regarding so-called
"nervous" patients, it is stated that the nitrous oxid-ether sequence is
well suited to them. If chloroform is given, it should follow ether. Ref-
erence is made to the great difficulties encountered in anesthetizing
alcoholics. In extreme cases of alcohol-indulgence nitrous oxid may be
found practically useless as an anesthetic. In a number of cases Hewitt
has met with nearly as much difficulty in anesthetizing patients addicted
to the excessive use of tobacco as he has in alcoholics. In these cases he
has been unable to devise any method of administration or combination
of anesthetics which is perfectly satisfactory. The greater difficulty
arises in cases in which there is found a combination of the difficulties
already discussed ; for instance, when an excellent muscular development
is complicated by nasal obstruction or excessive smoking or drinking.
The best plan, as a rule, in these cases is to employ the chloroform-ether
sequence, or, if the ether is badly borne, the ether-chloroform sequence.
Should the anesthetist desire to administer nitrous oxid and ether, it is
essential first of aU to insert a mouth-prop. It is very necessary in these
cases of combined difficulties to provide for and maintain an oral air-way
throughout. In closing, Hewitt refers to patients who exhibit peculiar
idiosyncrasies under certain anesthetics. [Several times I have met
serious embarrassment in anesthetizing heavy users of tobacco. It may
occur in chewers or smokers. There may be trouble with the circulation
or great respiratory embarrassment and rigidity of the jaws.]

Eisendrath^ discusses the accidents of anesthesia together with
their prevention and treatment. His remarks are summarized as
follows : " (1) Chloroform has a narrower zone of safety than ether.
Its toxic effects are as a rule manifest at the time of administration.
Ether is the cause of death in many cases through renal or pulmonary
complications from hours to days after the anesthesia. The late deaths
due to chloroform are so rare as to render this factor practically of no
importance. Chloroform is a more dangerous anesthetic than ether and
must be watched far more carefully. (2) Chloroform kills more fre-
quently through primary cardiac respiratory syncope, and the anesthe-
» Amer. Med., Nov. 15, 1902.

ANESTHETICS. 45

tizer must watch constantly the decrease in volume and rapidity of the
pulse, indicating the fall of blood-pressure, and a slowing of the more
shallow respiration. Chloroform syncope can be avoided by keeping the
head low, if possible turned to one side, keeping the jaw forward, watch-
ing the pulse, respiration, and pupil, keeping the patient's mind quiet,
and keeping the chloroform well diluted with air. (3) Ether rarely
causes death through its immediate effects, but more frequently through
its after-effects, such as pneumonia and uremia. These complications
may be avoided by keeping the head lower than the level of the body,
turned to one side, and not giving the ether in too concentrated a form;
also by not keeping the patient on his back too long, and by relieving
postoperative tympanites as soon as possible. The contraindications to
the use of chloroform are myocarditis, pericardial adhesions, and non-
compensated valvular disease. In all other forms of heart-disease it
may be given. It should not be given when the blood-pressure is low
or in status thymicus, or when a prolonged anesthesia is necessary. (4)
The pulmonary complications are relatively more frequent with local
anesthesia than if a general anesthetic is given. They may be due to
aspiration of mucus or food, or due to hypostasis and to embolism. The
latter is far more frequent than is ordinarily thought. Avoid these by
exposing patients as little as possible. Use heated operating tables,
avoiding recumbent position and tympany. (5) Avoid renal complica-
tions by careful examination of the urine before anesthesia. (6) Begin
process of resuscitation immediately and systematically: Artificial res-
piration, the method of Konig-Maas, or massage of the heart, rhythmic
traction of the tongue, method of Prus, or direct exposure of the heart
and intravenous salt transfusion. I prefer to begin with massage of the
heart and rhythmic tractions of the tongue (16 to 18 times a minute)."

Galloway^ advises the use of nitrous oxid alone as a preliminary
to ether or chloroform in general surgical work, and reports 250 ad-
ditional cases in which this practice was followed. The average time for
the patient to become unconscious in these cases was 2\ minutes. In no
case, when ether was to follow, was administration of the gas continued
for more than 3 minutes. In one case requiring 10 minutes the patient
had a heavy beard, and this probably admitted air under the inhaler
sufficient to produce the excitement and struggle during which the patient
partly revived and had to be anesthetized with ether as if no gas had
been used.

Chloroform as an anesthetic in short operations upon the
throat and nose is discussed by Chaldecott,^ who strongly condemns it,
referring to 50 recent cases in which death had occurred in these other-
wise simple operations. Even in the hands of an experienced anesthe-
tist, chloroform in these cases is extremely dangerous. For infants less
than 12 months old ether should be employed on an open mask. Children
from 1 to 4 years of age do not take nitrous oxid well, especially if there
is any obstruction of the respiratory tract. Ether in these cases is usually
taken without trouble. From 4 to 12 j^ears of age nitrous oxid is generally

» Amer. Med., Feb. 14, 1903. ^ Lancet, Sept. 13, 1903.

46 GENERAL SURGERY.

satisfactory. This agent is also usually satisfactory in adolescents and
adults. Gas and ether are rather to be preferred to gas and oxygen.
Ethyl chlorid the author has employed in 80 cases, but considers it less
trustworthy and more tedious to administer than ether. The best gag
to employ in these cases is Doyen's, and it should be introdiiced before
the administration of the anesthetic. The author closes with repeated
advice against the use of chloroform in nose and throat work.

Recent improvements in general anesthesia are reported very
carefully by Willy Meyer. ^ He pays particular attention to anesthol,
which he has used very extensively. Anesthol is a clear, transparent
fluid of very agreeable odor. It is a chemical combination of ethyl
chlorid and M. S. (a combination of chloroform and ether), and not a
mixture. Meyer first used anesthol in 1898 in an interval operation for
appendicitis, since when he has used it extensively in hospital and private
practice. The only exceptions were operations upon the face, in which
pure chloroform was deemed preferable. At first his experience was
that deep anesthesia was not caused and that muscular rigidity was
sometimes troublesome. This objection, however, was readily overcome
by administering | grain of morphin hypodermatically prior to the ad-
ministration of anesthol. The agent should be administered upon an
Esmarch mask covered with sterile gauze and by the "drop-by-drop"
method. It is necessary to continue the anesthetic throughout the entire
course of the operation, as the recovery from it is very prompt. It is
claimed for this agent that its administration is simple, not objectionable
to the patient, and that few of the disagreeable and troublesome symp-
toms following other general anesthetics are seen. In his entire experi-
ence with the drug but 2 deaths have occurred, and one of these can
certainly be accounted for by the condition of the patient. He has not
hesitated to use the remedy in the presence of marked organic disease
both of kidneys and heart. Guth has administered the anesthetic
in 200 private cases for Meyer without any disagreeable results. [Anes-
thol has been used to a considerable extent at the Pennsylvania Hospital,
and Gibbon's only criticism of it is that in abdominal surgery the rigidity
of the muscles is not sufficiently overcome. This is obviated to some
extent by the previous administration of morphin, but in a number of
instances it has been necessary to change from anesthol to ether because
of the persistent rigidity.]

W. J. McCardie^ discusses ethyl chlorid as a general anesthetic,
his remarks being based upon an experience of 620 cases. Heyfelder, in
1848, used ethyl chlorid as a general anesthetic, his example being fol-
lowed by others. About 1880, however, the agent was tried as a general
anesthetic upon animals by a committee of the British Medical Associa-
tion, who condemned its use, claiming that it produced convulsions and
arrest of respiration. About 1895 or 1896 the subject was again brought
up by Carlson and Thiesing, and it was soon used extensively by other
Europeans, particularly in dental work. Seitz, of Konstanz, in 1892
reported 16,000 cases of ethyl-chlorid narcosis gathered from the litera-
1 Jour. Am. Med. Assoc, March 7, 1903. =* Lancet, April 4, 1903.

ANESTHETICS. 47

ture of the subject. But 1 death was reported, and that in a very un-
favorable subject. This writer is a strong advocate of the use of ethyl
chlorid, claiming that with the exception of nitrous oxid it is the safest of
all the anesthetics, and that the death-rate is in the proportion of one to
many thousand administrations. Its great volatility causes it to be
quickly absorbed and almost as quickly eliminated. McCardie has
assured himself from a large personal experience that arterial tension is,
as a rule, lowered during the administration of ethyl chlorid, but that
during deep narcosis the pulse becomes rather slower than normal,
usually preserving its regularity. During deep anesthesia the respiration
is markedly increased both in frequency and depth, and the color is im-
proved, due to vasomotor dilation, sometimes resulting in sweating,
and in one instance giving rise to a well-marked rash, like the ordinary
ether rash. Both adults and children take ethyl chlorid very well and
quietly, and come under its influence very rapidly. Trouble during the
induction of anesthesia is sometimes encountered in hysteric people,
drinkers, smokers, and muscular subjects. McCardie lays emphasis on
the fact that if excitement takes place, it is due to the too free admission
of air, and yet a free use of air should be allowed. Failure of the anes-
thetic is also traceable to the too free mingling of air with the vapor. It
has been asserted that tea-drinking is more productive of excitement than
alcohol, and that coffee-drinking tends to cause vomiting. Upon first
using ethyl chlorid as an anesthetic the "writer used Breuer's mask, but
has recently employed Ormsby's ether inhaler, and in 350 cases has
known of but 1 instance of great mental or muscular excitement, which
occurred in a young man who had just been drinking freely. With this
inhaler anesthesia is much more quickly produced. The most useful
form is that devised by Hewitt, containing a movable air-chamber which
can be heated in hot water and, lying against the sponge, prevents it
from freezing, which is likely to occur when either ether or ethyl chlorid
is used. McCardie has mostly used kelene or Henning's aether chloratus
pro narcosi. The vapor of ethyl chlorid is not objectionable. The
author has given it to himself and finds the subjective symptoms as
nearly as possible those of nitrous oxid. He has mostly employed the
drug for anesthesia in the removal of adenoids and tonsils or in dental
extractions, but once employed it in an operation requiring 26 minutes.
The drug has been used by many Europeans for much longer operations,
such as herniotomy, etc. Ethyl chlorid produces a larger pupil during
early deep anesthesia than is seen with other anesthetics. If anesthesia
is not induced in less than a minute to a minute and a quarter, it is because
air is being too freely admitted to the inhaler or else insufficient ethyl
chlorid is being given. For continuation of anesthesia 2 cc. or 3 cc. is
sprayed on every 2 or 3 minutes, and air is admitted at frequent intervals,
as the state of the patient may require. The rapid production of anes-
thesia is sometimes startling, occurring in one instance after 6 full breaths
of ethyl chlorid. In operations upon the nose and throat McCardie
prefers the patient to assume the recumbent posture, the head being
somewhat lower than the body. In none of the 620 cases mentioned has

48 GENERAL SURGERY.

he noticed an}^ syncope, either respiratory or cardiac, the only difficulty
arising during the operations being from obstruction of respiration, the
result of blood or the falling back of the tongue. The drug occasionally
produces headache and vomiting. When full anesthesia is employed the
muscles are almost invariably flaccid, although rigidity has been com-
plained of by a number of writers. The writer has used the French prep-
aration called "somnoform," composed of 60 parts ethyl chlorid, 35 parts
methyl chlorid, and 5 parts ethyl bromid. He found the results, how-
ever, to be practically those of ethyl chlorid. Reports are given of a
number of cases of particular interest in which anesthesia has been pro-
duced by ethyl chlorid with the greatest satisfaction where nitrous oxid
and ether had been badly taken or were unsuccessful. The only contra-
indication to the administration of ethyl chlorid is marked narrowing
about the larynx, in which cases chloroform is a better anesthetic, as
being less stimulating. The drug is a perfect anesthetic for small opera-
tions in children. McCardie has used ethyl chlorid with satisfaction as a
preliminary to ether, but has never given it as a preliminary to chloro-
form. The recovery from the anesthesia is very prompt and complete.
[An objection to ethyl chlorid in many cases is the rarity of complete
muscular relaxation. Sometimes it fails to produce complete uncon-
sciousness.]

Solenberger^ discusses ethyl bromid as a general anesthetic in the
removal of adenoids and tonsils. The drug should only be used in prop-
erly selected cases, and therefore has definite limitations. The following
rules are given for the use of ethyl bromid: (1) Do not use ethylene
bromid. (2) Do not use an old or impure solution. (3) Do not ad-
minister it in repeated and small quantities. Give en masse, admit no air.
(4) Do not continue its administration longer than 1 minute. Rapidity
of operation is another essential to success in the use of ethyl bromid,
and to this end a small and accurate instrument must be used. The
^vriter presents photographs and a description of an instrument which
he has found useful.

Schicklberger^ has tested the morphin-scopolamin anesthesia
(Schneiderlein) in 11 cases and is somewhat disappointed. In most of the
cases he made 3 injections of 1 eg. of morphin-hydrochlorate and 0.5 mg. of
scopolamin-hydrobromate. The first injection was made about 4 hours,
the second about 2 hours, and the third about ^ hour before operation.
The operations done under this anesthesia were very varied, a number of
them being abdominal operations. The first effect of the drug was observed
in about 10 or 15 minutes, and was marked by giddiness and suffocation,
with a gradually developing hyperemia of the face, mydriasis and sluggish
action of the pupils. The pulse-rate became later very much accelerated.
After a third injection there was no disturbance of the breathing nor of
the stomach, but the patients were often very restless, interfering consider-
ably with the operation, especially on the abdomen. The duration of the
sleep was from 3 to 8 hours, and when it was over the patient remained
somewhat muddled for a time. Tachycardia in some of the cases did
1 Jour. Am. Med. Assoc, April 18, 1903. ^ Wien. klin. Woch., Dec. 18, 1902.

ANESTHETICS. 49

not disappear for 36 hours. In a number of the cases when muscular
relaxation was desired the drug was altogether insufficient. In 7 of the
11 the anesthesia was not sufficient for the completion of the operation,
and in these an inhalation-anesthesia had to be resorted to. The author
thinks that morphin-scopolamin in anesthesia might be found useful in
those cases in which both chloroform and ether were contraindicated,
but that its action is not sufficiently satisfactory to ever take the place
of these anesthetics. [Recently Wild has reported alarming results from
scopolamin-morphin anesthesia, employed in Konig's clinic by the method
of Blos.^ He points out that it is dangerous to induce anesthesia by this
method without careful preliminary trial to determine the necessary dose
for an individual. Even an hour or two after the operation respiratory
failure may occur. It may be necessary to complete the anesthesia with
ether.]

WilUam M, Perkins^ has collected 2345 cases of spinal analgesia
including 27 cases in which this method was employed by either Parham
or himself. Of the 2345 cases collected, 16 patients died. It is not
thought, however, that these figures are sufficiently large to warrant one
in supposing that the mortality is 1 in 146 cases, as they would indicate.
Of the 27 cases of Parham and the author, 18 were satisfactory, 7 were
partly satisfactory, and 2 were failures. Cocain was used in all cases in
this series, eucain-B only being used in 1 case, and even then followed
by cocain. A 2 % solution was used in almost all the cases. The in-
jections were from 10 to 40 minims, the total amount varying from ^
grain to nearly 1 grain. The most frequently used injection was about
10 or 15 minims of a 2 % solution of cocain muriate, containing i grain to
y\ grain of the drug. No symptoms of spinal infection followed in any
case. It was found by making the patient alternately straighten and
bow the spine that the fourth lumbar interspace could be much more
easily located. The results in this series of cases would indicate that
analgesia may be expected to begin in 10 minutes or less and to be com-
plete in from 10 to 20 minutes, although it often takes longer to become
complete as far up as the umbilicus. In one of these cases it apparently
occurred over an hour after the injection. The duration of the analgesia
was usually over an hour, though sometimes it lasted scarcely half an
hour. The analgesia usually extended about as high as the umbilicus or
nipple, but in a few cases it was noticed as high as the arm, throat, and
even scalp. Paresthesia usually appeared before analgesia, the first
symptom of successful analgesia often being a tingling and numbness of
the feet. In the majority of cases in which the method was employed
there was some special contraindication to the use of a general anesthetic.
Of the 7 partly successful cases, the 4 following are worthy of special note :
Case III: Analgesia, though delayed, did finally appear. Case VI:
The dilation of the sphincter, which was the main reason for the anal-
gesia, was accomplished with comparatively little pain, although the legs
were not analgesized. Case XVII: A full-sized straight Keith needle

' Berl. klin. Woch., March 2, 1903.

^ New Orleans M. atid S. Jour., Sept., 1902.

50 GENERAL SURGERY.

was thrust through the skin of one of the patient's legs and he was per-
fectly unconcerned. From the time the word "knife" was spoken, he
became increasingly nervous and hysteric. Case XXVII: Satisfactory
analgesia, but extreme nausea and vomiting accompanied by collapse.
Nausea was disagreeably present in less than one-third of the cases, and
headache in only a few. The method would seem to be contraindicated
in children and in hysteric or very nervous patients. Morphin hypoder-
matically before the operation may materially increase the usefulness of
this method. Strychnin and digitalis should be used as the pulse de-
mands. Hyoscin hydrobromate is often useful in preventing disagreeable
after-effects. Perkins states that "the method of inducing analgesia
evidently has its advantages, but the question of the relative mortality
to that of other methods must be carefuUy determined." [We believe
that deaths from this method are by no means rare, and that it should
only be employed when other forms of anesthesia are positively contra-
indicated. Cases have been reported which suggest the possibility that
the cord may sometimes be permanently damaged by the injection.]

Kozlowski,* after referring to the complicating sequels of spinal
anesthesia, describes a method which he believes prevents these. Into
a dry sterilized graduate is placed 0.05 gram of tropacocain in powder
form, and upon this the cerebrospinal fluid is allowed to fall as it passes
through the needle. When 5 grams have escaped a tropacocain solution
of 1 % is made in the fluid and at once injected. The drug dissolves with
very little shaking. The author uses Merck's tropacocain directly from
the bottle without any sterilization, and has seen no bad effects from not
sterilizing it. Guinard has also employed the cerebrospinal fluid as a
menstruum for the cocain, but he first dissolves the drug in a small amount
of water. [A. W. Morton,^ of San Francisco, has for a long time advo-
cated the use of the cerebrospinal fluid to dissolve the cocain.]

E. Denegre Martin^ discusses spinal analgesia and reports 18 cases
in which he has used a more concentrated solution of cocain than is gener-
ally employed. It is the author's custom to inject 5 minims of a 2 % or
4 % solution of cocain, thereby disturbing the tension just as little as
possible. Only 1 or 2 drops of cerebrospinal fluid are allowed to escape
before the injection is made. The patient's head and shoulders are
elevated upon the operating table and this position is maintained for
several hours after the operation or until all effects of the cocain have
disappeared. Martin's experience is that one-tenth of a grain (5 minims
of a 2 % solution) is sufficient for all operations about the rectum, but
that more is required for operations on the extremities. Brief notes of
the 18 cases referred to are presented.

A. W. Morton* briefly describes a case of excision of the superior
maxillary bone under medullary narcosis. The operation was done
for cancer. The patient was a man of 39 j^ears. One-half grain of cocain
dissolved in cerebrospinal fluid was injected between the third and fourth
lumbar vertebras. Analgesia was complete in about 20 minutes, and the

» Centralbl. f. Chir., Nov. 8, 1902. Uour. Am. Med. Assoc, Nov. 8, 1902.

^New Orleans M. and S. Jour., April, 1903. ■• Amer. Med., March 21, 1903.

ANESTHETICS. 51

operation, which required the employment of bone forceps and chisels
and also the Paquelin cautery for the control of hemorrhage, was borne
by the patient without any expression of pain, and when the operator
spoke of the possibility of a recurrence in the other side, the patient re-
quested him to remove this bone also if it was necessary. Throughout
the operation the patient was able to expectorate the blood which accu-
mulated in the pharynx or to retain it until it was wiped away.

Gibbon^ reports a case of painless amputation of the leg after the
intraneural injection of cocain. The patient was a man aged 50
years, who suffered from tuberculosis of the ankle-joint, and to whom it
was thought unwise to administer a general anesthetic. The method
employed was that described by Crile,^ and successfully practised by him
and by Matas. In the case reported the sciatic and anterior crural nerves
were exposed and injected by the infiltration method with a 1 % solution
of cocain. Amputation of the leg was then proceeded with and accom-
plished without complaint of pain on the part of the patient and without
his knowledge. No shock was noted after the operation and the patient
made a good recovery. Gibbon states that he was very much impressed
with the success of the method, but warns those unfamiliar with in-
filtration-anesthesia against its employment in extensive operations.
The technic of infiltration should be carefully studied and successfully
practised in small operations before it can be employed in the more ex-
tensive ones with any degree of satisfaction. The solution used must
be pure and fresh and the technic perfect in order to give good results.
"Crile learned by his experiments that a 1 % solution of cocain injected
into a nerve-trunk produced in a few minutes an absolute physiologic
' block ' to both efferent and afferent impulses, and that hence any opera-
tion might be done on the parts supplied by the nerve without the pro-
duction of shock. This is certainly more than can be claimed for any
general anesthetic, these agents but slightly influencing the afferent
impulses which produce the shock. Crile states that the general anes-
thetic abolishes the afferent impulses which produce pain, but does not
abolish those affecting the vasomotor, respiratory, and cardiac mechan-
isms. He says the injection may be looked upon as a temporary physio-
logic amputation of the part. By the intraneural injection method Crile
has amputated 5 times below the knee, once at the shoulder-joint, and
once he removed the entire upper extremity with satisfaction."

George Y. Myrtle' reports 4 cases showing the danger of cocain used
externally. In these cases the injurious effects followed the local use
of cocain, and in 2 of them after a single application.

Frederick Griffith* reports a typical case of poisoning following the
use of cocain as a local anesthetic. According to a rough estimate,
from 2^ to 3 grains of cocain was injected. The cause of the poisoning in
this case was that it was found necessary to use a larger amount of the
infiltrating solution than was at first supposed and the strength of the
solution was not changed.

* Phila. Med. Jour., May 2, 1903. => Year-Book of Surgery, 1903.

^ Quarterly Med. Jour., Aug., 1902. * Amor. Med., March 7, 1903.

52 GENERAL SURGERY.

Braun ^ relates the results of extensive experimentation regarding the
action of adrenalin in local anesthesia. A solution of adrenalin alone
does not produce local anesthesia, but when added to solutions of cocain
or eucain it increases the anesthetic property of these drugs to an extra-
ordinary degree. Experiments upon animals demonstrate the fact that
the toxic effects of cocain are greatly diminished by the addition of ad-
renalin. Tropacocain and adrenalin were found to be imcompatible, the
latter losing the vaso-constricting qualities in the presence of tropacocain.
Adrenalin added to cocain and eucain not only increases but considerably
prolongs the anesthesia. When this combination is used, the anesthesia
does not cease for from 20 to 30 minutes after the injection is made. As
a general rule the amount of adrenalin injected at one time should not
exceed 15 drops of a 1 % solution. Three drops of a 1 % adrenalin
solution added to a cubic centimeter of a 1 % solution of cocain was found
useful for teeth extraction, but the full effects of the injection were de-
layed for 10 minutes.

ESOPHAGUS, STOMACH, AND DUODENUM.

James P. Marsh^ discusses the rare condition of congenital absence
of the entire esophagus and describes a case coming under his care.
After a careful investigation of all reported cases Marsh estimates the
number of instances of entire absence of the esophagus at 5. The symp-
toms in all these cases were practically the same. The chUd appeared
perfectly normal, but after taking a mouthful of milk or water was seized
with a severe attack of strangling and became cyanotic. Repeated
attempts at nursing were followed by similar attacks. The bowel move-
ments became gradually less in amount and the secretion of urine was
diminished. Emaciation was rapid and death followed from starvation.
Toward the end inspiration-pneumonia occurred in quite a large pro-
portion of the cases. The diagnosis is made sure by the passage of a
catheter into the esophagus. The diameter of the esophagus of a new-
born child is 4 mm. ; from the border of the gums to the cardiac orifice the
distance is 17 mm. Marsh thinks that the passage of an instrument is
not without danger, as there is considerable liability of its entering the
trachea or a bronchus. The only treatment that is possible is surgical,
and consists either in the establishment of an opening from the blind
esophagus into the stomach or the performance of gastrostomy. Where
there is absolute absence of the esophagus the only operation to be con-
sidered is that of gastrostomy. The only case thus treated is that of
Charles Steele, who performed the operation upon a child 24 hours old.
The child died 24 hours after the operation. Brief notes of all the cases
reported conclude Marsh's article.

Fatal perforation of the esophagus in a young girl is illustrated
by a case of Tirard's.^ The patient was a girl 19 years of age, admitted

» Miinch. med. Woch., Feb. 24, 1903. ^ Am. Jour. Med. Sci., Aug., 1902.

3 Lancet, July 12, 1902

ESOPHAGUS, STOMACH, AND DUODENUM. 53

because of cough accompanied by nausea, but no expectoration. Later
the expectoration of a large quantity of yellow, purulent, offensive spu-
tum occurred. The chest symptoms continued until it was finally deter-
mined that the patient might be suffering from a localized empyema or a
lung-abscess. Mr. Barrow operated, but was unable to discover pus.
At the autopsy a smooth, round hole, the size of a No. 8 catheter, was
found in the anterior wall of the esophagus at the bifurcation of the tra-
chea, and led into an abscess-cavity in the mediastinum. This cavity was
about the size of a hen's egg ; its walls were ragged and gray, and it was
the seat of a gangrenous odor. There was also found an aperture into
the right bronchus about 1 inch from the bifurcation.

Three cases of perforation of the esophagus are reported by Riviere.^
The author made a postmortem examination in each of the 3 cases. The
patients were all under 2 years of age. In each the perforation occurred
near the bifurcation of the trachea, and it was the gland or glands situated
below the bifurcation which caused the trouble. In each of the cases
abdominal tuberculosis was a striking feature. In one there were tuber-
culous ulcers in the stomach, a very rare condition. In all 3 there were
intestinal tuberculous ulcers and caseous mesenteric glands, and in 2 the
retroperitoneal glands were also caseous, a condition which is by no
means common. In 2 of the cases the gland below the tracheal bifur-
cation had completely emptied its caseous contents, leaving its cavity
smooth-walled and apparently lined with mucous membrane. The
author is inclined to think that many cases of esophageal diverticulum
occurring at this situation are due to such a cause.

Symonds^ presents an instructive discussion of the diagnosis and
treatment of malignant stricture of the esophagus. The diagnosis
of the condition is summarized as follows: "(1) Among early symp-
toms we may have so-called dyspepsia, nausea, and repulsion for food;
pain alone when the central district is affected. (2) The passage of a
bougie is the only way to clear up the case, and its employment need not
be feared. (3) Extraesophageal disease rarely gives rise to serious
dysphagia. (4) Spasmodic obstruction, apart from the hysteric form,
has always, when decided, an organic cause, and this would be better
called intermittent dysphagia. (5) With regard to the three special
districts, it may be said (a) that all organic obstruction in the upper third
is malignant and has a special tendency to cicatrize ; (b) that in the central
half of the gullet a sarcoma or a myoma, both rare diseases, may cause
fatal obstruction, and here also a pouch may give rise to difficulty in
diagnosis, but can generally be excluded ; and (c) that in- the lower diffi-
culty was encountered in passing the first long feeding-tube. The rubber
form was easily introduced after a few days' residence of the sUk-web
tube. From time to time small pieces of the rubber tube had to be re-
moved, as it split near the sUver cannula. The patient died with the
original tube in position." The general question of treatment as apply-
ing to all cases is stated as follows: " (1) While the patient can swallow
fluids and semisolids, and while a bougie can be passed and plenty of
' Brit. Med. Jour., Jan. 24, 1903. » Lancet, Aug. 9, 1902.

54 GENERAL SURGERY.

nourishment taken, he may be let alone so long as (a) he can swallow well
or (h) a small bougie, No. 12 catheter gage, can be passed. (2) If the
dysphagia increases, even though a bougie can be passed, then a tube
must be inserted or gastrostomy must be performed. These conditions
are seen in the soft fungating forms. (3) If a bougie cannot be passed
or goes with difficulty, then the same course must be followed, as we
know that complete closure may occur at any time. (4) If both con-
ditions arise, — i. e., the patient cannot swallow and a bougie cannot be
passed, — then immediate mechanical treatment is required." The
passage of bougies is not advocated with the view of dilating the stricture.
Employed in this w^ay their passage irritates and leads to increase of ob-
struction. A small bougie is employed simply to secure the route, so
that at any time a tube can be passed for feeding purposes or the time
fixed for gastrostomy. The passage of a tube should be attempted after
a night's rest and a dose of opium. The longest time which Symonds
has known a rubber tube to remain unchanged was 13 months. He has
now under treatment a patient who has worn a tube for 11 months and
a tracheal tube for 4^ months. When the disease involves the lower end
and cardiac orifice, treatment by the tube is difficult and early gastros-
tomy is to be recommended. The short tube is useful in strictures oc-
curring at a point 10 inches to 14 inches from the teeth. The tube is
of no use when cough or swallowing indicates perforation of the respira-
tory tract. A reference is made to the accidents which accompany at-
tempts at intubation of malignant esophageal strictures, such as forcing
a passage into the trachea. The employment of the larj^ngoscope to
ascertain the position of the tube in cricoid strictures is of the greatest
help in avoiding accidents, especially when a general anesthetic is em-
ployed. A short tube is serviceable in a fair number of cases of disease
of the central portion of the esophagus, and when it acts well is superior
to any other method. It must be replaced by a long feeding-tube when
pulmonary symptoms arise. The tube should be kept continuously in
position, and if for any reason it is to be changed the new tube should be
inserted at once.

J. G. EmanueP relates the history of 6 cases of cancer of the
esophagus without obstructive symptoms that occurred in the City of
London Hospital from the years 1897 to 1899, inclusive. Dysphagia in
these cases was altogether absent or else obscured by other more prom-
inent symptoms. Three of the patients sought admission because of
laryngeal symptoms, 3 hoarseness or aphonia, and in 2 of these cough
and expectoration were present. Shortness of breath, cough, and ex-
pectoration were the cause of admission in a fourth, and hemoptysis
accounted for the admission of another. In the sixth case there was
vomiting, which was apparently due to a simple gastritis, and which was
not accompanied by any difficulty in swallowing. Those cases presenting
any trouble in deglutition showed that the difficulty was not associated
with trying to get food through a stenosed esophagus, but was caused by
perforation of the trachea, bronchus, or lung by the growth. Great im-

> Lancet, Oct. 18, 1902.

ESOPHAGUS, STOMACH, AND DUODENUM. 55

portance is attached to this form of dysphagia which is characterized
by reflex paroxysmal cough immediately after swallowing. The im-
portance of recognizing this symptom is obvious, for although the patient
may succeed in getting part of the food into the stomach, some will find
its way into the air-passages and sooner or later set up an inhalation-
bronchopneumonia. In 2 of the cases reported the growth was in the
upper part of the esophagus and caused perforation of the trachea; in 3
it was opposite the bifurcation of the trachea and perforated the left
bronchus; in 1 case it was at the lower end of the esophagus and per-
forated the lung itself. In 3 cases death was caused by inhalation of food
into the air-passages, which set up a septic bronchopneumonia in 2 cases
and a septic bronchitis in the third. The death of another patient was
due to pneumothorax, and of another to pyopneumothorax, and in the
last case to hemorrhage into the left bronchus. This series illustrates
well the frequency with which laryngeal paralysis forms an early symptom
of esophageal growth. This laryngeal paralysis has a special importance
when the symptoms of obstruction are absent, and may lead to a correct
diagnosis when there are no other definite symptoms to be found. A
complete history of each case concludes the article.

C. B. Lockwood^ describes the treatment of a case of so-called
idiopathic dilation of the esophagus. The case had been previously
reported by James Swain as a case of idiopathic dilation. A full-sized
esophageal tube always passed with ease and never became entangled.
The esophagus was filled with about a pint of rather thick fluid with some
bismuth in suspension, and then the shadow of the dilated esophagus was
plainly seen with x-rays. The dilation was fusiform and reached from
about the left bronchus to the diaphragm. Acting upon the assumption
that the dilation of the esophagus was secondary to systematic contrac-
tion of the cardiac orifice, Lockwood determined to try the effects of
stretching. He had an instrument constructed which consisted of an
ordinary esophageal tube with a distensible rubber bag around the last
4 or 5 inches of its stomach end. This bag was distended with air by
means of an ordinary air-pump, the air being transmitted by a small
tube which ran down inside of the esophageal tube. As the patient
had been accustomed for a long time to the passage of a tube for the
purpose of feeding, there was no difficulty in using the instrument. The
patient, after the frequent use of this instrument, was able to partake
plentifully of food and gained a great deal in weight.

A. J. Ochsner^ presents some clinical observations on stomach
surgery. It is stated that ultimately stomacli sin-gery will consist
chiefly of operations for gastric ulceration or for one of its various sequels,
liemorrhage, perforation, adhesions, etc. Operation for the relief of
sequels, however, will not be so frequent as at present because of the
growing favor of early operative treatment of ulcer. The greatest credit
is due to MsLjo for firmly establishing in gastroenterostomy the principle
of providing drainage of the stomach at the ver}^ lowest portion of this
organ. Ochsner states that since observing this principle he has not

' Brit. Med. Jour., June 13, 1903. ^ Jour. Am. Med. Assoc, June 6, 1903.

56 GENERAL SURGERY.

been troubled with persistent vomiting after gastroenterostomy. He
believes that if the proper point of the stomach is chosen for anastomosis
with the bowel, all the complicated operations for the prevention of post-
operative persistent vomiting will be unnecessary. In the majority of
his own cases Ochsner has employed the Murphy button, but in 9 cases
operated upon during the present year he has employed the McGraw
elastic ligature, and has found the method exceedingly easy and satis-
factory so far as immediate results are concerned. None of the patients
showed shock, all were able to sit up in bed the day following operation,
and all recovered. The duration of time since the operation, however,
has been too short in these cases to speak of ultimate results. In em-
ploying the McGraw elastic ligature the following rules should be borne
in mind: '■' (1) Around rubber cord 2 mm. in diameter, made of the best
material, should be used. (2) A posterior row of Lembert sutures is
applied. (3) A long, straight needle armed with the rubber ligature is
passed into the lumen of the intestine and out again at the desired dis-
tance, from 5 to 10 cm. away from the point of introduction. (4) While
an assistant holds the intestine the surgeon stretches the rubber in the
needle, and when quite thin draws it rapidly through the intestine. (5)
The same step is repeated through the stomach. (6) A strong silk liga-
ture is placed across and underneath the rubber ligature between the
latter and the point where the stomach and intestine come together. (7)
A single tie is made in the rubber ligature after it has been drawn
very tightly. (8) The silk ligature is passed around the ends of the
rubber ligature where they cross and tied securely three times. (9) The
ends of the latter are released and cut off, being held by the silk ligature.
(10) The Lembert suture is continued around in front until the point of
its beginning is reached, where it will be tied. (11) Care must be exer-
cised to prevent tying the rubber ligature too far backward and thus
getting behind the posterior row of Lembert sutures." It is found that
in gastroenterostomy done with a Murphy button the opening will remain
patulous and act perfectly in cases in which the pylorus is permanently
occluded, but in cases in which it is only temporarily obstructed the
gastroenterostomy opening contracts as soon as the pylorus again becomes
normal, or nearly so. Unfortunately this closure of the gastroenteros-
tomy opening is likely to be followed by a recurrence of the ulcer, necessi-
tating possibly a repetition of the operation. The operation of pyloro-
plasty has not been found very satisfactory, but the operation of Finney
seems to promise very well. Finney's operation is easy of performance
and the cases reported show good results. Regarding the various opera-
tions for gastroptosis, Ochsner states that the majority of those devised
with the object of elevating the stomach are faulty because they interfere
with the mobility of the organ. The operations of Beyea and Bier,
which consist in the shortening of the gastrohepatic and gastrophrenic
ligaments, do not possess this objection. When the pylorus is obstructed
by cancer, there is never any indication for performing complicated
operations. After removing the pylorus, the cut surfaces of the duode-
num and the stomach should be completely closed by the inversion of

ESOPHAGUS, STOMACH, AND DUODENUM. 57

the edges, and a separate gastroenterostomy be made at the lowest part
of the remaining portion of the stomach. When a cancer is so extensive
as to render impossible complete removal, it is much better for the
patient to have gastroenterostomy performed. Gastrectomy must ever
remain a rare operation, because cases in which the disease is sufhciently
advanced to cause the surgeon to consider this operation are usually so
far advanced that even complete gastrectomy is useless. Ochsner calls
attention to the method which he has found of the greatest use in pre-
paring a case of obstruction of the pylorus for operation. Often these
patients are so emaciated and weakened from want of nourishment that
an operation cannot be done. He states that if the stomach is carefully
washed out every 3 to 6 hours and a small amount of predigested food
introduced, in addition to the administration of food by the rectum, the
patient will greatly improve in strength. Unless the pylorus has been
entirely occluded it is well to inject 2 ounces of olive oil once a day,
as the oil will find its way into the intestine and aid the nutrition of
the patient. The greatest care should be employed in using gastric
lavage after operation, a half-pint of salt solution being quite sufficient.

Bevan^ gives a review of the history and the present status of sur-
gery of the stomach. The surgery of the stomach is discussed under 4
heads — operation for malignant disease, operation for benign pathologic
conditions, operative treatment of wounds of the stomach, and removal
of foreign bodies. Each of the various operations is briefly discussed, and
the author concludes by making a plea for a wider application of operative
procedures to lesions of the stomach. Disappointing as is the surgery of
malignant disease, yet to-day operation is our only hope in these cases.
Certainly the surgery of benign lesions has given brilliant results. It is
capable of doing much more than even it is doing to-day. In almost
every community patients afflicted with ulcer of the stomach die from
obstruction, perforation, or hemorrhage, who could be saved by timely
operative interference. Such patients are entitled to the benefits of
modern surgery, and they will obtain it if the surgeon can convince the
general practitioner of the possibilities for good in radical treatment.
These cases are on the borderland between medicine and surgery, and
the best results can be obtained only by the helpful cooperation of surgeon
and physician; never by indiscriminate operating, nor by protracted
routine medical treatment, but by the judicious selection of the treatment
required to cure the individual case.

In an address on gastroenterostomy and its uses, A. W. Mayo
Robson^ refers to the high mortality presented by this operation between
1881 and 1885 (65.71 %). At present he sets the mortality at under
5 %. In preparing the patient for operation it is said to be generally
unnecessary to put him through a severe course of preliminary treatment,
such as frequent lavage of the stomach and prolonged abstention from
food before operation, as such treatment is exhausting to weakened
patients. Gushing has shown also that the stomach-contents speedily
become aseptic if the mouth is repeatedly cleansed and if only aseptic

» Jour. Am. Med. Assoc, Jan. 24, 1903. ^ Lancet, Feb. 28, 1903.

58 GENERAL SURGERY.

foods are administered, and clinical experience shows that elaborate pre-
liminary treatment is not an essential to success. Robson prepares his
patients by carefully cleansing the mouth and teeth and administering
sterilized foods. About 12 hours before operation the last light meal is
given, the stomach is washed out about 2 hours and a nutrient enema
given about 1 hour before operation. The enema consists of brandy §j,
liquid peptonoids oij, and noraial salt solution Sx. Great care is taken
to avoid exposure to cold while on the operating table, and strychnin is
administered to anticipate shock. The author prefers posterior gastro-
enterostomy except when the posterior wall of the stomach is rendered
inaccessible by adhesions or by involvement in a malignant growth. By
this operation free drainage of the stomach into the bowel is produced
and exact apposition by posture of the newly joined structures is secured.
Any complicated method of operation is usually unnecessary and should
be avoided. The point on the bowel for anastomosis preferred by the
writer is in the anterior operation 13 inches and in the posterior operation
from 6 to 9 inches from the commencement of the jejunum. In the
former operation a point is selected on the stomach near the pylorus
and as near as possible to the greater curvature. After the completion
of the anastomosis a few additional stitches are introduced into the
proximal end of the loop to secure it at a higher level on the stomach-
wall, and also into the distal end, securing it at a lower level in order
to prevent kinking. Robson prefers a simple suture or his bone bobbin
for effecting the anastomosing; he does not like the Murphy button.
When a. continuous suture is used, it is well to interrupt it at several
points in order to avoid drawing or puckering of the orifice. A descrip-
tion is given of the method of removing a portion of the mucous mem-
brane from both bowel and stomach. This prevents contraction of the
opening and has given satisfactory results in Robson's cases. Among the
complications which may follow the operation, regurgitant vomiting is
first mentioned. It is more frequently met with in malignant than in
simple disease, but its cause is difficult to determine. It is best con-
trolled by lavage, placing the patient in the semi-erect posture, abstinence
from mouth-feeding, and securing free action of the bowels. It is some-
times relieved by the free administration of milk or some other fluid.
Robson quotes numerous authorities to show that the vomiting is not
due to the presence of bile in the stomach. He believes that this regurgi-
tant vomiting is dependent upon obstruction to the onward passage of
the intestinal contents, an obstruction caused either by kinking or paraly-
sis of the anastomosed jejunal loop, or later by adhesions. Another and
a later complication is contraction of the new orifice. This occurs more
or less in all cases in which the stomach is markedly dilated at the time
of operation. Robson has not found that pneumonia and pleurisy have
followed operations on the stomach with greater frequency than other
operations upon the abdomen. Cases of peptic ulcer in the jejunum
after gastroenterostomy have been reported by several writers. Adhe-
sions subsequent to gastroenterostomy causing intestinal obstruction are
probably uncommon. Failure of union in the newly joined structures

ESOPHAGUS, STOMACH, AND DUODENUM. 59

is a serious and almost always fatal accident, but is now seldom seen.
It was much more frequent when operations were not done until the
patients were moribund. Robson believes it is less likely to occur when
a double line of sutures has been employed than when a Murphy button
has been used. The passage of the small intestine through the loop
formed by the junction of the jejunum and stomach has been reported
by Mayo, but is only possible after the anterior operation. As regards
the condition of the patients subsequent to operation, it is usually found
that the peristaltic power of the stomach immediately improves, although
it never becomes normal. Conditions of hyperacidity and anacidity are
not changed by the operation. We thus learn that these conditions are
dependent upon changes in the mucous membrane rather than on obstruc-
tion. If dilation has not lasted for too great a time, it will certainly be
overcome. When there is great dilation of the stomach and the duode-
num is mobile these two portions of the alimentary canal may be united,
the operation causing but little disturbance on exposure of the viscera.
This plan is not possible, however, when the pyloric region is extensively
diseased or adherent. The fact that contraction occasionally follows
pyloroplasty, especially if there is active ulceration at the time of the
operation, has led Robson to prefer gastroenterostomy, although on
many occasions he has done gastroduodenostomy with excellent results.
He is a strong advocate of gastroenterostomy for irremovable malignant
stenosis of the pylorus, and emphasizes this inclination by reporting a
number of cases markedly benefited by the operation. It is believed that
a degree of congenital stenosis is a frequently unrecognized cause of
dilation of the stomach in young adults. Several cases are reported to
impress upon surgeons the fact that a hopeless prognosis after gastro-
enterostomy for tumor should not be hastily made ; it is well to give the
patient the benefit that is derived from the hope of cure if there is any
possible doubt as to the malignancy of the growth. In cancer and other
tumors of the duodenum producing obstruction to the onward passage
of the stomach-contents, gastroenterostomy is preferable to resection; in
hour-glass contraction of the stomach gastroplasty is in many cases the
preferable operation, but if the stricture be a long one and there is ex-
tensive thickening, gastroenterostomy is the better operation. One must
be careful in these cases to make sure that the intestine is anastomosed
to the proximal portion of the stomach. The mistake has been made on
several occasions of attaching the bowel to the distal portion. In peri-
gastric adhesions the operation of gastrolysis is usually entirely curative,
but when the adhesions are extensive, dense, short, and firm, posterior
gastroenterostomy should be performed. When, in acute or chronic
gastric ulcer, medical treatment is not productive of benefit, gastro-
enterostomy will in many cases give excellent results, but the operation
must be determined on after considering the situation and condition of
the ulceK. Robson will subsequently report a series of cases of duodenal
ulcer treated by gastroenterostomy. When gastric or duodenal hemor-
rhage is not cured by general medical treatment, operation for the finding
and securing, if possible, of the bleeding point, or the performance of

GENERAL SURGERY.

gastroenterostomy, is indicated. In persistent spasm of the pylorus, or
Reichmann's disease, Robson has abandoned the operation of stretching

Fig. 11. — Gastrojejiinostoniy with tlie JicGraw elastic ligature. Approximation of serosa witti contin-
uous silk suture (Walker, in Jour. Am. Med. Assoc, Jan. 17, 1903).

Fig. 12.— Gastrojejunostomy with the McGraw elastic ligature. Elastic ligature introduced (Walker, in
Jour. Am. Med. Assoc, Jan. 17, 1903).

the pylorus and favors gastroenterostomy. As a rule, hyperchlorhydria
responds to medical and general treatment; but if it does not, and the

ESOPHAGUS, STOMACH, AND DUODENUM.

life of the patient is made miserable, it is well to consider gastroenteros-
tomy. Robson refers to a case of persistent gastralgia in which the
condition was unrelieved by all medical measures, but which made a
good recovery and was ultimately restored to health after the performance
of gastroenterostomy. Tetany occurring in those suffering from gastric
dilation is undoubtedly very serious, the mortality being nearly 75 %.
Satisfactory results are reported in a case in which pyloroplasty was
performed. Acute gastric dilation is one of the most serious diseases that
can be encountered. In the Leeds General Infirmary during the past
10 years there have been at least 4 fatal cases. Robson mentions a case
in which this condition arose and was relieved by the prompt use of
lavage; but should this treatment fail to give relief, Robson says that

Fig. 13. — Gastrojejunostomy with the McGraw elastic ligature. One tie of tiie elastic ligature with a
strong silk ligature underneath ready to fasten the elastic ligature where it is drawn taui (Walker, in
Jour. Am. Med. Assoc, Jan. 17, 1903).

rather than let the patient die the stomach sliould be opened and be
connected with the jejunum. He knows of no case in which this opera-
tion has been performed. In conclusion, the author states that, if the
procedure of gastroenterostomy is to hold its place as one of the most
beneficial operations in surgery, it must continue to be done with a very
small mortality, which will be effected only by observing every care in
detail before, at the time of, and subsequent to, the operation. [Robson's
recommendation as to the advisable procedure in a case of acute dilation
of the stomach is worthy of careful consideration. That acute dilation
may occur in a person who has pyloric obstruction is illustrated by a
recent case under the charge of one of us (DaCosta) in the Jefferson
Hospital. The patient, a woman, 42 years of age, was brought into the

GENERAL SURGERY.

hospital with a history of prolonged gastric disturbance and violent vom-
iting for several days, followed by collapse. The abdomen was opened,
and it was found that profuse hemorrhage had occurred from a vessel

Fig. 14. — Gastrojejunostomy with the McGraw elastic ligature. The ligature tied (Walker, in Jour
Am. Med. Assoc, Jan. 17, 1903).

Fig. 15. — Gastrojejunostomy with the McGraw elastic ligature. Operation completed (Wallcer, in .Tour.

Am. Med. Assoc, Jan. 17, 1903).

of the gastrocolic omentum. A tear existed in this structure as large as
a 25-cent piece. The stomach was enormously dilated and a cicatricial
stenosis of the pylorus was readily detectable. The bleeding vessel was

ESOPHAGUS, STOMACH, AND DUODENUM. 63

ligated, the tear was sutured, pyloroplasty was performed, and the patient
made an uninterrupted recovery. It is interesting to note that there was
no history of traumatism in this case, and the inference is that vomiting
caused the rupture and hemorrhage.]

H. 0. Walker^ discusses the cases of 3 women who suffered from
gastroptosis and on whom he performed gastrojejunostomy with the
McGraw elastic ligature. In each case the result was satisfactory. He
is a strong advocate of this method in making lateral anastomoses of
the alimentary tract. The illustrations accompanying the article show
the method of applying the ligature (Figs. 11-15). Its advantages are
the following: " (1) Its simplicity, which is far greater than any other yet
presented. (2) Ease and rapidity with which it can be done. (3) Less
liability to sepsis than by any other method. No danger of a foreign
body. (5) A larger opening can be made wdthout liability to cicatricial
contraction."

Dalziel, of Glasgow,^ reports 30 cases of gastroenterostomy for non-
malignant affections of the stomach \vith but one death. The patients
had all suffered for many years from intractable dyspepsia, and many of
them presented evidences of marked pyloric obstruction. They had been
under treatment prior to operation for periods varying from 2 to 17
years. In 16 of them there was a definite history of ulceration. In 18
of these cases there was well-marked contraction of the pyloric orifice.
Many of the cases presented marked perigastric adhesions. The patient
who died after operation was one in whom a large area of the posterior
wall of the stomach had been destroyed by ulceration, the body of the
pancreas forming the base of the ulcer.

Samuel Lloyd ^ presents his personal experience with the McGraw
method of gastroenterostomy. He was much pleased ^ith the method
in each case.

Hall* describes the difficulties and disadvantages of both the anterior
and posterior methods of performing gastrojejunostomy and reports 4
cases in which he has anastomosed the jejunum and the stomach through
an opening made in the gastrocolic omentum. He believes that this
method does away with the usual objections to both the anterior and
posterior operations.

George R. Fowler'' discusses at considerable length the literature
relating to "vicious circle" following gastroenterostomy, and de-
scribes a new operation which he has devised to prevent the occurrence
of this condition. The author thinks that the term "vicious circle" has
been too extensively used, and that if employed at all it should be re-
stricted to those cases in which the stomach-contents pass into the
afferent or duodenal side of the loop of intestine forming the gastro-
enterostomy, and are subsequently returned to the stomach mixed with
the secretions from the duodenum, these including bile and pancreatic
juice. In the remaining cases of persistent vomiting the term "reflux"

' Jour. Am. Med. Assoc, Jan. 17, 1903.

' Laneet, Aug. 23, 1902. » N. Y. Med. Jour., Dec. 27, 1902.

* Lancet, Sept. 6, 1902. " Ann. of Surg., Nov., 1902.

GENERAL SURGERY.

is thought to be more applicable. After describing and comparing the
various methods which have been devised for performing gastroenteros-
tomy he states that the conditions most to be feared, next to collapse
during or immediately following the operation, are the occurrence of,
first, the vicious circle; second, distention of the duodenum from forcible
propulsion of the stomach-contents directly into the afferent portion of
the intestinal loop employed; and, third, reflux of the jejunal contents.
In order to prevent vomiting as an effect of the anesthetic taking place,
the operation should be done, whenever possible, under infiltration
cocainization. In order to prevent establishment of what is called the
vicious circle the clear indication is to prevent any communication be-
tween the stomach and the afferent loop, and at the same time permit

of the escape of the biliary
and pancreatic secretions
from the duodenum, and
preserve them for the pur-
poses of effecting digestion.
" Enteroenterostomy, by
one or another of the
methods devised, is a ra-
tional resource. Of these
methods, that of making
the anastomosis between a
loop of the jejunum and the
stomach, and subsequently
establishing a communica-
tion between the afferent
and the efferent portions of
the loop, is the simplest and
at first glance ideal. This
procedure alone does not,
however, prevent the pass-
age of food from the stomach
into the afferent loop, nor
make ample provision for its escape after it has become lodged
therein, particularly if the orifice at this point is only sufficiently large
to permit of the escape of the secretions from the duodenum." The
indications arising from the vicious circle, as well as overfilling of the
duodenum and consequent motor insufficiency, can only be met by abso-
lutely cutting off all communication between the stomach and the afferent
portion of the loop. The method which Fowler describes consists in first
securing a communication between a loop of the jejunum and the stomach,
then performing an enteroenterostomy between the afferent and efferent
loops, and, finally, obliterating the lumen of the afferent loop between
the two points of anastomosis. The obliteration of the afferent loop is
accomplished by constricting it by two or three turns of No. 20 silver
wire, the cut ends of the wire being so placed as to avoid irritation of
the neighboring viscera. The accompanying illustration shows the

Fig. 16. — Fowler's method of gastroenterostomy (Ann. of
Surg., Nov., 1902).

ESOPHAGUS, STOMACH, AND DUODENUM. 65

appearance of the parts at the completion of this portion of the operation
(Fig. 16). The application of a ligature to the small intestine for the
purpose of occluding its lumen is not new, but was first suggested to
Fowler by Dawbarn's work on the cadaver, and was first practised by
him in operating for the cure of fecal fistula of the large bowel in which
an ileosigmoid anastomosis was done. In this case Fowler constricted the
ileum so that none of its contents passed into the cecum. This put the
large bowel at absolute rest and resulted in healing of the fistula. The
constriction was later removed and the small intestine was found not to
have been injured at all. The operation described by Fowler has been
employed by him in 6 cases with no bad results due to the constriction
of the bowel by the silver wire ligature.

A. E. Barker^ discusses lo consecutive operations performed for
nonmalignant disease of the stomach during the past year. These
cases include all Barker has operated upon for nonmalignant disease
during this period. Seven of the 10 cases were cases of pyloric stenosis
due to ulcer. One was a duodenal ulcer with severe hemorrhage ; another
was hourglass contraction, and the third a bleeding gastric ulcer. In
every case posterior gastroenterostomy was performed and all of the
patients recovered, and the change in health in those who have had
time to show it is most remarkable. One of the marked changes noted
in every case is the increase in weight after operation. In almost all of
these cases there had been careful medical treatment before the question
of surgical interference was entertained. Barker lays particular stress
upon the necessity for carefully preparing the patient before operation.
His preparation consists not only in gastric lavage, but also in rendering
the mouth as aseptic as possible by the removal of carious teeth, the
use of mouth-washes, etc. He also administers 10 grains of carbonate
of bismuth 3 times a day during the several days immediately preceding
operation. It is an intestinal antiseptic. He also washes out the lower
bowel once a day for several days previous to operation. The operation
in each case was done without the use of any mechanical device. The
operation is that which Barker used in his first cases 15 years ago, and
is accomplished by uniting the serous and muscular coats behind the
proposed opening, before the latter is made, and then by opening the
gut and stomach and uniting the resulting edges and finishing the con-
tinuous suture over the front which had been begun before the viscera
were opened. If the patient shows any sign of shock upon the operating
table a pint of saccharosaline solution is injected into the areolar tissue.
Immediately after the operation the patient is placed upon his back, but
as soon as he wishes it, usually on the second day, he is kept in a semi-
recumbent position while awake and laid on his right side for sleep or
change of position. A point worthy of note is that all of these patients
were fed at first by the mouth as well as by the rectum, and in almost
every case the stomach was washed out during the first 24 hours after
operation with the idea of relieving the organ of bile, blood, and mucus,
which are usually present and may decompose if allowed to remain.

1 Lancet, Aug. 23, 1902.

66 GENERAL SURGERY.

Henri Hartmann/ deals with the surgical treatment of nomnalig-
nant diseases of the stomach based upon 60 operations for this condi-
tion. Of these 60 patients, 10 died, making a mortality of 16.5 %. The
operations are divided into two periods. The first includes all cases be-
tween 1895 and 1899. In this group the mortality rate was 26 %. The
second includes all cases between 1900 and 1902. The mortality rate in
this group was 10.5 %. In Hartmann's table 6 operations for perforated
gastric ulcer are not included. Another division is also made in these
cases — a division which is striking. Hartmann places those referred to
him by physicians well informed in diseases of the stomach in one group,
and those sent by other physicians generally late in the disease, in a
different group. Of the former series of 36 cases, but one ended fatally ;
and in the second series of 26 cases, 9 were fatal. These facts go to
show that the mortality in operations for nonmalignant disease of the
stomach depends almost entirely upon the physician and the early diag-
nosis. Under the term " pyloric syndrome" the author includes pain and
dyspeptic troubles arising 3 or 4 hours after meals without arrest of food
and without hypersecretion of gastric juice. The results obtained in
these cases are given in detail and are remarkably satisfactory. Regard-
ing the indications for operation, Hartmann states that he does not
accept the opinion of surgeons who say that operation is to be resorted
to in every case of intractable dyspepsia. Atonic dilation is rarely an
indication for surgical interference. Out of the 60 cases reported, there
was but one such case. In pyloric stenosis operative treatment is indi-
cated as soon as the diagnosis is made. Were it not that operation has
so frequently to be performed upon patients weakened by too long wait-
ing, the operative mortality would be reduced to nearly nothing. The
acute ulcer without complications is practically always cured by medical
treatment. Surgical treatment is indicated in chronic ulcer when mechan-
ical troubles present themselves and when the ulcer is situated at the
pylorus and causes the pyloric syndrome. Delay is useless in such cases
of chronic ulcer, since even if the ulcer heals it will be followed by fibrous
stricture. It is thought that hypersecretion or hyperacidity associated
with pyloric syndrome is an indication for operation. Because of the
high operative mortality, Hartmann does not think that profuse hemat-
emesis requires operation, but surgical treatment is certainly indicated in
small and repeated hemorrhages. Regarding the best operation Hart-
mann states that he performs gastrectomy only in those cases in which
he fears an epithelial grafting ; there were 4 such in his present series of
cases. The indications for pyloroplasty are very limited. Gastroenteros-
tomy is the best operation in nonmalignant disease of the stomach.

In a comprehensive paper read before the American Surgical Associa-
tion Moynihan,^ of Leeds, discusses the surgery of the simple diseases
of the stomach. The subject is divided into four parts: (1) perforation
of gastric or duodenal ulcers; (2) hemorrhage from gastric or duodenal
ulcers; (3) chronic ulcer, its various clinical types; and (4) hourglass
stomach. ''The perforation of the gastric or duodenal ulcer is one of the
»Med. News, March 14, 1903. ^ Boston M. and S Jour., June 4, 1903.

ESOPHAGUS, STOMACH, AND DUODENUM. 67

most serious and most overwhelming catastrophes that can befall a
human being." In addition to acute and chronic perforation, Moynihan
describes a subacute form of perforation in which the ulcer gives way
almost as quickly as in the acvite form, but, owing to its small size, or
to the emptiness of the stomach, or to the instant plugging of the opening,
the escape of fluid from the stomach is small in quantity and the damage
inflicted is considerably less than is inflicted by acute perforation. In the
subacute form he has found that there is always a complaint of great
discomfort for several days preceding the rupture. Chronic perforation
occurs more frequently on the posterior surface of the stomach, and the
perigastric abscess resulting is termed subphrenic. The acute and sub-
acute forms of perforation are more common on the anterior surface.
IVIoynihan admits the possibility of a recovery even after acute or subacute
perforation, but the likelihood of its occurring is so remote as to render
imperative the opening of the abdomen at the earliest possible moment.
"The risk of operation is definite, the hazard of delay is immeasurable."
The adininistration of morphin after a gastric perforation does much to
obscure the symptoms, but attention is called to the fact that although
the patient may be comfortable and complain of little or no pain there
remains a continued hardness and rigidity of the abdominal muscles. In
any uncertain case Moynihan wouid incline to operation rather than to
indefinite postponement to solve the diagnosis. A set of symptoms
closely resembling those of perforation are occasionally presented at the
commencement of a menstrual period. From some unexplained cause a
sharp attack of abdominal pain followed by vomiting, distention, pros-
tration, and collapse may accompany the commencement of menstrua-
tion. It did so in 3 cases with which Moynihan is acquainted, and in
which a negative exploration was performed. The knowledge of these
cases enabled him to avoid a similar mistake in another instance. The
operation for perforation should be conducted speedily and all possible
precautions taken against shock. The excision of the ulcer is unneces-
sary; it should be inverted by two rows of sutures. If the peritoneal
cavity is much soiled, free flushing is necessary; but if the operation is
done within 10 or 12 horn's, gentle wiping of the surrounding area with
wet swabs will suffice. Drainage, as a rule, is unnecessary except in late
cases, but when adopted it should be free, and if necessary a suprapubic
opening should be made. Emphasis is laid upon the fact that perforating
ulcers are often multiple, and therefore after suturing one ulcer others
should be carefully looked for. Double perforation occurs in no less than
20 % of the cases; in the majority the second ulcer is on the posterior
surface at a point exactly opposite the one on the anterior surface. In
duodenal ulcer closure may result in so much constriction of the gut
that gastroenterostomy may be required.

Hemorrhage is discussed under two heads ; that from an acute ulcer,
and that from a chronic ulcer. The characteristics of hemorrhage from
an acute gastric ulcer are spontaneity, abruptness of onset, the rapid loss
of a large quantity of blood, marked tendency to spontaneous cessation,
infrequency of a repetition of the hemon-hage in anything but trivial

68 GENERAL SURGERY.

quantity, and the transience of the resulting anemia. Hemorrhage from
a chronic ulcer is divided into 4 groups as follows: (1) The hemorrhage is
latent or concealed, is always trivial. (2) The hemorrhage is intermit-
tent, but in moderate quantity, occurring spontaneously and with appar-
ent caprice at infrequent intervals. The life of the patient is never in
jeopardy from loss of blood, although anemia is a persisting symptom.
(3) The hemorrhage occurs generally, but not always, after a warning
exacerbation of chronic symptoms. It is rapidly repeated, is always
abundant, its persistence and excess cause grave peril, and will, if un-
checked, be the determining cause of the patient's death. (4) The hemor-
rhage is instant, overwhelming, and lethal. The treatment of hemorrhage
from an acute ulcer in almost every instance should be medical, but there
are a few cases in which the hemorrhage may be both copious and recur-
rent and may threaten the life of the patient, and under such circum-
stances operation is necessary. Moynihan is strong in his statement that
the best operation for the control of hemorrhage is gastroenterostomy,
and he states that it is "futile, harmful, and quite unnecessary" to search
for the bleeding point. It is in the third class of hemorrhage from
chronic ulcer that operation will most frequently be necessary. In this
class the base of the ulcer is, as a rule, densely hard, and the vessel
traversing it is like a rigid pipe. In« these cases bleeding is frequently
arrested by the plugging of the vessel by a thrombus, but recurrent
bleeding is apt to occur. Moynihan believes that the recurrence of the
bleeding is a result of gastric dilation. It is probable, therefore, by pre-
venting this dilation of the stomach, that gastroenterostomy accom-
pHshes the cure. In these cases also a prolonged search for the ulcer
is injudicious. The only case of operation for this condition which
Moynihan has lost was one in which he did not do gastroenterostomy
but only excised the ulcer. In but two instances has he excised the
ulcer; in one instance the jejunum was anastomosed at the site of excision,
and in the second case, the one already referred to, the ulcer was alone
excised and the patient died. In all cases of severe hemorrhage from a
chronic ulcer operation ought to be performed at the earliest possible
moment.

In dealing with chronic ulcer Moynihan states that the induration
which a persisting ulceration may cause is remarkable both in its extent
and for its accurate mimicry of the appearances of malignant disease,
and that he has no doubt that many patients who have died from sup-
posed malignant disease of the stomach have suffered from nothing but
chronic ulceration. Frequently it is difficult to tell a mass of chronic
inflammatory tissue from malignant disease. The perfect smoothness of
the surface over the inflammatory mass as compared with the nodular,
rough, and irregular surface of the malignant mass is of great value.
Moynihan is inclined to believe that Hauser's estimate of the frequency
with which carcinoma develops upon a gastric ulcer (6 %) is too high; in
his own experience he has only seen one case. Dyspepsia of an intract-
able, constantly recurring form is more often a matter of physics than
chemistry. When such cases are operated upon, nearly always there will

ESOPHAGUS, STOMACH, AND DUODENUM. 69

be found some mechanical deviation from the normal. Again, attention
is called to the frequency "with which two ulcers are found. The indica-
tions for operation in chronic ulcer of the stomach are of mdely different
character. When the ulcer is near the pylorus, a dilated stomach will
probably be the chief clinical sign; when the ulcer is in the body, an
hourglass stomach may be caused; when the ulcer is nearer the cardiac
end, gastralgia and dyspepsia may be the only indications. The author
believes that there is no operation in surgery which gives better results
and which gives more complete satisfaction to both the patient and the
surgeon than gastroenterostomy for chronic ulceration of the stomach.
The operation of gastroenterostomy is the one which is used in all cases
of chronic ulcer regardless of its position. That it will reUeve the symp-
toms completely and permanently and will permit of the sound heaUng
of the ulcer, statistics plainly show. Excision is unnecessary, often im-
possible, always insufficient. The operation of pyloroplasty is not recom-
mended. The operation which is recommended is posterior gastroenter-
ostomy made by simple suture, the gastric and intestinal contents being
controlled by Doyen forceps. The time required for this operation is
usually about 30 minutes, although Moynihan has performed it in 17.
The various steps of the operation are minutely described, and closely
resemble those already detailed by Barker. Moynihan uses for his suture
material Pagenstecher thread. He does not suture the mesocolon to the
stomach. When the patient is returned to bed, his shoulders and head
are supported by 3 or 4 pillows. Nutrient enemas are given every 4
hours and the bowel washed out every morning with a pint of hot water.
No fluid is given by the mouth for 12 hours, or until the ether sickness
is over, and then in very small quantities frequently repeated. At the
end of 48 hours milk, puddings, soups, and so on are given.

In discussing hourglass stomach the surgeon is reminded of the
possibility of the stomach being divided into 3 instead of 2 pouches. In
one instance Moynihan found an hourglass duodenum as well as an hour-
glass stomach. Although acknowledging that there is no inherent im-
probability in the existence of congenital hourglass stomach, it is stated
that the condition lacks proof. The condition may be produced by : (1)
perigastric adhesions; (2) ulcer, with local perforation and anchoring to
the anterior abdominal wall; (3) chronic ulcer generally at or near the
middle of the organ ; (4) malignant disease. All of the symptoms of hour-
glass stomach are carefully described, but the two most to be depended ,
upon are gastric lavage and the distention with gas by administering a
Seidlitz powder in two portions. When the stomach is washed out with ■
a known quantity of water, the loss of a certain quantity will be observed
when the return fluid is measured. Again, if the stomach be washed out
until the fluid returns clear, a strong rush of foul and evil-smelling fluid
may occur; or if after washing the stomach clean the tube is withdrawn
and passed again in a few minutes, several ounces of dirty, offensive fluid
may emerge. When the cardiac portion is small, the symptoms may
closely resemble those of obstruction of the lower portion of the esopha-
gus. A correct diagnosis can be made by introducing the esophageal

70 GENERAL SURGERY.

bougie; if the bougie passes over 16 inches from the teeth the obstruction
probably Hes in the stomach. Regarding the treatment of this condition
the surgeon must be very careful when the abdomen is opened to examine
all parts of the stomach up to the cardiac orifice. In many cases of
hourglass stomach no single operation will suffice to relieve the symptoms.
This is due to the fact that when a stricture is present in the body of
the stomach, a second one near the pylorus may also be found. The
follo\^ing operations may be performed for hourglass stomach, and the
choice will necessarily depend upon the condition which is found: (1)
gastroplasty; (2) gastrogastrostomy or gastroanastomosis ; (3) either of
the foregoing, with gastroenterostomy from the pyloric pouch, in cases of
dual stenosis; (4) gastroenterostomy from cardiac pouch, when the pyloric
pouch is so small that it can be ignored ; (5) gastroenterostomy from both
pouches; and (6) partial gastrectomy. These remarks of Moynihan are
based upon the following operations: Perforating gastric or duodenal
ulcer, 12 cases, 6 recoveries; gastroenterostomy for chronic ulcer, etc, 70
cases, 1 death; pyloroplasty, 3 cases, 0 deaths; hourglass stomach, 15
cases, 3 deaths; gastroplication, 1 case, recovered; excision of ulcer for
hematemesis, 1 case, died.

Kellock* presents a very interesting report of a case of excision of a
chronic gastric ulcer in a woman 36 years of age. The ulcer was
situated in the posterior wall of the stomach near the cardiac extremity
of the lesser curvature. The case is interesting in that it showed an
elongated band attaching the site of the ulcer to the lesser omentum.
The band was divided and the ulcer, with an indurated portion of the
stomach- wall, excised. The wound was closed with 3 layers of sutures,
one in the mucous membrane, one in the muscular wall, and a third
in the serous coat. The patient was fed by the rectum for 7 days, and
made an uneventful recovery. The final outcome of the case w^as most
satisfactory. It is thought that the band had been produced from an
adhesion, the result of a former attempt of the ulcer to perforate.

Moullin^ strongly advocates operative treatment in cases of chronic
ulceration of the stomach. When an ulcer once becomes chronic, a
cure, in the full sense of the word, is seldom attained by medical treat-
ment. The longer the ulcer remains unhealed, the less likely becomes
the chance of healing and the greater becomes the liability to complica-
tions. The operation, when performed before complications have set in,
should present no higher mortality than interval operations for appendic-
itis. The conditions which prevent the healing of a chronic ulcer are
entirely local. Moullin has operated upon 5 uncomplicated cases, 3 by
excision, and 2 by ligature of the whole thickness of the stomach, and
repair was rapid and complete in each. Persistent irritation of the surface
of the sore and the dense, almost cartilaginous, infiltration of the base
and edges prevent a chronic ulcer from healing. Some of the conse-
quences of chronic ulcer of the stomach are perforation, subphrenic and
perigastric adhesions, hourglass contraction of the stomach, pyloric
stenosis, and hemorrhaige. All of these complications can be prevented

1 Lancet, July 12, 1902. ' Lancet, Dec. 27, 1902.

ESOPHAGUS, STOMACH, AND DUODENUM. 71

by a timely operation. The ulcer may be excised or ligated, according
to its depth and extent. Difficulty in operating occurs only when the
ulceration has reached such a size or depth or has caused such dense
adhesions that simple excision or ligature is not longer practicable.

Moullin^ presents the question of gastrotomy for recent gastric
ulcer, and reports 3 late cases. In addition to these cases, Moidlin
published in the Lancet^ 3 other cases, in which he operated for hematem-
esis, and all of which recovered. Of the present cases, 2 patients were
operated upon for hematemesis, one of whom recovered, and the other,
who was very much exhausted at the time of operation, died. Three of
these 5 patients had lost so much blood that transfusion was necessary
at the time of operation. Attention is called to the mistake of comparing
the mortality-rate of all cases of hematemesis which are not operated
upon with that of those severe cases in which operation is performed.
In the first class are included a large number of slight cases in which
no surgical treatment would be thought of. The only way to compare
the results of the two treatments is to take those cases in which surgical
treatment is recommended and declined, and compare the mortality of
those with that of those in which the operation is accepted. A study of
246 cases of hematemesis from gastric ulcer occurring in the London
Hospital in the 5 years from 1895 to 1899 inclusive, shows that the
condition is much more apt to be fatal in patients over 30 years of age.
In women under 30 hematemesis rarely requires surgical treatment. The
author considers operation indicated when there is a single severe hemor-
rhage occurring in a case of gastric ulcer; when there is a second separate
attack of severe hematemesis after a short interval; and when there are
frequent small hemorrhages which render the patient sore and more
anemic. Any case of gastric ulcer in which medical treatment is accom-
plishing nothing, in which vomiting obstinately persists, and in which
the patient is losing ground, should also be submitted to operation.

An interesting case of chronic ulceration of the stomach compli-
cated by a hair-ball was reported by Mallins.^ The patient was a
woman aged 22. She had suffered from attacks of nausea and pain for
2 years. Shortly before admission to the hospital she vomited a quantity
of blood. She was extremely emaciated and anemic. On admission the
chief complaint was of pain in the left side just below the ribs. A large
tumor of somewhat rounded outline was easily felt. It extended from the
tip of the ensiform to the transverse line, running 2 inches below the
umbilicus. The tumor was firm on pressure and quite free from tender-
ness, with the exception of one point. It could be easily moved about.
No pain was complained of except after taking food. It was thought
that the tumor was either a retroperitoneal sarcoma, a pancreatic cyst,
or was made up of enlarged tuberculous glands. Because of the ex-
tremely feeble state of the patient's circulation operation was considered
to be contraindicated. At the necropsy the mass proved to be in the
stomach and to consist of a black hair-ball weighing 1 pound and 9

' Lancet, July 5, 1902. ^ Lancet, Oct. 10, 1900.

' Lancet, June 6, 1903.

72 GENERAL SURGERY.

ounces, reaching from the cardiac end through the dilated pylorus into
the duodenum. It completely filled the stomach cavity. Several large
chronic ulcers were found in the stomach wall, one measuring 3^ by 2
inches. A smaller ulcer had perforated the gastric wall and its floor was
formed by the adherent pancreas. Several healed ulcers were also found.
The case teaches that in tumors of the gastric region the possibility of
hair-ball distention should not be overlooked, and that in all cases when
the patient's strength is equal to it an exploratory operation should be
made.

E. Cautley and Clinton Dent^ discuss interestingly the subject of
congenital hypertrophic stenosis of the pylorus and urge the operation
of pyloroplasty as the most beneficial for this condition. Two cases are
reported in which Dent performed this operation with satisfactory results.
The authors have been able to collect reports of over 50 cases, and in
19 of these operation was performed. Infants affected with this condi-
tion, if untreated, die in about 3 or 4 months. The symptoms in the
two cases operated upon were quite typical, and consisted in persistent
vomiting, dilation of the stomach with visible peristalsis, and constipation.
The symptoms developed when the children were but a few weeks old.
Persistent vomiting and constipation are not sufficient to make a diag-
nosis, but when these are accompanied by dilation of the stomach and
visible peristalsis, and are themselves persistent, a diagnosis of hyper-
trophic stenosis of the pylorus should be seriously considered. The first
case operated upon by Dent made an excellent recovery; the second
showed great improvement, but died several months later from zymotic
enteritis. Of the 19 reported cases of operation for this condition pylorec-
tomy was performed once; gastroenterostomy 9 times; dilation of the
pylorus 6 times, and pyloroplasty 3 times. Gastroenterostomy has been
the favorite operation, though the authors maintain that pyloroplasty is
much to be preferred, and also state that dilation of the pylorus is prefer-
able to gastroenterostomy. Pyloroplasty permits the removal of the
longitudinal fold of mucous membrane which is so often found in these
cases. Pyloroplasty is simpler and can be more quicldy performed than
gastroenterostomy.

Robert Jones^ reports 4 cases in which he operated for perforating
gastric ulcer, 3 of which terminated in recovery. The first patient, who
had quite a typical case, was operated upon 3 hours after the onset of
acute symptoms. The ulcer was situated on the anterior surface of the
stomach and was easily inverted. The abdominal cavity was irrigated
and closed without drainage. The patient made a perfectly satisfactory
recovery. The second case was a very difficult one, due to adhesions
between the stomach and the abdominal wall and the liver. The per-
foration would admit a small finger. There was so much infiammation
around the ulcer that it was closed with great difficulty. The general
cavity was shut off by adhesions, and therefore only the field of operation
was irrigated and drained. On the fourteenth day after operation the
patient developed a cough and expectorated a quantity of foul-smelling

1 Lancet, Dec. 20, 1902. » Brit. Med. Jour., Nov. 29, 1902.

ESOPHAGUS, STOMACH, AND DUODENUM. 73

pus. A few hours later, the patient's condition having become worse,
she was anesthetized and the former seat of operation explored, but
there was no collection of pus. Only clear fluid could be drawn from
the thorax. In the left hypochondrium pus was found and evacuated by
a free incision. The patient died soon after the second operation. At
the necropsy it was fornid that the left lung was firmly fixed to the
diaphragm and a small hole was seen entering the lung tissue, perforating
the diaphragm and discharging foul-smelling pus. The third and fourth
patients were operated upon one 14 and the other 9 hours after per-
foration, and both recovered.

Three cases of perforated gastric ulcer are reported by Althorp.^
In the first and second cases the perforations were in hourglass stomachs.
In the first case, owing to the position of the perforation, and adhesions
which had formed, it was impossible to close the opening with sutures.
As the general peritoneal cavity was shut off by adhesions, it was deter-
mined to drain the inflamed area with gauze packing. The patient did
well until the tenth day, when she began to cough and expectorated a
quantity of offensive pus. Consolidation occurred at the base of the left
lung, and an exploring needle introduced into this area reached pus.
The patient died, and at the necropsy an opening in the diaphragm was
found opposite the opening in the stomach, and at this point the lung
was adherent and near the base was a small abscess. [This case closely
resembles in every respect the one reported by Jones.] The second case
recovered after operation, although she developed subsequently an
abscess in the left flank, probably the result of ineffectual washing of
the left kidney pouch at the time of the operation. No drainage was
employed in this case. In the third case the perforation was in the
posterior wall of the stomach. The pelvis and right kidney pouch were
full of turbid stomach-contents, and after thorough irrigation the pelvic
cavity was drained through a suprapubic opening. The operation in this
case was performed 8 hours after perforation and the patient recovered.
The first case reported, the fatal one, was operated upon 32 hours after
perforation.

Perforating gastric and duodenal ulcers are dealt with at consider-
able length by A. A. Berg,^ who reports 4 cases with operation, 2 of
which terminated in recovery. In perforating posterior ulcers of the
duodenum it is recommended that the retroduodenal, retrocolic, and
perinephric spaces should be drained through a lumbar incision and
the orifice of the ruptured ulcer tamponed with gauze. The abdomen
should then be opened, gastrojejunostomy be performed, and the pylorus
constricted with a purse-string suture. This method will exclude the
duodenum from the intestinal circuit and cause the ulcer to close. It is
believed that this procedure is better than jejunostomy. The author has
not performed the operation.

Bailey^ reports 3 cases of perforating gastric ulcer presenting
atypic symptoms. These patients were in the West London Hospital

' Lancet, May 30, 1903. ^ Med. Rec, June 6, 1903.

» Lancet, April 18, 1903.
6S

74 GENERAL SURGERY.

under the care of a number of different men. A remarkable feature of
the first case was that although a gastric ulcer had been diagnosed prior
to perforation, when the latter event took place the patient became
markedly collapsed but suffered absolutely no pain in the abdomen. An
enema given at this time was returned with a large melenic movement;
there was no vomiting, no rigidity, and no pain. It was supposed that
the collapse was due to hemorrhage from a duodenal ulcer. No operation
was performed. At the necropsy a perforation the size of a half-crown
was found on the posterior wall of the stomach and the lesser peritoneal
cavity was filled with blood. The foramen of Winslow was occluded and
therefore there was no blood or gas in the general peritoneal cavity. The
patient died 12 hours after the onset of acute symptoms. The second
case reported is interesting as showing (1) that in a condition of acute
septic peritonitis there may be practically a normal pulse and temperature,
and also that vomiting and abdominal tenderness are not necessary
symptoms of this condition ; (2) that collapse does not always accompany
perforation, for perforation in all probability must have occurred 9 days
before death and immediately before the physician met the patient run-
ning to consult him; and (3) that a peptic ulcer on the point of per-
forating caused no digestive or abdominal symptoms whatever. With
regard to the third case, here also collapse did not follow perforation,
for the temperature half an hour after perforation had risen to 100.2°.
The change in the aspect of the patient was the most valuable indication
of perforation. The presence of melena without hematemesis or vomiting
was evidently due to the hemorrhage occurring on the pyloric side of
the constriction produced by the ulcer. In none of the 3 cases was there
obliteration of the liver dulness.

A case of recovery after operation for perforating gastric ulcer
is reported by Fraser.^ An interesting point in this case is the fact
that the patient had two sisters suffering from gastric ulcer and a third
who had died from what was apparently the same condition. The patient
was operated upon 6 hours after the perforation.

Five cases of perforated gastric ulcer treated by operation are
reported by George Heaton,^ who presents a brief discussion of the
subject. The first case was one of chronic perforation with the formation
of a perigastric abscess. The abscess cavity was freely opened and
drained and the patient recovered. The second case was one of per-
foration of an old gastric ulcer on the anterior surface of the stomach.
The abdom^ was opened 37 hours after the onset of symptoms and the
ulcer closed. The patient died on the twentieth day from right-sided
empyema and liver abscess. The third case was one of perforation of a
gastric ulcer followed by subsidence of symptoms for 3 weeks, which in
turn was followed by a sudden onset of acute general peritonitis. The
abdomen was opened and an abscess found between the liver and stomach.
A small perforation was seen on the anterior surface of the stomach,
apparently closed by recent adhesions, which fixed the organ to the
costal arch on the left side. This was closed and the abscess cavity

» Brit. Med. Jour., Feb. 21, 1903. ^ Brit. Med. Jour., July 12, 1902.

ESOPHAGUS, STOMACH, AND DUODENUM. 75

was wiped out and drained. The peritonitis rapidly extended after
operation and the patient died 4 days later. Heaton states that he was
probably in error in this case in not operating when the first perforation
took place, but when he saw the patient all signs of collapse had disap-
peared and she appeared to be so well and so free from pain that he
doubted if it was justifiable to even explore to see if a perforation had
actually occurred. The fourth case was quite a typical one occurring in
a young girl. The operation was 'performed 27 hours after the perfora-
tion. The perforation occurred on the anterior surface close to the
pylorus. Irrigation was not employed in this case, but the cavity was
sponged dry and drained. The patient recovered. The fifth case was a
typical one so far as symptoms went, and operation was performed 4^
hours after their onset. The perforation was on the anterior surface of
the stomach; irrigation was not employed, but the abdomen was care-
fully cleansed with sponges and the left hypochondrium drained. The
patient died on the fifth day after operation from general peritonitis.
Heaton has collected all the cases operated upon for perforated gastric
ulcer in several large London and provincial hospitals during the last 5
years, including only those where upon operation an actual perforation
was seen and sutured. Forty cases have thus been collected with 14
recoveries and 26 deaths.

C. F. Barber^ reports an interesting case of multiple ulcers of the
stomach in a boy of 10 years. The patient died from perforation without
operation, Barber seeing him but 2 hours before death took place. At
the autopsy 4 ulcerated patches were found, 2 of which had perforated.
The symptoms of perforation were very obscure and were much aggra-
vated by the administration of a purgative by the boy's mother.

In reporting a number of operations for gastric ulcer, acute and
chronic, Rushton Parker^ reports 5 cases of perforation with 4 recoveries.
In one of these cases perforation took place at the point of constriction
in an hourglass stomach. He also reports 4 cases of operation for chronic
perforation, 2 of which ended in recovery and 2 of which were fatal.

F. Gregory Connell^ deals extensively with gastrointestinal perfora-
tions and their diagnosis, devoting considerable space to the history
and to the quotation of authorities. His conclusions are as follows : " (1)
The previous attempts at an early and accurate diagnosis of perforation
of the gastrointestinal tract without opening the abdominal wall have not
been adopted. (2) There has been practically no improvement in the
method of diagnosing such conditions during the past century. (3) The
treatment of the perforation per se during the last century has progressed
to a state bordering on perfection when compared with the older methods.
(4) The diagnosis of gastrointestinal perforations is one of the most
important unsolved questions in the domain of abdominal surgery. (5)
There is no pathognomonic sign or symptom or group of signs or symp-
toms of perforation. (6) The only positive method of arriving at a
diagnosis to-day is to either perform an exploratory laparotomy or await

» Brooklyn Med. Jour., Dec, 1902. * Brit. Med. Jour., Nov. 29, 1902.

'Jour. Am. Med. Assoc, March 28, 1903.

76 GENERAL SURGERY.

the development of a peritonitis. (7) To await the development of a
peritonitis will reveal the diagnosis too late for the most effectual treat-
ment. (8) Exploratory laparotomy as a routine measure will of necessity
result in some cases being needlessly exposed to the many dangers of a
major operation. (9) Exploratory laparotomy is not a harmless pro-
cedure. (10) The consensus of opinion is in favor of exploratory lapar-
otomy as a choice between two evils. (11) The fact that even the most
expert clinicians fail to diagnose perforation in all cases and even diagnose
such a condition when it does not exist shows the great need of improve-
ment in diagnostic methods. (12) The diagnosis should be arrived at
before the treatment of the perforation is complicated by the presence of
a peritonitis. (13) The injection of air or normal salt solution into the
peritoneal cavity and withdrawal of the same for examination will do no
harm. (14) Such a procedure will, in many instances, reveal a perfora-
tion before any sign or symptom of peritonitis exists. (15) The treat-
ment of the perforation per se is simple and satisfactory. (16) The
treatment of the complicating peritonitis is multiple and unsatisfactory.
The best treatment is prophylactic, i. e., early diagnosis and repair of
perforation before peritonitis has become established."

John B. Murphy and J. M. Neff^ present an exhaustive study on
perforating ulcers of the duodenum. Weir, in a paper read before the
American Surgical Association in 1900, reported all the cases of perfora-
tive duodenal ulcer up to that date, and the authors have collected from
the literature of the subject between May, 1900, and July 1, 1902, 19
cases, including one operated upon by Murph3^ A careful study of these
cases causes the authors to reach the following conclusions: "The diag-
nosis of perforating duodenal ulcer is difficult, or, better, practically
impossible without an exploratory laparotomy. In many cases there is
no evidence of duodenal disease previous to the perforation. The most
important physical sign, in addition to those of perforative peritonitis
from perforations in other portions of the intestinal tract, is the flatness
of the superficial, piano, percussion-note. The leukocytosis in our case,
the only one in which it was given, was pronounced, showing an inflamma-
tory condition in contradistinction to the absence of it in intestinal
obstruction and fat necrosis of the pancreas. It must be borne in mind,
however, that leukocytosis is not a necessary manifestation of perforation
or of inflammation. It is a manifestation of the reaction of blood to
infections. It is often entirely absent in typhoid perforations, as we
have observed in repeated blood examinations after perforation during the
present epidemic in Chicago. Collapse is absent in duodenal perforations,
except where associated with severe hemorrhage. Collapse in intestinal
perforation is the manifestation of the absorption of the products of
infection, and not a manifestation of the perforation per se. Collapse is
always secondary to abrasion or denudation of the endothelial covering
of the peritoneum, which abrasion permits of rapid absorption. In all
cases of perforative peritonitis, to which duodenal perforations are no
exception, an operation should be performed at the earliest possible
1 N. Y. Med. Jour., Sept. 20 and 27, 1902.

ESOPHAGUS, STOMACH, AND DUODENUM. 77

moment after perforation has taken place ; and clinical experience shows
that the mortality is in direct proportion to the length of time that
elapses between the occurrence of perforation and the operation. In
perforation, the longer the escaping material is in contact with the
peritoneum, the greater the danger of destruction of its endothelial
covering, and thus the greater the danger of absorption. Of 13 cases
operated on 30 hours after perforation, all terminated fatally; while in 12
cases where less than 30 hours had elapsed, 66f % recovered (Weir).
These comparisons emphasize more than words can the importance of
early operation. The operation must be complete; that is, it must be
pursued to an effective suture of the perforation. Drainage is insufficient,
as 18 patients treated by drainage alone all died (Laspeyres). Suture of
the opening can be easily accomplished, as in 98 % of the perforating
ulcers the opening was in the first portion of the duodenum, its most
accessible portion. Where duodenal perforation is suspected, the in-
cision should be through the right rectus muscle. It can then be carried
upward to the costal arch or do\\Tiward to the symphysis pubis without
dividing any of the transverse muscles. The incision through the rectus
muscle is the one which we commonly make in operating for appendicitis.
It can be enlarged upward or doAvnward without interfering with the
muscle. Drainage or no drainage is a matter of personal election, influ-
enced more or less by the pathologic condition present at the time of
the operation. The after-treatment is that commonly followed after
abdominal section, except that the patient is kept elevated in bed at
an angle of 35 degrees for the first 48 hours after the operation. The
prognosis depends: First, on the virulence of the peritonitis produced;
second, on the time the material has been allowed to remain in the
peritoneum; third, upon the presence or absence of blistering or abrasion
of the peritoneum at the time of operation."

D'Arcy Power^ reports 4 instructive cases of acute perforation of a
duodenal ulcer. The first case is that of a strong man 41 years of age,
and is particularly interesting because the localized peritonitis must have
lasted a much longer time than the sudden onset of the symptoms seems
to indicate, and also because the symptoms were so obscure as to make
it seem even to competent observers that the patient was suffering from
pneumonia rather than acute peritonitis. Power operated upon the
patient as soon as he saw him and found a perforation upon the posterior
wall of the first portion of the duodenum. Because of its position it
was very difficult to close the ulcer with sutures. Death occurred a few
hours after operation. The second case was that of a fat, healthy-
looking cabman, 47 years of age. He was seized with sudden and severe
pain in the abdomen while eating his breakfast. He gave no history of
previous attacks of indigestion. Perforation in this case was also in the
first portion of the duodenum, behind. The abdominal cavity was
sponged out and completely closed. The patient died 8 days after
operation, and at the necropsy a pint of foul pus was found in the perito-
toneal cavity situated above the stomach and the first part of the duo-
1 Brit. Med. Jour., Jan. 10, 1903.

78 GENERAL SURGERY.

denum. [This case teaches us that although a patient may be doing well
rapidity of pulse should cause suspicion, and also that drainage of the
abdominal cavity should always be employed.] The third case was that
of a clerk 37 years of age, who gave a history of frequent attacks of
stomach-ache about half an hour after taking food. On the day of
admission he was suddenly seized with severe pain in the abdomen in
the neighborhood of the umbilicus. The abdomen in this case, after the
closure of the perforation, was drained by rubber tubes. The patient
died about 20 hours after operation. In the fourth case, that of a well-
nourished man 26 years of age, there was a history of previous attacks
of stomach-ache. The present illness began with severe abdominal pain
and nausea. The symptoms in this case were referred to the right iliac
region particularly. The patient was thought to be suffering from an
attack of acute appendicitis. The abdomen was consequently opened
in this region. As the appendix and intestine in the neighborhood were
found normal, a second incision was made in the middle line and a per-
foration found in the anterior surface of the first part of the duodenum.
In this case the peritoneal cavity was drained by large tubes passed
into the space below the liver, into the rectovesical pouch, and into both
flanks. This patient was fed by the rectum for 10 days and recovered.
A consideration of these cases causes Power to reach the following con-
clusions: " (1) Duodenal ulcers occur more often in men than in women.
(2) The extravasated fluid trickles into the iliac fossas, and causes local
peritonitis which may be mistaken for acute appendicitis. (3) The trans-
parent or bile-stained succus entericus found in the peritoneal cavity is
diagnostic of a perforated duodenal ulcer. It is quite different from the
gastric contents escaping at a perforated ulcer of the stomach. (4) The
prognosis of a duodenal ulcer is worse than that of a perforated gastric
ulcer on account of the greater difficulty in closing it satisfactorily. (5)
The prognosis should not be too sanguine until after the lapse of the
eighth day, and it is always bad, however well the patient may appear,
if the pulse-rate continues rapid. The pulse is a much better guide than
the temperature. (6) Free drainage is imperative, both iliac fossas, the
rectovesical pouch, and the space below the liver more particularly need
tubes. It is better that the patient should recover with a scarred belly
than that he should die with an abdomen full of pus. (7) The feeding of
the patient is a matter of great importance. SmaU quantities of food
should be given frequently, and if the patient feels sick the amount must
be reduced at once. It is better to give nutrient enemas for some days
after the operation than to administer food by the mouth." [Gibbon
operated recently upon a young man suffering from an acute peritonitis
supposed to be due to appendicitis. When the abdomen was opened, the
pelvis was filled with a flocculent fluid and the appendix and small
intestine in its neighborhood were much inflamed. The appendix was
removed, but seeing that it could not be the cause of so extensive a
peritonitis, a further search was carried out and a perforated duodenal
ulcer found. It was closed with difficulty, the abdominal cavity thor-
oughly irrigated and extensively drained. Although the patient's con-
dition on the table was very bad, he recovered.]

ESOPHAGUS, STOMACH, AND DUODENUM. 79

Angus^ reports a case of ruptured duodenal ulcer in a man 41
years of age, who for 10 days had had pain in the stomach after drinking
bouts. The patient was a large, powerful-looking man who was ad-
mitted in a state of collapse, from which he somewhat rallied after stimu-
lation. He complained of great pain over the epigastrium and the
abdomen was tense and somewhat distended. The breathing was tho-
racic. The diagnosis of ruptured gastric ulcer was made and operation
immediately performed. A perforated ulcer was found in the anterior
surface of the first part of the duodenum. A gauze drain was placed
over the seat of ulcer and a Keith's tube placed in the pelvis. The patient
recovered.

The question of uremic ulceration of the duodenum is briefly dis-
cussed editorially in the Lancet.^ The subject of the editorial is a case
reported by Barie and Delaunay. For 2 months the patient had suffered
from breathlessness and at times had had attacks of severe dyspnea.
Digestion was painful and he often vomited food. The urine contained
albumin and the legs were edematous. About a month after his admis-
sion to the hospital diarrhea began, and later there was an abundant
entorrhagia, the mattress being soaked with blood. The next day the
patient became comatose and died. In addition to the pathologic lesions
of the kidneys there were found several ulcers of the duodenum, one
2 cm. from the pylorus, another a little further down, and opposite the
ampulla of Vater were two smaller ulcers. Uremic ulceration of the
duodenum generally takes the form of a single ulcer in the first part of
the bowel. The remaining part of the alimentary canal, however, may be
influenced or may present similar ulcerations. Sometimes the whole duo-
denum is inflamed. Duodenal ulcers occur in the most diverse renal
diseases, acute and chronic parenchymatous nephritis, interstitial neph-
ritis, renal tuberculosis, etc. The most reasonable explanation of the
duodenal ulceration in these cases seems to be that defective renal secre-
tion leads to vicarious excretion by the alimentary canal; hence, the
stomatitis, dyspepsia, gastralgia, vomiting, and diarrhea of uremia. It is
difficult to explain why the duodenum alone should be affected. Stas-
sano, however, has attempted to show that the duodenum plays a special
part in the excretion of poisons.

William S. Bainbridge^ discusses the subject of duodenal abscess
secondary to ulcer of the duodenum, reporting in full a case of his
own, and briefly 8 others which he has collected from literature. The
case reported by Bainbridge is that of a man 54 years of age. This
patient suffered from an attack that was diagnosed as acute gastritis
about a month before Bainbridge saw him. The attack came on sud-
denly, was accompanied by intense abdominal pain, and followed imme-
diately upon the ingestion of a glass of ginger ale. Under medical treat-
ment the symptoms subsided, and on the sixth day the patient was able
to walk about. On this day he ate 3 oranges. A few hours later vomiting
began, but the patient suffered none of the severe pain of the first attack.

» Brit. Med. Jour., Jan. 17, 1903. ^ Lancet, Feb. 14, 1903.

5 Med. News, March 7, 1903.

GENERAL SURGERY,

The stomach was given a rest of 2 weeks, rectal feeding being employed.
After this time light feeding was gradually resumed. When Bainbridge
saw the patient, he was in great emaciation, he seemed cachectic, and the
skin and conjunctiva were slightly icteric. There was some tenderness
and slight resistance in the region of the pylorus and of the hepatic
flexure of the colon. The diagnosis of abscess due to a perforated duo-
denal ulcer or of pyloric cancer was made. The patient was in no con-
dition for operation at this time, and an attempt to improve his condition
failed. Autopsy confirmed the diagnosis of abscess due to perforated
duodenal ulcer,

Henry D. Beyea^ describes an original method for elevation of the
stomach in gastroptosis by plication of the gastrohepatic and gastro-

Fig. 17. — Beyea's operation for gastroptosis. 1, Position of one suture of first row; 2, one suture
of second row ; 3, one suture of third row. Others of each row introduced at intervals to and including
the gastrophrenic ligament (Phila. Med. Jour., Feb. 7, 1903).

phrenic ligaments. Beyea first performed this operation on April 19,
1898, and has employed it in 4 cases. All of these patients, who had
been great sufferers prior to the operation, were wonderfully benefited by
it. The operation consists in a plication of the lesser omentum by
applying 3 rows of sutures across it, as shown in the accompanying
illustration (Fig. 17). The other operations which have been devised
for the cure of gastroptosis are briefly described. The operation of Bier
is much like that of Beyea ; so much so, in fact, that Beyea in discussing
his results combines with his cases 4 others operated upon by Bier. The
operations of Duret and Rovsing consist in fixing the stomach to the
abdominal wall. The advantage of the Beyea operation is that the
1 Phila. Med. Jour., Feb. 7, 1903.

ESOPHAGUS, STOMACH, AND DUODENUM.

mobility of the stomach is not interfered with, as the viscus is brought
to its normal position by shortening its normal ligaments. The only
difference between the Beyea and Bier operation is that in the latter
the pyloric end of the stomach is attached to the capsule of the liver.
In all of the cases operated upon by Beyea the s^miptoms were marked
and the patients had been great sufferers for a number of years. In
two a right nephropexy had been done, but without relief. All of the
patients were emaciated, but rapidly gained flesh after the operation.
The improvement in health in every case has been remarkable and the
relief of symptoms complete. The patients operated upon all presented
gastroptosis without relaxation of the abdominal walls or diastasis of the
recti muscles. Experience alone will teach what influence the operation
will have when the relaxation of the abdominal walls is active in the
production of the gastroptosis.

Fig. 18. — Finney's method of pyloroplasty.
Tlie retractor sutures (Bull. Johns Hopkins
Hosp., July, 1902).

Fig. 19. — Finney's method of pyloroplasty.
Suture of greater curvature of stomach to duo-
denum (Bull. Johns Hopkins Hosp., July, 1902).

A new operation for gastroptosis is described by Coffey,^ who has
put it to the test in 2 cases, which are minutely described. The operation
consists in attaching the omentum, as it comes off from the greater
curvature of the stomach, to the abdominal wall. The sutures are intro-
duced about 1 inch from the stomach and in such a manner as to avoid
the large blood-vessels. In one of the cases operated upon the lesser
curvature of the stomach was almost 2 inches below the umbilicus. The
omentum was stitched to the abdominal peritoneum about 1 inch above
the umbilicus by means of chromicized catgut sutures. The patient in
this instance had suffered a great deal prior to operation ; since operation
she has had practically no disturbance of digestion, is able to do her
own work, and is apparently perfectly well. The result in the second
case was quite as satisfactory, the same method being employed. In

> Phila. Med. Jour., Oct. 11, 1902.

GENERAL SURGERY.

extreme cases when the transverse colon is also very low, it is recom-
mended that the omentum be sutured to the parietal peritoneum, both
above and below the colon. Dilation of the stomach, which is almost
always associated with gastroptosis, is also relieved by the operation in
the majority of cases.

Fig. 20. — Finney's method of pyloroplasty.
Shows tlie three retractor sutures, the posterior
line of sutures tied and the anterior line of su-
tures untied (Bull. Johns Hopkins Hosp., July,
1902).

Fig. 21. — Finney's method of pyloroplasty.
The anterior sutures gathered and lifted (Bull.
Johns Hopkins Hosp., July, 1902).

Fig. 22.— Finney's method of pyloroplasty.
The continuous posterior catgut sutures (Bull.
Johns Hopkins Hosp., July, 1902).

Fig. 23. — Finney's method of pyloroplasty
completed by tying the anterior sutures (Bull.
Johns Hopkins Hosp., July, 1902).

A new method of pyloroplasty is described by Finney, ^ who in pre-
senting it first discusses the history of pyloroplasty and describes and
compares the former methods of doing this operation. Finney has done
this new operation upon 5 patients with most satisfactory results, all the
patients recovering and being relieved of symptoms. The operation can
readily be understood by consulting the accompanying excellent illustra-
'Bull. Johns Hopkins Hosp., July, 1902.

ESOPHAGUS, STOMACH, AND DUODENUM. 83

tions (Figs. 18 to 23). [This operation of Finney's has much to com-
mend it, and we beheve it will be extensively practised.]

A. H. Buck* reports a case of postoperative hematemesis occurring
in a woman 53 years of age from whom he had removed both ovaries
and the uterus. The vomiting occurred 4 hours after operation. The
temperature fell to subnormal but the pulse was not affected. The quan-
tity vomited on each occasion was large. A lead and opium pill was
administered and on the next day, as the vomiting continued, 4 doses of
liquor chlorid of adrenalin were administered hourly, the first two doses
consisting of 30 minims each and the last two of 10 minims each. The
patient recovered. This case would seem to corroborate the view ex-
pressed by Robson and Moynihan that postoperative hematemesis is due
to reflex nervous action. It is also thought that the blood coagulability
was below par in this case, as the patient had suffered from urticaria
all her life. The blood condition greatly improved under treatment with
calcium chlorid.

A case of operation for acute hematemesis is detailed by A. H.
Buck.^ The patient was in extremis as a result of repeated profuse
hemorrhages. As no ulcer could be felt from the outside, the stomach
was opened and an ulcer was found at the cardiac end of the posterior
wall. It was brought into view with difhculty and was thought to be
acute, as there was no thickening around the edges. The ulcer was
excised and the aperture was closed by a purse-string suture on the
peritoneal aspect and by another purse-string suture of the mucous mem-
brane. The patient developed parotitis after the operation, but except
for this made an uninterrupted recovery.

Henry M. Joy^ discusses gastrorrhagia and reports 2 cases on which
he has operated. In each of these cas^s the hemorrhage came from a
number of eroded areas in the mucous membrane. The stomach was
opened in each case and the bleeding points were controlled by purse-
string sutures. The first patient recovered, but the second died from
continued hemorrhage. In the second case 13 points of bleeding were
ligated. A second operation was performed in this case and 6 or 8 more
bleeding points were ligated. In neither case was there any condition
which might produce a mechanical congestion of the stomach. In neither
ease were there any symptoms indicative of ulcer prior to the hemorrhage.

Mayo Robson^ deUvered an address on the importance of an early
diagnosis of cancer of the stomach with a view to radical treatment.
He calls attention first of all to the great improvements recently ob-
tained by early operation in cases of gastric cancer. He states that no
one has done more than Osier in advocating the early diagnosis of cancer
in order that an early operation may be performed at a time when there
is hope of cure. The three most important symptoms are pain, vomiting,
and tumor. The latter, however, is not an early symptom. One should
not wait for its development before making a diagnosis. The author
relates many cases to fortify his conclusions which go to prove: ''(1) How

' Lancet, Aug. 23, 1902. ' Lancet, April 4, 1903.

» Med. News, Aug. 16, 1902. * Brit. Med. Jour., April 2.5, 1903.

84 GENERAL SURGERY.

desirable it is to make an early diagnosis of cancer of the stomach in
order that a radical operation may be performed at the earliest possible
moment. (2) That it may be needful to perform an exploratory opera-
tion in order to complete or confirm the diagnosis. (3) That such an
exploration may be done with little or no risk in the early stages of the
disease. (4) That even where the disease is more advanced and a tumor
perceptible, an exploratory operation is as a rule still advisable in order
to carry out radical or palliative treatment. (5) That where the disease
is too extensive for any radical operation to be done the palliative opera-
tion of gastroenterostomy, which can be done with, very small risk, may
considerably prolong life and make the remainder of it much more com-
fortable and happy."

Syme,^ of Melbourne, discusses the surgical treatment of cancer of
the stomach. The author maintains that the results of operation for
cancer of the stomach would improve if we applied the same principles
to that organ that we do to the breast, uterus, and other parts — namely,
early diagnosis and prompt radical removal. So long as we remain
ignorant of the cause of cancer its treatment must be entirely surgical.
A strong plea for early diagnosis is made and Hemmeter is quoted as
follows: "The simple continuance of a chronic gastritis, or nervous dys-
pepsia, in spite of logical and scientific treatment, accompanied with
progressive loss of body-weight, during 3 to 4 weeks, justify the suspicion
of latent gastric carcinoma." In addition to the symptoms of progressive
emaciating gastritis, valuable aids to early diagnosis are loss of gastric
motility and diminution of free HCl in the stomach-contents. We should
not wait for a palpable tumor before interfering surgically, but the
existence of a tumor is not a contraindication to operation, as some have
urged. Even should the diagnosis of gastric cancer prove incorrect on
exploration, some other condition, benign in character but the cause of
the symptoms, and which can be remedied, will generally be found.
Next to early diagnosis the most important thing is early removal.
Syme shows that it is the pylorus which is most frequently involved in
gastric cancer, and that the disease extends first along the lesser and
then along the greater curvature in the line of the lymphatics and blood-
vessels, and that the tuberosity of the stomach is practically never in-
vaded by extension from the pylorus. Another important feature of
gastric carcinoma is that it shows little tendency to general metastasis.
Not only is this true, but if a recurrence takes place after the removal
it is mainly local. Gussenbauer examined 542 cases of pyloric cancer and
in 41 % there was no metastasis. These facts all go to show the advan-
tage of removing a large portion of the stomach instead of doing simple
pylorectomy. It is advised that all the stomach except the great tuber-
osity, along with the glands in the gastrohepatic and great omentum,
should be removed. Up to 1888 the mortahty from the operation was
about 60 %, and recurrence was the invariable rule. Kocher's mortality
by his present method is 8.7 %, and out of 57 extirpations 11 were alive
after such fairly long periods as to justify us in regarding them as cured.
1 IntercoJ. Med. Jour, of Australasia, Feb. 20, 1903.

ESOPHAGUS, STOMACH, AND DUODENUM. 85

Willis McDonald collected 527 operations performed by various modern
operators, and found that 43 patients were alive and free from recurrence
3 years after operation. Although the removal of the whole stomach is
possible, Syme beUeves that it is a great advantage to leave the tuber and
that there is little danger in doing so. In operations upon the stomach
the author irrigates freely with normal salt solution, believing that it
diminishes the irritation produced by the mere exposure of peritoneal-
covered viscera. The first important step in the operation is to secure
the main blood-vessels. Care must be taken in doing this to avoid
injury to the transverse mesocolon. In discussing the use of clamps
Syme refers to a case in which necrosis of the duodenum took place at
the point at which the bowel was controlled by Kocher's clamp. The
clamps, however, possess many advantages and greatly aid the perform-
ance of gastrectomy. If possible, the duodenum should be implanted on
the portion of the stomach left, as it is the best substitute for the stomach
to first receive the food. If this cannot be done, the duodenum should
be closed and the jejunum attached to the stomach. The use of con-
tinuous sutures is advocated. If the disease is found to be too extensive
for resection or if the adhesions are too numerous and dense, gastro-
enterostomy should be performed.

An interesting case of the carcinoma of the pylorus occurring in a
man of 19 years of age is reported by Anning.^ The patient was oper-
ated upon by Littlewood and it was found that the growth involved the
pylorus and the glands in the neighborhood to such an extent that a
resection of the growth and removal of the glands seemed inadvisable.
Posterior gastroenterostomy was therefore done, and gave absolute
relief to all stomach symptoms until about the time of the patient's
death, 8 months later. After death it was found that there was a general
carcinomatous condition of the peritoneum and the abdominal viscera.
The case was of interest because of the age of the patient, and because
of the relief of symptoms from the gastroenterostomy.

Three cases of diffuse carcinomatosis of the stomach and intes-
tines are recorded by Nuttall and Emanuel. ^ The authors do not think
that such a condition has been previously described. In the first case the
parts affected were the pyloric half of the stomach, the small intestine
in places, and the entire colon, while the cecum was free from growth.
In the second case the entire stomach was infiltrated, the small intestine
in places, and the whole colon, the cecum being free. In the third case
the entire stomach, the small intestine in places, the cecum, the colon,
and the rectum were involved. In each case the growth in the stomach
and large intestine could be described as "leather bottle" in character.
In all the cases the great omentum and the mesenteric and retroperi-
toneal glands were free from growth. In each case the growth was a
glandular carcinoma arising in the deep layers of the gastric mucous
membrane and undergoing colloid degeneration.

In discussing syphilis of the stomach, Max Einhorn^ describes an

' Lancet, Nov. 22, 1902. ^ Lancet, Jan. 17, 1903.

3 Miinch. med. Woch., Dec. 2, 1902.

86 GENERAL SURGERY.

interesting case of syphilitic tumor of the stomach! Syphilitic growths
bear a close resemblance to cancer, but they can be differentiated by the
administration of antisyphiUtic treatment. The case reported is that of
a man 42 years of age who had for a number of years been troubled
with symptoms of indigestion. He suffered from pain in the stomach,
the appetite was poor, and the bowels were constipated. He had lost
some weight. Twelve years previous to his present illness he had con-
tracted syphiHs. A resistant tumor could be palpated in the epigastrium.
The growth presented an irregular, nodular surface, and measured 5 cm.
in length and 2 cm. in breadth. The stomach-contents showed free HCl.
The case was at first thought to be one of cancer, but the long duration
of the disease, the presence of free HCl, and the history of syphiHs caused
Einhorn to place the patient upon antisyphilitic treatment. After 6
weeks of this treatment the tumor had entirely disappeared and the
patient had increased in weight and strength. After 3 months of treat-
ment he was perfectly well.

Bird,^ of Melbourne, describes a case of sarcoma of the stomach.
In this case Bird performed a successful partial gastrectomy. The
patient was a man 41 years of age. The principal symptoms were con-
siderable loss of strength and some loss of weight. The only gastric
symptom was a tendency to flatulence after food. A distinct tumor,
however, could be felt in the pyloric region, which presented a remarkable
range of movement. There was no obvious dilation of the stomach.
When the abdomen was opened, a large tumor involving the pyloric
antrum and a portion of the anterior wall of the greater curvature of
the stomach was encountered. The two unusual features here were the
rather extensive involvement of the duodenum and the want of involve-
ment of the lesser curvature. After removal the gastric tumor measured
5^ inches from side to side, 5^ vertically and 1\ in thickness. The
infiltration of the duodenum necessitated its removal nearly as low down
as the entrance of the bile-ducts. Considerably over one-half of the
stomach was removed with the growth. The absence of adhesions which
are so characteristic of carcinoma of this size rendered the manipulation
of the organ easy, but the removal of so large a portion of the duodenum
rendered the anastomosis between the remaining portion of the stomach
and this portion of the bowel very difficult. It was, however, accom-
plished, and the patient recovered. Until lately sarcoma of the stomach
was looked upon as a great rarity. The Fenwicks, however, have esti-
mated that it is present in about 5 % to 8 % of all primary neoplasms
of the stomach. [There are over 60 cases of gastric sarcoma on record.
In 25 % of cases the pylorus is involved, but stenosis is rare. It is
more common in early life than cancer.]

A, MacCormick,^ of Sidney, presents brief histories of 6 cases, occur-
ring during the last 3 years, in which pylorectomy was performed for
cancer. The author's first pylorectomy was done in 1890 and the
patient lived 7 years. Four of these 6 later cases were well when last

* Intercol. Med. Jour, of Australasia, Feb. 20, 1903.

* Australasian Med. Gaz., Dec. 20, 1902.

ESOPHAGUS, STOAIACH, AND DUODENUM. 87

heard from; and of the remaining 2, one died of secondary hemorrhage
from the portal vein due to ulceration at the duodenal stump 17 days
after operation, and the other died of bronchitis one month after opera-
tion. In performing pylorectomy MacCormick prefers the method of
direct suture of the divided ends, but if much stomach has to be. re-
moved or if there is little duodenum available, he prefers gastrojejunos-
tomy with bhnd suture of the stomach and duodenum. A separate
suture of the mucous membrane the author believes does much to lessen
the tendency to cicatricial contraction and to lessen the surface exposed
to infection.

Vander Veer^ reports 2 cases of gastrectomy. In the first case the
cancer involved the greater curvature and the cardiac end of the stomach,
necessitating the removal of the entire organ. The cardiac end of the
esophagus was anastomosed to the duodenum by means of a Murphy
button. There was some difficulty in approximating the two structures
and considerable tension was present after they were attached. The
patient died the day following the operation, and the autopsy showed
that the duodenum had separated from the esophagus. In the second
case, one of round-celled sarcoma of the stomach, the stomach was ex-
cised at about 2 inches anteriorly and 3 inches posteriorly from the
cardiac end and just below the pylorus. An anastomosis was performed
with silk sutures. The patient recovered and 9 months after the opera-
tion was able to work in a blacksmith's shop and was apparently in full
health.

Moynihan^ reports a case of partial gastrectomy and presents some
remarks upon the treatment of malignant disease of the stomach. A
careful study of gastric cancer shows : " (1) That malignant disease of the
stomach begins in the majority of instances near the pylorus just below
the lesser curvature. (2) From this point it spreads most rapidly and
most widely in the submucosa. (3) The rate of growth toward the car-
diac orifice is rapid, toward the duodenal side extremely slow. The duo-
denum is rarely affected extensively. (4) The tendency of the growth is
to drift toward the curvatures." The accompanying illustrations (Figs.
24 and 25) show the distribution of the lymphatic vessels and glands
and the point at which it is safe to divide the stomach in cases of pyloric
cancer. The portion spoken of as the "isolated area" is rarely affected
by cancer spreading upward from the pylorus. An examination of a
large number of specimens shows that this area remains unaffected to
the last, and that its lymphatic vessels and glands are very rarely in-
volved in the spread of the disease.

A case of total gastrectomy is reported by Mayo Robson^ as well
18 months after operation. The patient was a man 38 years of age who
was suffering from a malignant growth involving nearly the whole of
the stomach, the only portion of the organ free from the growth being
a small area to the left of the esophageal opening. No enlarged glands
were found nor any evidence of secondary deposits. The duodenum was

1 Amer. Med., Oct. 25, 1902. ^ Brit. Med. Jour., April 25, 1903.

» Brit. Med. Jour., Nov. 8, 1902.

88 GENEIL\L SURGERY.

divided about an inch from the pylorus and all the stomach save the
portion free from growth was removed. The anastomosis was accom-
pHshed with a bone bobbin. The patient has gained much in weight,
but has to limit the amount of food taken at each meal. Robson states
that although the mortality of the reported cases of complete gastrectomy
is but 33 %, he is sure the unreported cases will bring the mortaUty
to 50 %.

Fig. 24.— The lymphatic vessels and glands of the stomach ; c is the " isolated area" (Moyiiihan, in Brit.

Med. Jour., April 25, 1903).

Fig. 25. — Showing the growth at the pylorus, the extensions along the curvatures, and the lines ot inci-
sion in the stomach and duodenum (Moynihan, in Brit. Med. Jour., April 25, 1903).

Syme^ reports a case of total gastrectomy successfully performed
for carcinoma of the pylorus and lesser curvature of the stomach in a
woman aged 55 years. The author states that compared with pylorec-
tomy the operation performed in this case was easier and took less time,
because there was less stomach surface to suture. Although the whole
stomach was not involved, a large portion of the lesser curvature was,
and for this reason it was deemed advisable to do a complete operation.
A small portion, however, of the greater curvature at the cardiac end
was left. A few obviously large and hard glands were also removed.

1 Lancet, Sept. 13, 1902.

ESOPHAGUS, STOMACH, AND DUODENUM. 89

The patient made a prompt recovery from the operation. Small quanti-
ties of water were given by the mouth on the second day after the opera-
tion, and feeding was gradually increased until the patient was given full
diet. At no time did the giving of food produce discomfort. The patient
was discharged about 4 weeks after the operation. The operation was
done on May 8, 1902.

Acute dilation of the stomach is discussed editorially in the Lancet.^
Reference is made to a number of cases of death following operation from
acute dilation. The postoperative form of acute dilation of the stomach
has been ascribed to the effect of the anesthetic on the gastric nerves;
others have attributed the lesion of the stomach to interference with the
solar plexus at the operation, but there is little to support these theories,
and it is much more probable that most of these cases of acute dilation
of the stomach are septic in origin. Perhaps the germs of their toxins
may have a direct effect on the gastric muscular wall, or perhaps they
may act on the abdominal plexuses of the sympathetic nervous system.
At present it is impossible to come to a decision on this matter, but a
general survey of the recorded cases goes far to establish the probability
of a microbic cause. Careful bacteriologic observation in future cases may
assist in establishing or disproving this theory.

Death from acute dilation of the stomach following an operation
for an acute ischiorectal abscess is reported by Frederick W. Stewart.^
The symptoms of acute dilation occurred 11 days after the operation.
The patient was suddenly seized with severe pain in the epigastric and
umbilical regions and at the same time vomited a large amount of bile-
stained fluid. The stomach was enormously distended. In spite of
treatment the dilation continued and the patient died 2 days after the
onset of the symptoms. At the necropsy the stomach was found to be
empty and much dilated, its capacity being 1 0^ pints. Stewart beheves
that this case is a similar one to those few described by Fagge as "acute
paralytic distention," and that it should be classed in this category.
The association with the operation is looked upon as purely accidental.

Moynihan^ presents a note on gastric tetany. The author is not
inclined to look upon the condition as one so rare as is generally sup-
posed. In the first 50 cases of gastroenterostomy there were 4 patients
who had suffered in a greater or less degree from gastric tetany. In 3
of these the tetany did not amount to more than painful cramps of the
legs and thighs, or of the hands, and was generally present only in the
early hours of the night. In the most severe cases which Moynihan has
observed the tetanic condition manifested itself on two occasions imme-
diately after gastric lavage. The 5 cases Moynihan has observed have
all been in males; all have been due to simple diseases; in all gastro-
enterostomy has been performed, and all the patients have recovered. It
is probably not too much to say that the extreme form of gastric tetany
is a preventable disease. The timely performance of gastroenterostomy
would remove the cause, whatever that may be, of the attacks.

» Lancet, April 11, 1903. ^ Lancet, May 9, 1903.

^ Practitioner, March, 1903.

90 GENERAL SURGERY.

A case of recovery after operation for gunshot wound of the
stomach was reported by Hugh Williams/ The patient was a boy of 16
who was shot at close range with a 32-caliber revolver. The wound of
entrance was 1 inch to the right of the umbilicus and a half inch below
it. The injury was received about half an hour after eating a full meal.
The patient did not vomit, but complained of severe pain in the epigas-
trium and was unable to urinate. WiUiams saw the patient 4 hours after
the injury, when he was perfectly quiet and in excellent condition. When
the boy was prepared for operation, a probe was passed obhquely into
the abdomen, entering it at the median hne 2 inches above the umbilicus.
The abdomen was opened in the median line between the ensiform and
umbilicus. Free gas was found in the peritoneal cavity, but there was
no free fluid of any kind. An obhque wound was found in the anterior
stomach-wall, the visceral peritoneum being lacerated for an inch before
the ball had entered the stomach-wall. After passing half an inch, the
baU apparently had turned backward and entered the stomach. The
wound of entrance was about 2 inches above the lower border of the
stomach and 4 inches from the pylorus. During the manipulations of
the stomach a small quantity of liquid escaped, though there was no
evidence that any fluid escaped before the operation. The stomach
itself was distended with a semi-solid mass of food. The stomach was
isolated from the rest of the cavity by gauze pads after partially closing
the wound of entrance. The lesser peritoneal cavity was then opened
and the posterior wall of the stomach was carefully examined, but no
wound was found. Fearing that with a stomach full of food vomiting
might produce serious damage to the suturing, WilHams determined to
empty this organ, and, after enlarging the wound on the anterior wall,
did so. The external surface of the stomach was then carefully searched,
but there was still no evidence of a wound of exit, nor was the bullet
found. The wound was then closed, a small wick was passed into the
lesser peritoneal cavity and another to the line of sutures in the stomach.
The patient recovered, being fed for a week entirely by the rectum. A
question of great uncertainty in this case is the course and point of
lodgment of the ball. The points which Williams especially calls atten-
tion to are the necessity for drainage in these cases and the importance
of emptying the stomach when it is full at the time of operation.

N. Senn^ strongly recommends the purse-string suture in repair of
gunshot wounds of the stomach. He states that it makes an efficient
closure and saves time. He also recommends that a posterior wound
should be required through the anterior wound, which should be suffi-
ciently enlarged to permit the posterior closure to be made. In case the
lesser peritoneal cavity is infected by the extravasation of stomach-con-
tents, it can be effectually irrigated through the wound in the posterior
wall and an opening in the gastrocoHc omentum. A catgut suture should
be employed for closing these wounds. Senn reports 4 experiments upon
dogs in which he has infficted and closed stomach wounds. In each case
the dog recovered, was killed later, and the wounds were found in excel-
» Boston M. and S. Jour., Dec. 28, 1902. ^ Jour. Am. Med. Assoc, Nov. 8, 1902

DISEASES OF THE PERITONEUM AND INTESTINES. 91

lent condition. It was found that in the course of 3 weeks the continuity
of the mucosa at the seat of the injury was completely restored.

An interesting case in which recovery took place after a minie ball
wound of the stomach is described editorially in the Boston Medical
and Surgical Journal.^ The patient was shot at Bull Run, the ball
entering and passing apparently directly through the abdomen. The
patient stated that he lay upon the battlefield for 9 days without food
and had only water, which the enemy gave him. Later he was removed
to a hospital and the ball was extracted from his back. This man died
recently, and a careful postmortem examination revealed the course of
the bullet. It had penetrated both walls of the stomach, but injured
neither the kidney nor pancreas. This wonderful recovery is thought to
have been due to the fact that the patient's stomach was probably
empty at the time of the injury and that he put httle into it for a number
of days.

J. C. OHver^ reports an interesting case of unique foreign body in
the stomach. The patient was a girl 10 years of age who, after picking
and eating persimmons, developed severe gastric pain. An emetic was
administered which caused the child to vomit some persimmon seeds and
other matter, but relief did not follow. An examination of the abdomen
revealed a hard mass in the epigastric region, which was unchanged both
in size and location after free emesis and catharsis. Oliver saw the
patient about 8 days after she was taken ill. At this time she com-
plained of some pain in the stomach, but there was no nausea or vomiting
and the bowels moved in a normal manner. The history seemed clearly
to associate the mass in the abdomen with the eating of the persimmons.
The abdomen was opened and two large masses were felt in the stomach,
one at the fundus and one near the pyloric extremity, and both were
closely attached to the stomach-wall. The stomach was then opened
and a futile attetnpt made to break down the masses for removal. Re-
course was then had to a pair of scissors for this purpose. In this manner
a mass of persimmon seeds, shells, leaves, twigs, etc., was removed piece-
meal through the stomach opening. The entire mass weighed 9 ounces.

A magnet for removing small foreign bodies from the stomach
has been described by Mayou.^ The magnet is made so as to fit an
ordinary stomach-tube, the end of which is cut off and encircled by a
silver band. The tube with the magnet is inserted into the stomach and
brought in contact with the foreign body, this being done with the aid of
the x-rays and the fluorescent screen. A case is reported of a l)oy 2 years
of age from whose stomach a hairpin was removed with this instrument.

DISEASES OF THE PERITONEUM AND INTESTINES.

Tuberculous peritonitis is dealt with by A. E. Halstead.* From a
clinical standpoint this condition can be considered under two heads:
cases in which ascites is predominant and those in which tumor-formation

1 March 19, 1903. * Jour. Am. Med. Assoc, Oct. 4, 1902.

» Lancet, Dec. 6, 1902. * Amer. MecL, Jan. 31, 1903.

92 GENERAL SURGERY.

is the distinguishing feature. The diagnosis of the first class of cases can
be made only when all other possible causes of ascites are excluded.
The history, especially of some antecedent tuberculous lesion, is of value.
It usually occurs between the ages of 20 and 40, and it is more common
in women than in men. The temperature is frequently subnormal. Pig-
mentation, especially of the face, is sometimes noted, and this may occur
when the adrenals are not affected. In many cases the recognition of
the disease is accidental. Emaciation, loss of appetite, and diarrhea are
symptoms which vary with the acuteness of the disease. The ascitic
form of tuberculous peritonitis is the most frequent variety, although a
moderate amount of fluid is observed in all forms of the disease. When
of rapid onset the disease may be confused with acute peritonitis of
gonococcic or pneumonococcic origin. Puncture and bacteriologic ex-
amination of the fluid withdrawn are the only means of differentiation.
The presence of the tubercle bacillus can only rarely he demonstrated
in the tuberculous ascitic fluid, and even the inoculation of guineapigs
does not always yield positive results. Tumor-formations resulting from
tuberculosis present great difficulty in diagnosis. Those tumors com-
posed of rolls of omentum are frequently mistaken for carcinoma. The
liistory of the patient still is of great value, especially that relating to
the appearance of tuberculous pleurisy. Abdominal tumors produced by
sacculated exudations are the most common as well as the most difficult
of diagnosis. These tumors may be found anywhere, but usually occupy
the middle zone of the abdomen, where they have many times been
recorded as of ovarian origin. There is no way of distinguishing positively
between sacculated effusions of tuberculous peritonitis and cystic tumors
of the abdomen. Tumors formed from matting together of coils of
intestine may simulate either solid or cystic growths and may be fixed
or freely movable. The majority of cases of tuberculous peritonitis
should be subjected to operative treatment. In the ascitic form evacua-
tion and drainage are all that is required. Most of the cases cured by
this method are of the acute miliary variety. The case should not be
considered cured until 5 years have elapsed after operation. Up to the
present time over 1500 cases of peritoneal tuberculosis treated by laparot-
omy have been recorded. In the ascitic form of the. disease the operative
treatment can be conservatively stated as giving from 40 % to 50 % of
definite cures. In the adhesive form the recoveries are probably about
25 %. In the ulcerating caseating variety the benefit of laparotomy is
questionable. The various hypotheses which have been suggested to
explain the cure of tuberculous peritonitis by operation are as follows :
(1) The action of the anesthetic; (2) psychic influences; (3) operative
trauma; (4) removal of ascitic fluid depriving the tubercle bacilli of
nourishment; (5) increased absorption of the peritoneum; (6) removal
of ascitic fluid containing ptomains; (7) inflammatory reaction following
entrance of air; (8) destruction of tubercle bacilli by septic inflammatory
reaction following opening of the abdomen.

H. F. Harris^ reports minutely a case of hypertrophic tuberculosis
» Ann. of Surg., Nov., 1902.

DISEASES OF THE PERITONEUM AND INTESTINES. 93

of the intestine. The patient, aged 39 years, was an inmate of an
insane hospital. The diagnosis was made postmortem, and among other
changes noticed were: nephritis, and amyloid infiltration of the kidneys,
cirrhosis and amyloid infiltration of the liver, tuberculosis of the peri-
toneum, atrophy of the pancreas, and hypertrophic tuberculosis of the
small intestine vdth amyloid infiltration of the mucosa. An illustration
accompanying the article represents a section of the ileum which shows
a marked constriction in the caliber of the bowel. This is one of the
common results of the thickening of the mucosa, and Harris places it
among the prominent causes of chronic obstruction of the bowels.

Porter^ gives a brief outline of the treatment of tuberculous peri-
tonitis and reports a unique case. It is thought that the curative
effect of light and air after the abdomen is opened is generally under-
estimated. The ascitic forms of the disease have yielded the best results
from operative interference, and the ulcerating and caseating forms the
worst results. Other tubercular foci are benefited by the opening of the
peritoneum. In operating for this condition the incision should be free,
adhesions should not be disturbed unless for the removal of tubercular
deposits or for the relief of bowel obstruction, drainage should not be
employed; irrigation with hot water may be beneficial. Chemic anti-
septics should not be used unless there is a mixed infection. The ab-
dominal cavity should be freely exposed to the light and air from 10
to 15 minutes. The author believes that both the ar-rays and the ultra-
violet rays of Finsen will be found of great value in this condition. The
case reported is that of a girl, 14 years of age, who suffered from tubercu-
lous ascitic peritonitis of the lower abdomen and pelvis, accompanied by
a hernial protrusion, the sac of which was the seat of tul^ercular disease.
This case was cured by excision of the sac, obliteration of the canal,
median laparotomy, and removal of the fluid.

Barnard^ discusses the simulation of acute peritonitis by pleuro-
pneumonic diseases. He gives brief reports of 6 cases in which the
resemblance to some form of acute peritonitis was markedly presented
by one of the forms of pleurisy or pneumonia, or both. In many of
these cases the patient did not complain of the chest condition, but
referred the pain to the upper abdomen, and presented a rigid and
tender abdominal wall. The pulmonary symptoms usually were marked
enough for recognition after 24 hours. The most interesting and difficult
case referred to was that of a girl with gastric ulcer, who was suddenly
seized with severe abdominal pain and collapse. A perforated gastric
ulcer was diagnosed and a laparotomy was performed. Nothing was
found and the patient subsequently died from pneumonia. The autopsy
revealed the gastric ulcer, but there was no tendency to perforation,
liarnard believes that mistakes in diagnosis frequently occur in the hands
of surgeons in the early stages of diaphragmatic pleurisies. If surgeons
bore this fact in mind and more frequently examined the chest, mistakes
would be less frequent. One of the most important differentiating symp-
toms is rapid respiration which is out of proportion to the pulse-rate.
' Jour. Am. Med. Assoc. Sept. 13, 1902. ' Lancet, Aug. 2, 1902.

94 • GENERAL SURGERY.

The abdominal tenderness is found to be superficial, deep pressure with
the flat of the hand often being possible. Another point of value is
that the abdominal wall becomes soft for a moment at each respiration,
which is not true in acute peritonitis. The temperature is usually much
higher than in peritonitis. Irritation in continuity in the lower six dorsal
nerves would explain the hyperesthesia and spasm of the abdominal wall.

Battle,* in a clinical lecture, discusses the importance of early diag-
nosis of peritonitis, referring to the frequency with which symptoms
of perforation of the appendix are overlooked, and reporting briefly 4
cases which illustrate his remarks. In each of these cases there was a
purulent peritoneal exudation of considerable amount within a few hours
of the commencement of the illness, and in 3 of them a perforation of
the appendix was present, and in the fourth an acute inflammation of
this organ without perforation. In a large number of these cases the
symptoms are insidious and do not become marked until the patient is
in a very serious condition. Stress is laid upon the importance of the
earl}'' recognition of peritoneal effusion.

Seven consecutive cases of acute intussusception are reported ,by
Rigby.^ These cases all came under the author's care at the London
Hospital during 9 days between December 26, 1902, and January 3, 1903.
Of these patients, 6 were operated upon, and 1 was beyond operation at the
time of admission. Of the 6 operated upon, 5 recovered. This is dis-
tinctly encouraging, and a strong argument in favor of early resort to sur-
gical interference in this too often fatal form of intestinal obstruction.
Rigby states that no class of statistics can be of less value than these, since
the operative mortality must vary enormously from time to time according
to the pathologic conditions present in the intussusception. The moment
the invaginated portion of gut becomes irreducible the mortality rises from
50 % to perhaps 100 %. The time at which operation is performed also
greatly influences the mortaUty. Of the present series, there was but 1 in
which the bowel was irreducible and gangrenous ; in this case the intussus-
ception was of .a retrograde or ascending character and involved only the
small intestine. A resection was done, but the patient died. Of the 5 suc-
cessful cases, 4 were in children under 8 months of age. In no case was in-
flation with air or injection of fluid attempted. The futility of wasting val-
uable time with these means has been amply demonstrated. These methods
are undesirable for two reasons: because of the danger of rupture of the
bowel and because the reduction is apt to be incomplete. Rigby states
that his experience has been that this condition is most frequently found
in children of good physique. He thinks that vigorous peristalsis is most
likely the cause of the trouble, and refers to the fact that the 7 cases
here reported occurred in the 9 days following the Christmas festivities.
In 3 cases the abdomen was opened by a median incision, and in the
other 2 cases the opening was made in the lower portion of the right
semilunar line. In every case the cecum, colon, and ileocecal juncture
had to be brought up in the wound and manipulated outside the ab-
dominal cavity in order to accomplish a reduction. The keynote of
1 Lancet, June 14, 1902. ^ Lancet, Feb. 7, 1903.

DISEASES OF THE PERITONEUM AND INTESTINES. 95

success in operating upon these cases is rapidity. In none of the cases
here reported did the operation exceed 15 minutes. The greatest precau-
tions were taken to prevent shock, the limbs and chest being encased
in cotton-wool and the operation performed on a hot-water pillow. An-
other point which Rigby lays stress upon is the necessity for early feeding
after operation. The children in this series of cases were fed as soon as
they recovered from the anesthetic. There is great necessity for imme-
diate operation in cases of intussusception, and it is urged that no time
be lost in attempting inflation with air or injection of fluid.

A case of transsacral removal of an intussusception complicated
by a malignant growth is reported by Barker.^ The patient was a
woman, aged 52, who suffered from a circular carcinoma causing an
intussusception which had been upon a previous occasion reduced. The
carcinoma was plainly palpable before reduction, but could be felt after-
ward. The intussusception recurred, and the cancer was easily felt with
the examining finger at the apex of the intussusceptum. Barker first
opened the left groin and attempted to draw the intussusception up, but
found it impossible. The wound was then closed, the anus dilated, and
a futile attempt made to pull the intussusception down so that it might
be excised. When this had failed, all further efforts at this time were
abandoned. A month later, however, the intussusception was attacked
from below, and after the removal of the coccyx and a portion of the
sacrum, the posterior wall of the rectum was divided, the intussuscep-
tion withdrawn, a resection made, and an anastomosis established. Ex-
cept for a slight fecal discharge beginning on the seventh day and lasting
for a few days, the patient made a good recovery. Barker claims the
originality for the proposal of this operation, which he recommended in
1887. He also suggests that it might be possible in some cases of car-
cinoma of the sigmoid \vithout intussusception to open the rectum below
the growth and pull it down and perform a resection, as was done in
this case.

A case of recurrence of intussusception after operation and
reduction is reported by Geoffrey Owen.^ The' patient was a child 7
months of age. The reduction was not difficult and the bowel not
greatly congested. The patient did well for about 24 hours, when all
the symptoms of intussusception again occurred and a second operation
was done. A reproduction of the intussusception was found and again
easily reduced. The child failed to rally, however, and died 24 hours
after the second operation.

John F. Erdmann^ discusses intussusception and reports 3 addi-
tional operative cases, making the following summary of 12 cases which
comprise his experience: "(1) There were 10 operative cases, of which 5
were of the ileocolic, one ileocecal, two enteric, one colonic, and one
multiple — ileocolic and enteric, varieties. (2) Only one patient recovered
by the use of injections. (3) One death occurred in which enemas, etc.,

' Lancet, May 9, 1903.

' Intercolonial Med. Jour, of Australasia, Oct. 20, 1902

3 Med. Rec, July 5, 1902.

96 GENERAL SURGERY.

had been used. No operation allowed. (4) Of 10 operative cases, 5
were fatal and 5 terminated in recovery; and of the deaths, 3 were cases
in which operation was done as a last resort after all mechanical means
had been exhausted, 2 being resections for gangrene and the third septic
from a 7-day s' duration of the intussusception. (5) The tumor could be
palpated through the abdominal wall in 5 cases, while through the rectum
only 3 cases were palpable. (6) Had we cases 1 and 2 to operate again,
resection would not have been done, but a temporary enterostomy would
have been made. Although the mortality rate is 50 % in the entire lot,
it must be remembered that the cases terminating fatally were of 2^,
3, 4, and 7 days' duration when operation was done, and that of these,
3 patients were practically moribund at the time of operation." Since
preparing the above contribution Erdmann has operated in 5 additional
cases, all under 12 months of age.

A case of intussusception occurring during convalescence from
typhoid fever is reported by Watkins-Pitchford. ^ The patient was a
man 29 years of age, who had recovered from an attack of typhoid fever
and had been going about taking solid food for more than 6 weeks.
His debility, however, was still very marked. He was seized with a
diarrhea, abdominal pain, and vomiting, which continued in spite of
treatment for 3 days, and then he began to have evacuations of almost
pure blood. No tumor could be felt, although intussusception was sus-
pected. He died 6 days after the onset of diarrhea. At the autopsy
there were 9 intussusceptions in the small intestine, all passing in the
downward direction; 2 of them were double. The longest measured 5|
inches and the shortest 3 inches. There was no exudation of lymph in
the peritoneal cavity.

Dobson^ reports an interesting case of invagination of Meckel's
diverticulum occurring in a boy 4^ years of age. The condition had
existed 36 hours before operation. The symptoms were acute abdominal
pain with vomiting, and the passage of blood and mucus by the bowels.
There was also a palpable tumor in the right iliac region. Upon opening
the abdomen an intussusception of the ileocolic variety was found and
reduced without much difficulty until the apex was reached. At this
point a Meckel's diverticulum was found invaginated and forming the
apex of the intussusception. It was impossible to reduce.it, therefore it
was excised with a portion of the bowel and an anastomosis made. The
abdomen was drained, as there was a large amount of free fluid in the
cavity. The morning following the operation the patient was extremely
ill, the pulse had risen, and death seemed apparent. One and a half
pints of normal salt solution was given intravenously, free stimulation
by strychnin hypodermatically was employed, and the lower bowel
washed out. The result was a copious evacuation of extremely offensive
bloody fluid, followed by the immediate improvement of the patient,
with ultimately good recovery. Dobson refers to the 13 cases already
reported of invagination of Meckel's diverticulum. If invagination takes
place, it is essential that the apex of the diverticulum be free and not

> Brit. Med. Jour., Sept. 6, 1902. ^ Lancet, April 25, 1903.

DISEASES OF THE PERITONEUM AND INTESTINES. 97

attached by ligament or adhesion to any other structure. It has been
found in the large majority of cases impossible to reduce the invaginated
diverticulum, although the invaginated bowel may be withdrawn. It is
better in all cases to remove the diverticulum if it cannot be reduced.
When resection is necessary, the question of anastomosis or the formation
of a temporary artificial anus arises. It is a wise precaution to adopt
drainage of the' peritoneum whenever a plastic operation is done on the
intestinal tract during an acute attack of obstruction.

A. E. Halstead,^ of Chicago, in discussing inflammation and perfora-
tion of Meckel's diverticulum as a cause of septic peritonitis, re-
lates 2 cases in which a Meckel's diverticulum was perforated by a
typhoid ulcer. Halstead operated upon one of these cases and Wm.
E. Schroeder on the other. False or retention cysts of Meckel's divertic-
ula are divided into two classes: those in which the cavity is continuous
with that of the intestine, and those in which it is shut off from the
intestinal lumen. In those communicating with the intestine the con-
tents are generally fluid or hard fecal matter. In the closed cysts the
contents are often fluid and frequently resemble mucus. Cysts having
the structure of the intestine are occasionally found in the anterior ab-
dominal wall near the umbilicus. Their structure and location suggest
their origin from the omphalomesenteric duct. "Inflammation of
Meckel's diverticulum may result (1) from participation of the mucosa
in a general inflammatory process involving the mucous membrane of
the intestine; (2) from local causes, as obstruction of the lumen from
twisting or kinking of the neck, or from foreign bodies and fecal concre-
tions which may lodge in this pouch. Trauma also appears to have been
the exciting cause of inflammation in some of the reported cases."
Tuberculous ulcers of the diverticulum have been observed in 2 cases.
Halstead's case of typhoid perforation of the diverticulum occurred in a
man 26 years of age, who had been ill with typhoid fever for 4 weeks.
The abdomen was opened under spinal anesthesia 5 hours after the symp-
toms of perforation. The peritoneal cavity was filled with liquid feces
and pus. The diverticulum was 3^ feet from the ileocecal valve and
was 2 inches in length, and in diameter was about the size of the intestine.
The perforation was at its extremity and sufficiently large to admit the
tip of the finger. The perforation was closed, the abdomen irrigated and
drained. The patient died 18 hours after operation. Autopsy showed
numerous typhoid ulcers, but no other perforation. Schroeder's patient
was a male 45 years of age, who developed symptoms of perforation in
the second week of the disease. The perforation in this case was also at
the tip of a Meckel's diverticulum. The diverticulum was attached to the
anterior abdominal wall to the right of the median line and half-way
between the umbilicus and the anterior superior spine of the ilium. The
perforation was closed, but the patient died some hours after oi^eration.
Autopsy showed no other perforations. Halstead has been able to find
but 2 cases of typhoid perforation of Meckel's diverticulum recorded.
One of these is reported by Galton and is that of a child 12 years of
^Med. Rec, Nov. 29, 1902.

98 GENERAL SURGERY.

age who died on the eighth da}^ of the fever with symptoms of peritonitis.
At the autopsy two perforations were found, one in the ileum and one
at the extremity of a MeckeFs diverticulum. Another case is reported
by Boinet and Delanglade, the patient being a woman 35 years of age.
She was operated upon because of symptoms of perforation, and a per-
forated ulcer was found at the tip of a Meckel's diverticulum. The patient
died 6 hours after the operation. In connection with the site of per-
foration in these cases it is interesting to note that examination of the
tip has shown that the muscular layer is frequently defective at its
distal end, thus permitting easy perforation of any ulcer of the mucous
membrane at this point. Perforations following gangrenous inflamma-
tion from twisting or traction of the neck of the diverticulum are more
common than those from specific ulceration of the mucosa. Reference is
made to the frequency with which foreign bodies are found in diverticula.
In none of the reported cases of inflammation of Meckel's diverticulum
has a diagnosis of the true condition been made, the majority having
been operated upon for appendicitis or intestinal obstruction.

In a case of invagination of Meckel's diverticulum followed by an
intussusception of the ileum operation was done by Terry.' The
patient was a boy 12 years of age. Although the symptoms of intussus-
ception were acute, they were not very marked. A sausage-shaped tumor
was easily felt in the right iliac fossa. When the abdomen was opened,
an intussusception 12 inches long was encountered. The intussusception
was gradually reduced, but the apex of the intussusceptum was found
to consist in an invaginated Meckel's diverticulum, almost 6 inches in
length, and sloughing. The diverticulum was removed and the boy made
a good recovery.

Three cases of intestinal obstruction due to a Meckel's diverticu-
lum are reported by James E. jNIoore." In 2 of these cases operation was
performed by Moore and in 1 by Abbott; all of them terminated in
recovery.

Travers^ presents an interesting case of a boy in whom there existed
an intussusception of a Meckel's diverticulum with a secondary ileo-
colic intussusception. The diverticulum was situated about 18 inches
from the cecum. It is supposed that the secondary invagination of the
ileum into the colon took place after the boy's admission to the hospital,
and at this time there was a marked change in the physical signs. Al-
though the examination of the abdomen pointed to an intussusception
as the cause of obstruction, yet there was the absence of the classical
symptoms of the passage of blood and mucus. The boy was operated
upon, the intussusception reduced, and recovery followed.

An interesting case of intestinal obstruction due to impaction with
lumbricoids is reported by W. 0. Bullock.* The patient was a child
6 years of age. He was not seen for 5 days after the onset of symptoms
of obstruction, and he was not brought to the hospital until the sixth
day. At this time he was in a condition of extreme emaciation, the

1 Lancet, April 4, 1903. ^ Jour. Am. Med. Assoc, Oct. 4, 1902.

3 Lancet, July 19, 1902. < Amer. Med., Jan. 31, 1903.

DISEASES OF THE PERITONEUM AND INTESTINES. 99

abdomen was flat, and a sausage-shaped mass could be easily made out
in the right iliac region. His temperature was normal, but his pulse was
from 130 to 140 and weak. During his illness he had vomited persistently
and suffered with absolute constipation. He was operated upon on the
day of admission. When the abdomen was opened, the distal end of
the ileum was distended to the size of the ascending colon for a distance
of about 8 inches and packed solidly with lumbricoid worms. For 8 or
10 inches more the bowel was filled with worms. The distention at the
extremity of the ileum was so great that the worms could be felt readily
through the bowel-wall. Ninety-two worms were removed through an
incision in the bowel and after the operation 2 more were passed by the
bowel. The child died 12 hours after operation.

Bowlby^ discusses at some length intestinal obstruction and espe-
cially the diagnosis of this condition, confining his remarks to mechanical
obstruction of the bowel within the abdomen. The symptoms of internal
strangulation are sudden in onset and peritonitis and septic infection
develop early. Peritonitis, particularly if due to appendicitis, more fre-
quently simulates mechanical obstruction than does any other affection.
Many of the affections of the solid viscera simulate obstruction, disease
of the kidney being the most frequent. Acute pancreatitis and embolism
of the superior mesenteric artery also produce symptoms resembling ob-
struction. Functional constipation and acute enteritis may be occasion-
ally mistaken for intestinal obstruction. Bowlby relates cases illustrating
each of his points in differential diagnosis, and does not urge that the
abdomen be opened in every case in which symptoms of obstruction
present themselves. A careful consideration should be paid to all symp-
toms and an attempt be made to arrive as nearly as possible at a diag-
nosis before deciding upon the treatment. When the abdomen is opened
in a doubtful case the following steps are recommended : " (1) Open in the
middle line below the umbilicus, because most of the causes of obstruction
will be found in the lower half of the abdomen. (2) Without allowing
any intestine to escape, examine first with two or more fingers, or even
the whole hand, the right iliac region, and pass from there toward the
umbilicus to feel whether there are any adhesions there. It is in this
right lower half of the abdomen that most of the causes of obstruction
are to be found, for here are (a) the appendix; (h) intestinal diverticula,
perhaps attached to the umbilicus or to the neighboring mesentery; (c)
the commonest site for volvulus, that is, the cecum; (d) the usual site
for the lodgment of an impacted gallstone — that is, the lower part of the
ileum; (e) a common place for adhesions due to caseous mesenteric
glands; (/) the sites of inguinal, femoral, and obturator hernia. Further,
if the obstruction be in the small intestine, it is in the right iliac fossa
that undistended intestine will be found, and if this can be secured and
traced upward it is the surest guide to the seat of obstruction. (3) Ex-
amine next the left iliac region and the pelvic region, the latter especially
if the patient be a woman, for there, as additional causes of adhesions,
may be inflamed ovaries or tubes or some uterine trouble with neighboring
' Brit. Med. Jour., Jan. 3, 1903.

100 GENERAL SURGERY.

inflaniination. (4) If no cause can be discovered, then either open a coil
of distended intestine and suture it to the skin, if the patient be too ill
to bear more ; or else decide to take the distended bowel out of the abdo-
men altogether, and if necessary open it, empty it, and suture it. It is
only by so doing that you will be able to return it once you have decided
to let it escape, and it is often only by so doing that you will find a
deeply-seated obstruction."

H. B. Delatour^ describes a number of cases of acute intestinal
obstruction and reaches the following conclusions: "The sudden onset
of obstruction of the bowels does not always mean the presence of a
recent lesion, especially in those at or beyond 40 years of age. In many
cases the symptoms may point to an attack of appendicitis, as the appen-
dix becomes distended by gas or fecal matter. It is best in all cases
where a new growth is suspected, or where there is much distention, to
first make an artificial anus, and to use the cecum for this. At this time
do not spend valuable time, and produce some shock, by making a
thorough exploration of the entire abdomen, in order to satisfy yourself
of the exact condition. Always open the intestine immediately, as you
need to give relief as soon as possible, and there is no danger of leakage
of feces back into the abdomen, provided the exit at the anus is not
blocked by too tight dressings. Better leave the wound exposed, the
nurse being instructed to clean away the fecal matter as it appears. Do
not be contented to leave these cases with the artificial opening, unless
at the primary operation the tumor has been found immovable and
anastomosis impossible, for many cases may live months with the tumors
in situ if the current of fecal matter is diverted by placing the loop of
intestine containing it out of the fecal current."

E. Wyllys Andrews^ reports 2 of his own cases and refers to a number
of others in which death has occurred before, during, or after operations
for intestinal obstruction and septic peritonitis from drowning of the
patient in fecal vomit. His conclusions ai*e as follows : " (1) Flooding of
the air-passages by fecal vomit is a real danger, and probably has caused
many unexplained deaths. (2) Resuscitation is impossible or very diffi-
cult. (3) The fluid may flow by gravity through the relaxed stomach
sphincters directly out of the intestine where it has accumulated in
enormous quantities. (4) The accident occurs with great suddenness
and with a stomach supposedly empty. The suffocation may be so com-
plete that no outcry is made and may not be noticed by the attendant.
(5) It may occur as late as an hour after anesthesia, or at any time
until consciousness is restored. (6) We have no evidence that it can
occur during consciousness even in extremis. (7) After septic laparotomy,
patients, w^hen returned to bed. should be watched without even momen-
tary intervals to full consciousness. (8) A suggestion made to me by
Dr. McArthur, that operation under cocain-anesthesia, be done in as
many as possible of such cases, seems to me sound in the light of the
above report."

Perforation of the bowel in typhoid fever is discussed by G. E.

iMed. Rec, Oct. 18, 1902. => \jj„ ^f g^-g.^ June, 1903.

DISEASES OF THE PERITOXEUM AXD INTESTINES. 101

Armstrong, ^ who bases his remarks upon 34 cases of perforation occurring
in 932 cases of typhoid fever treated during the past 6 years in the
Montreal General Hospital. In 1 case the perforation was first recog-
nized at the autopsy. This case was of a most malignant type, with
tympanites, dulled sensorium, and profound toxemia. In the other 33
cases the perforation was recognized during life and operated upon. Five
of these recovered and another lived 5 days, the death at this time being
reported by the pathologist due to typhoid toxemia and not to perfora-
tion. Including this case, the percentage of recoveries was 18.18 %.
The percentage of recoveries among female patients was twice as great
as that among males, and this tallies with the statistics of Keen. This
difference in the mortality-rate caused Armstrong to ask whether the
thoracic type of respiration in woman results in a more limited diffusion
of the escaped intestinal contents. He has been struck with the fre-
quency with which many of the patients persisted in going about for
days and in some instances for a week or more after the onset of typhoid
symptoms. In several cases the initial pain was complained of during
or shortly after a bath, but the hospital records show no increase in
the percentage of perforations since the adoption of tubbing. Regarding
the diagnosis, Armstrong states that it cannot be too strongly urged that
with the onset of ominous symptoms the physician should associate with
himself a surgeon of experience in abdominal work. The note of alarm
is pain, — "abdominal pain referred to the umbilical or hypogastric
regions. A very common bedside note is to the effect that ' at midnight
on a certain date the patient complained of the sudden onset of abdominal
]iain; an enema was given and followed by a stool, semisolid or watery,
which gave great or complete relief. About 4 hours later the pain re-
curred, and the abdomen was then found to be tender on pressure at
some point, — more frequently in the right hypochondnum, — and more or
less rigidity with rounding up.' " It would seem that the administration
of enemas is a mistake, and yet physicians state that the giving of an
enema will not infrequently permanently relieve suddenly occurring ab-
dominal pain. The first difficulty then resolves itself into the question
of differentiating between colic and abdominal pain secondary to organic
lesion. It can only be done by carefully studying the associated symp-
toms. The association of localized tenderness in a fixed spot and rigidity
with pain should arouse one's most active suspicions. The change in
type of respiration from abdominal to thoracic Armstrong has been led
to believe to be of considerable significance. The temperature frequently
rises or falls notably, but not invariably by any means. The same may
be said of the pulse. Vomiting or nausea frequently occurs. The diag-
nosis of a small pin-point perforation, particularly if near the cecum
where a state of rest is more po.ssi])le, and especially if sealed or tem-
porarily closed by adherent omentum or an adjacent coil of intestine,
is particularly difficult. The most important diagnostic feature in such
a case is the persistence of a little pain, a little tenderness, and a little
rigidity, with fluctuation in temperature and pulse. If these symptoms
» Ann. of Surg., Nov., 1902.

102 GENERAL SURGERY,

are due to colic, they should disappear in a few hours or change their
location. The occurrence of perforation in a patient profoundly toxic,
almost comatose, with a tympanitic abdomen, may be absolutely un-
recognizable by the most astute clinician, and only be found in the
autopsy room. The author puts little reliance upon the leukocyte-
count, although he believes it should be carefully observed and con-
sidered in association with the presence or absence of other symptoms.
He relates a number of cases in which the count was below the normal
and in which perforation had occurred, and also instances in. which the
count was very high and yet no perforation was found. It is thought
to be true conservative surgery to recommend an exploratory incision in
cases of doubt rather than to wait and take chances. Armstrong has on
two occasions opened the abdomen without finding any perforation. In
one case no cause was found for the pain and in the other swollen mesen-
teric glands were discovered. Both patients recovered. Faihng to find
a perforation in any case, a careful examination of the mesenteric glands,
the appendix, and the sigmoid flexure should be made. Having made
a diagnosis of perforation, every means possible should be employed to
localize the seat of trouble. This is best accomplished by arresting peris-
talsis so far as possible by prescribing absolute rest in bed, the withholding
of all food by the mouth, avoidance of laxatives and enemas, and the
application of ice to the abdomen. The question of delaying operation
until some hours after perforation is considered, but advised against. In
the Montreal cases the operation was performed during the first 12
hours in 10 cases, with 4 recoveries, or 40 % ; during the second 12 hours
in 10 cases, with 1 recovery, or 10 %. Of those operated upon after
the second 12 hours, all died save one operated upon on the seventh
day. This, however, was practically only the opening of a localized
abscess. These figures support the author's attitude, and he urges early
operation without waiting for recovery from shock. It is his belief that
marked shock indicates a large perforation or at least the escape of a
considerable quantity of the contents of the bowel. In the majority of
cases shock is absent at first. It is thought we should aim to anticipate
shock and by so doing give aid while the infection is still confined to
the narrowest possible area. In many cases there is a period of a few
hours immediately following the perforation during which things seem to
remain almost in statu quo. This quiescent period is the surgeon's
opportunity. Operations done at this time may possibly find beginning
peritonitis from infection through the still intact base of an ulcer. That
localized peritonitis can result from infection through the thin and
altered base of a typhoid ulcer is now generally admitted ; and that even
fatal general peritonitis may result from infection through such a base
and without macroscopic perforation is proved to be true by the Munich
autopsies, in which peritonitis was present without perforation in 2.2 %
of the cases. We have the best possible reason, then, for interfering if
we think a perforation has occurred, because by so doing we give the
patient the only chance there is of recovery. Armstrong holds that early
operation anticipates shock in most instances, anticipates perforation or

DISEASES OF THE PERITONEUM AND INTESTINES. 103

rupture of a suppurating mesenteric gland in a few instances, and may
occasionally be done in time to relieve the conservative adhesion of
omentum or other serous surface before it is forcibly separated by peris-
taltic or intraintestinal pressure. As a great majority of the perforations
occur in the tenninal 18 inches of the ileum, the lateral incision is usually
indicated in early operations. . A number of cases in the series considered
have succumbed to a second or third, and in one instance to a fourth,
perforation. This fact emphasizes the necessity for making a careful
inspection of the bowel after closing one perforation in order that all
suspicious looking and feeling ulcers may be inverted. Irrigation and
drainage is recommended. "If the patient is in good condition, without
pulmonary complications or renal insufficiency, ether-anesthesia gives the
surgeon a better opportunity for thoroughness; but in bad conditions,
especially with renal disease, one can get along very well with local
anesthesia. These patients are often extremely toxic and apathetic.
The sensorium is dulled and the sensitiveness to pain lessened."

In a discussion of typhoid perforation the surgical remarks are made
by Robert G. Le Conte.^ It is stated that the sooner operation is under-
taken after perforation occurs, the greater will be the changes of success.
The delay in operating is due to the difficulty in making a diagnosis
or because the classical symptoms are awaited. In hospital practice
delay is caused frequently by waiting for the consent of relatives or
friends. It is recommended that in hospital practice this consent for
operation should be gained in all cases of typhoid fever before perforation
takes place. The time for a successful operation is the moment the
diagnosis is probable and not when it is made certain by the signs of
peritonitis. It is a mistake to await the subsidence of shock after a
perforation. The incision recommended is that in the right semilunar
line. If the point of perforation cannot be located through this incision,
and if yet the signs of perforation are present, the median incision should
be made and the sigmoid flexure, descending and transverse colon, and
then the remaining portion of the small bowel be examined in the order
named. It should be remembered that the perforation may be com-
pletely hidden from sight by lymph, and therefore all areas that are
covered by lymph should be carefully examined. When the perforation
is found, it should be closed with sutures, either transverse or longitudinal,
according to which produces the least narrowing of the bowel. Inter-
rupted mattress sutures give the best support with the least danger of
cutting. After the closure of the perforation other threatening points or
points of perforation should be sought for. If it is not practicable to
close the ulcer because of its size or because of the friability of the bowel
about it, four procedures are open: First, a plug of omentum may be
fashioned to fit the opening and be held in place with stitches. Le Conte
states that he has seen on the postmortem table a perforation perfectly
closed in this manner by nature, the omentum protruding well into the
lumen of the bowel. Second, resection of the bowel may be practised.
This is a procedure which can rarely be done with success in typhoid
fever. Third, an artificial anus may be formed. This will be practicable
1 Phila. Med. Jour., Dec. 13, 1P02.

104

GENERAL SURGERY.

only in cases with a single perforation, and if successful will frequently
require a second dangerous operation to close the opening. Fourth, the
damaged area of the intestine may be separated from the general peri-
toneal cavity by walls of gauze. Le Conte has successfully employed this
method and recommends it. Of the four procedures, however, the plug-
ging of the opening with omentum, in the very limited number of cases
to which it is applicable, is to be preferred. Resection of the bowel, as
well as the establishment of an artificial anus, should be reserved for
exceptional cases. In those rare cases in which a perforation produces
a localized abscess, the parietal peritoneum forming a portion of the
wall of the abscess, the treatment should be drainage. If a wall is not
so formed, the mass should be walled off with gauze, adhesions be broken
up, and perforations should be sought for and dealt with. Time counts
for a great deal, and the simplest and shortest procedure should always
. be chosen. Where the area of infected peritoneum is limited it is recom-
mended that the peritoneal cavity and intestines be cleansed with sponges
and irrigation be not performed. When the peritonitis is extensive,
copious douching is recommended. Drainage should be thorough, and
after the operation the patient's head should be elevated to cause gravi-
tation of the fluids to the pelvis. At the Pennsylvania Hospital during
the past year there were 509 patients with typhoid fever, 36 of whom
died, a mortality of 7 %. Of this number, 8 were transferred to the
surgical wards for perforation and operated upon; 1 recovered. During
this period 3 cases of perforation were admitted directly to the surgical
wards and immediately operated upon and all recovered. In 2 of these
cases a diagnosis of appendicitis was made prior to operation.

Geo. L. Hays,^ of Pittsburg, discusses perforation in typhoid fever,
his remarks being based upon 7 cases operated upon with 3 recoveries.
The following table presents the interesting points in each case :

N OF
ION.

'ERA-
FTER
TION.

5^2

Result.

Remarks.

o as

w o S

S HPh

"■

Sixteenth.

Ileum.

Coeain.

20 hours.

Died.

Death occurred 5 hours
after operation.

Twenty-first.

Ileum.

Cocain.

SJ liours.

Recovered.

III

Fifteenth.

Ileum.

Coeain.

12 hours.

Died.

Death occurred 30 hours
after operation.

Nineteenth.

Ileum.

Cocain.

5 hours.

Recovered.

Tlie patient developed a
catarrhal pneumonia
and a fecal tistula.

Thirty-ninth;

thirteenth day

of a relapse.

Ileum.

Cocain.

4J hours.

Recovered.

The perforation oc-
curred during a re-
lapse ; the typhoid
bacillus found in
tluid of abdomen.

Thirteenth.

Ileum.

Cocain.

G hours.

Died 48 hours
after opera-
tion.

Death caused by acute
obstruction by kink-
ing of bowel ; typlioid
bacillus found in ab-
dominal fluid.

VII

Twenty-sixtli.

Ileum.

Cocain.

12 hours.

Died 13 hours
after opera-
tion.

Streptococcus pyogenes
was found in the ab-
dominal fluid.

1 Amer. Med., Sept. 6, 1902.

DISEASES OF THE PERITONEUxM AND INTESTINES. 105

In discussing the symptoms Hays states that the drop in temperature
which is so often spoken of occurred in but 1 case of his 7, and in this
was not very marked. The greatest symptomatic vahie is placed upon
pain followed by rigidity and tenderness with suppression of peristalsis.
Such symptoms call for surgical interference. The cases in this series go
to prove the value of early operation. Cocain-anesthesia was employed
in all the cases and the operation was performed w4th but little discomfort
to the patients. In all but the last 2 cases Hays employed a median
incision. In these the incision was made in the right semilunar line, and
it is this incision which he believes to be most desirable. Flushing of
the peritoneum with salt solution is advocated, and in all the cases here
reported a large glass drainage-tube was inserted into the pelvis. After
operation the head of the bed should be elevated so as to cause the
fluids to gravitate to the point of drainage. The drainage-tube should
not be removed until the fluids drawn from it are found free from pus-
producing organisms or until firm adhesions have taken place about it.
The case in which the patient died from acute obstruction due to a kink
of the bowel presented a most hopeful outlook until the symptoms of
obstruction arose. [This series of cases with a percentage of recovery of
42.85 certainly is most encouraging, and should make us consider the
points which they seem to emphasize, namely, the necessity for early
operation, the use of cocain as an anesthetic, the irrigation of the abdo-
men, and thorough drainage. Raising the head of the bed, a procedure
suggested by Fowler, we believe a useful plan after operation.]

Thomas McCrae and James F. Mitchell,^ of the Johns Hopkins Hos-
pital, discuss at length the surgical features of typhoid fever, pre-
senting a summary of all the cases of typhoid occurring in the wards
of the Johns Hopkins Hospital from June, 1900, to June, 1902. This 2
years' experience is summarized as follows : " (1) There have been treated
275 cases. (2) Of these a certain number had unimportant complications^
as boils or abscesses, the cultures from which in every instance yielded
pyogenic cocci. (3) Periostitis and perichondritis have been seen occa-
sionally, always subsiding without surgical interference. (4) Glandular
affections, especially mastitis, occurred, but were not serious. (5) Ab-
scess of the liver occurred once with recovery, the cultures being practi-
cally negative. (6) There have been symptoms of cholecystitis in 5
cases, of which 3 subsided without operation, 1 patient was operated upon
and recovered, while in 1 the gallbladder ruptured and general peritonitis
resulting in death followed. (7) Appendicitis was suspected on admission
in 3 cases and developed once during the course of typhoid fever. (8)
Perforation of the intestine occurred in 8 patients. Of these, 7 were
operated upon with 2 recoveries, a third dying of toxemia after a week.
All of these 7 were recognized within 9 hours, except 2, in which hemor-
rhage from the bowel accompanied the perforation. In 1 case operation
was not advised because the patient was evidently in extremis. (9) Ex-
ploratory laparotomy was done in 2 cases in which no perforation was
found. In one the symptoms proved to be due to intestinal hemorrhage;

1 Amer. Med., Sept. 6, 1902.
8S

106 GENERAL SURGERY.

in the other, to a low grade of peritonitis. The first patient died; the
second recovered. (10) Eleven patients with suspicious abdominal symp-
toms were not operated upon. Of these, 2 died and the autopsies showed
no perforation. The remaining 9 recovered." The authors' discussion
of the perforation cases is deserving of special attention. If a patient
has been having abdominal symptoms for some days, the onset of per-
foration may mean little change and only the development of extensive
peritonitis may be recognized. So frequently do suspicious abdominal
symptoms, such as pain and tenderness, perhaps associated with leuko-
cytosis, clear up completely, that they cannot be considered as warning
symptoms. They should, nevertheless, make us most careful in our
observation of the patient. Four of the cases of this series of 8 per-
forations presented no abdominal features before perforation; 3 had dis-
tention, rigidity, and abdominal pain accompanied by leukocytosis. In
1 case there was intestinal hemorrhage on the day preceding perforation.
The onset of pain was sudden in all but 1 case; in this there was pain
throughout the whole course of the fever, and the time of perforation
could not be fixed. The patients usually cried out with pain so as to
attract the attention of the nurses or attendants. In 2 the pain came
on during a tub bath, and in 1 case while the patient was on the bed-pan.
The pain was usually severe and was referred to various parts, but most
often to the lower abdomen in the umbilical region. In 2 instances it
began in the penis and extended into the abdomen. In 2 cases the pain
and perforation were accompanied by hemorrhage from the bowels; in
one of these a chill accompanied the onset. Profuse sweating was twice
noticed. A noteworthy fact is that in only 1 case was there any drop
in temperature at the onset, and in this case it was immediately followed
by elevation, and that in 6 cases there was immediate elevation after
the onset. The symptoms after perforation depend upon the position of
the perforation, the organisms escaping into the abdominal cavity, and
the general condition of the patient. These are considered under two
heads — general symptoms and local abdominal features. The facial ex-
pression in this series of cases varied greatly. Collapse was present only
twice, and both times in association with hemorrhage. In 1 case there
was no change in temperature. In 7 there was a slight elevation following
the perforation, and this in 6 instances was followed by a fall in tempera-
ture, although most marked in the case in which hemorrhage accom-
panied perforation. In 6 cases the pulse-rate increased, in 2 suddenly,
in 4 gradually; in the remaining 2 there was practically no change. The
respirations were unchanged in 3 cases. Nausea and vomiting were ob-
served in only 1 instance, and in this occurred somewhat late. Hiccough
occurred in 3 cases, and in 2 of them it was rather a late symptom. In
5 cases the bowels moved after perforation; 1 of these was a case of
general peritonitis. In 2 cases the stools contained large amounts of
blood, and in 1 there was diarrhea with pain. Three patients expelled
flatus after perforation. The leukocytosis varied from the normal to
17,500. Of the local abdominal features pain was a prominent one in 7
of the 8 cases ; in the eighth it was severe at the onset, but disappeared

DISEASES OF THE PERITONEUM AND INTESTINES. 107

after the administration of opium. In 5 cases it was paroxysmal. In 3
instances the abdomen was natural and without distention; it was dis-
tended in 4, and in all of these 4 the distention existed before perforation.
There was no case which showed immediate diminution of abdominal
respiratory movements, and in 4 instances abdominal respiration was
marked throughout. In 3, abdominal respiration was diminished.
Rigidity was present in some degree in all cases, being greater on the
right side in 3 and fairly general in 3. In 1 case it appeared only as a
late symptom. Muscle spasm was never an early symptom. Tenderness
on palpation was an early and striking sign, but varied much in degree.
The absence of liver-dulness varied greatly. Dulness in the flanks was
made out in 5 cases, in 2 of which it was distinctly movable. The per-
foration was recognized within 9 hours of its occurrence in 5 cases, but
in the 2 with hemorrhage it was not diagnosticated until 24 hours had
elapsed. The combination of hemorrhage and perforation is not rare.
It is suggested that morphin should be given hypodermatically rather
than by the mouth to control the hemorrhage. As to the diagnosis of
perforation, one has but to see a few cases to appreciate the fact that
there is no regularity in the symptoms, and that no symptom or group
of symptoms is pathognomonic. Much depends upon seeing the patient
at the onset of symptoms, and it is at this time that the surgeon should
see the patient with the physician. It is hopeless to attempt to recognize
the perforation by any combination of signs. The sudden onset and the
pain are the two most valuable indications of perforation. The other
symptoms accompanying the pain vary greatly, as shown in the present
series of cases. Tenderness and rigidity are also of the greatest value.
The absence of other symptoms is of no importance, though their occur-
rence would be of great importance. Exploratory operation under cocain
when there is reasonable doubt is considered to be wise surgery. The
shortest time elapsing between perforation and operation was 3^ hours.
The patients recovering were operated upon 13 and 7\ hours respectively
after perforation. In 3 of the cases cocain followed by whiffs of chloro-
form after the peritoneum was opened was employed; in the, other 4
cases cocain alone was used. The incision of choice is through the right
rectus muscle. In 3 cases, when the abdomen was opened there was an
escape of gas, and in 4 there were feces in the abdominal cavity. In
only 1 case was there more than one perforation. The ileum was the
seat of perforation in all the cases. The perforation was closed by a
purse-string suture of fine silk reinforced by one or two mattress sutures.
It was impossible in 1 instance to close the perforation. Irrigation was
used in only 1 case. In the others the exudate was thoroughly wiped
away with gauze pads moistened in salt solution. Great care was taken
to keep the intestines within the abdominal cavity during cleansing.
Two patients eventually recovered. One lived a week and died from
profuse toxemia; 1 died 1 hour; 1, 12 hours; 1, 22 hours; and 1, 63
hours after operation. In the 2 cases of suspected perforation in which
operation was performed, there was a moderate grade of peritonitis in
one which cleared up after the operation and the patient recovered

108 GENERAL SURGERY.

rapidly; in the second case the symptoms were evidently due to intes-
tinal hemorrhage. The course of the disease was not affected by the
operation and the patient died of hemorrhage and toxemia. In 11 cases
there were conditions causing abdominal symptoms in which operation
was not thought to be indicated. In 4 of these the symptoms were the
result of abdominal distention and severe toxemia; in 1 they were ex-
plained by iliac thrombosis; in 1, by hemorrhage; in 1, most peculiarly
by a termination by crisis ; and in 2, by a neurotic condition.

An exhaustive article on typhoid perforation is contributed by C.
E. Briggs.^ The history and statistics are presented and the authorities
on the subject freely quoted.

John C. Munro^ deals with the clinical diagnosis of typhoid per-
foration, basing his remarks upon 26 cases, 21 of which he has seen at
the Boston City Hospital in the past 4 years. There were 15 operations
in cases with perforation, with 1 recovery. In 2 fatal cases the cause of
the abdominal symptoms and of death could not be determined at opera-
tion. Two patients died and 3 recovered without operation. In 1 case
of peritonitis from a ruptured mesenteric gland the patient died and 1
case of cholecystitis was fatal. One patient exhibiting a Widal reaction
died from pyelitis and cystitis. In these 3 cases operation was per-
formed for perforation. Munro is an ardent advocate of exploratory
incision when there is any good reason to suspect perforation. It is a
great mistake to expect a fall of temperature or an increase in pulse-rate
in all cases of perforation. Muscular spasm, although difficult to estimate,
is the keynote to the early detection of perforation in a large proportion
of the cases. Cases with hemorrhage are the most perplexing. The
majority of the cases here reported were explored under ether. So far
as could be determined, the operations were done in 1 case 48 hours,
in 2 cases 24 hours, in 1 case 18 hours, and in 2 cases 12 hours after
perforation. In one case of operation within 4 hours there was probably
a sudden, profuse gush of intestinal contents. In Thorndike's case of
recovery the abdomen was opened within 6 hours after perforation.
Regarding the cases operated upon in which there was no perforation,
it is interesting to observe that the case with ruptured mesenteric glands
gave typical symptoms of perforation. In 2 cases in which no perfora-
tion was found at operation no definite cause of death could be discovered
at the autopsy. Both of these cases presented typical symptoms of
peritonitis. In one of the cases of cholecystitis the possibility of per-
foration was considered only as remote. The patient with renal trouble
could speak no English, was very ill, and a diagnosis was made on the
association of abdominal symptoms with a Widal reaction. In the 2
cases which recovered without operation, Munro thinks that the per-
foration healed spontaneously.

A. W, Mayo Robson^ discusses the question of the radical treatment
of chronic intestinal tuberculosis and makes suggestions for treatment
in the more acute disease and in tuberculous peritonitis, and reports a

' Am. Jour. Med. Sci., May, 1903. ^ Boston M. and S. Jour., Feb. 5, 1903.

» Lancet, Sept. 27, 1902.

DISEASES OF THE PERITONEUM AND INTESTINES. 109

number of cases to illustrate his attitude. The first case was one of
tuberculous appendicitis involving the cecum and a portion of the ileum
and presented a stricture of the ileocecal valve. The patient had been
once operated upon for appendicitis, but the appendix was not removed
because of adhesions. Robson resected the cecum with a portion of the
ileum and ascending colon. This patient a year after operation was
greatly improved in health, but suffered from some abdominal pain sug-
gestive of obstruction; it was not severe enough, however, to warrant an
exploratory operation. Another case reported is one of multiple tubercu-
lous strictures of the ileum, in which enterectomy was performed. A
year later the patient was perfectly well. The third case reported is
one of multiple tuberculous strictures of the ileum, in which a short-
circuiting operation was done. It was intended that the patient should
return later to have a portion of bowel excised, but her gain in health
and the relief from the diarrhea made her hesitate to submit to another
operation, and Robson thinks that it may not be necessary. The fourth
case is one of stricture of the duodenum, probably of tuberculous origin,
associated with tubercle of the stomach and stenosis of the pylorus.
This patient was operated upon in 1895. The pylorus was opened with
the idea of performing pyloroplasty. The duodenal stricture was dilated
through the pyloric wound and pyloroplasty performed. The patient
died in the second week from exhaustion. At the present time Robson
would treat such a case by performing gastroenterostomy. The fifth
case was one of tuberculosis of the cecum, in which a resection was done.
This patient developed pleurisy some months after operation and died a
year later. The last case was one of tuberculous disease of the rectum
and sigmoid flexure of the colon, in which an excision was done. This
patient's convalescence was slow, but he steadily gained strength. Atten-
tion is called to the frequency with which tul:)erculosis produces stricture
of the bowel. In the first 4 cases here reported there was no difficulty
in making a diagnosis of stricture, and from the length of time that
the obstructive symptoms (constipation alternating with diarrhea) had
existed it was supposed that the character of the stricture was non-
mahgnant. It is thought that some cases of obstruction are put down
as malignant which are really tuberculous. A second case of tuberculous
appendicitis is also placed in this series. Robson has acted for many
years on the principle that when a tuberculous area in the abdominal
cavity can be removed, it should be removed. The success which has
accompanied the carrying out of this principle tends to fortify it.

Crile^ presents a preliminary note on the diagnostic value of blood-
pressure determinations in the diagnosis of typhoid perforation,
taking as a basis 5 cases of perforation in which blood-pressure deter-
minations were made. In each of the cases the blood-pressure assumed
the high level attending peritonitis from other causes.

The results obtained by operation in typhoid perforation are discussed
by Depage,^ and an interesting case in which recovery followed operation

^ Jour. Am. Med. Assoc, May 9, 1903.

^ Jour, de Chir. et Ann. de la Soc. Beige de Chir., Nov. and Dec, 1902.

110 GENERAL SURGERY.

is described. The patient was a woman, 42 years of age, who was
operated upon 3 days after perforation. The abdomen was opened in
the median line under cocain-anesthesia and a collection of fetid pus was
evacuated. A small perforation was found in the ileum about 10 cm.
from the cecum. A V-shaped resection of the bowel was done at the
point of ulceration. The distention of the small intestine was relieved
by needle punctures. Drainage was established and the patient made
an uninterrupted recovery. Perforation in this case took place between
the twelfth and the fifteenth day of the disease, and as the patient was
not operated upon until 3 days later, the infection was general. This case
illustrates the fact that, although a patient may be in an extremely
grave condition from typhoid perforation, operation may save him.

Murphy^ discusses the treatment of general suppurative peritonitis
and reports a case of typhoid perforation and 5 other consecutive
cases of general suppurative peritonitis in which the patients all
recovered after a plan of treatment which it is now his custom to carry
out. General suppurative peritonitis is not necessarily a fatal disease.
The result depends upon the type of infection, whether of streptococcic
or staphylococcic origin, for instance. A virulent streptococcic infection
produces rapid denudation of the endothelial covering of the peritoneum,
rendering absorption very prompt. With the staphylococcus or colon
bacillus infection this change takes place more slowly, and the patient
may survive such infection for a number of days. Another feature
which determines the result is the period of time which elapses between
the infection and the time of operation. In times past the diagnosis of
perforation was based on the condition of collapse, while at present it
is more on the symptoms of pain, nausea, vomiting, localized tenderness,
circumscribed flatness or piano percussion, elevation of temperature, and
hyperleukocytosis. The tension under which the products of infection
are retained in the peritoneal cavity is another question deserving serious
consideration, since the greater the pressure under which the pus is
retained in these acute conditions, the more rapid is the absorption.
When the pressure is removed, absorption ceases, as after the opening
and draining of an abscess. The diffusion of the infective material
through the peritoneal cavity, the administration of antitoxins and other
substances to antidote or dilute the poison, the length of time the
patient is kept under the anesthetic, all influence the result. Murphy
believes in general anesthesia, as so much time can be saved as to more
than compensate for the dangers attending its use. Time is of the most
vital importance in these operations. In all of the cases reported Mur-
phy's method of operating was to open the abdomen quickly on the
right side and without sponging or irrigation to introduce two large
drainage-tubes, one into the pelvis and one into the right iliac fossa.
The patient before, during, and after operation was kept in a semisitting
posture in order to produce a gravitation of the fluid to the pelvis.
Thorough stimulation was employed in all the cases, and antistrepto-
coccic serum was employed in some. In each of the cases reported,
1 Jour. Am. Med. Assoc, April 11, 1903.

DISEASES OF THE PERITONEUM AND INTESTINES. Ill

excepting the typhoid perforation, the source of the infection was the
appendix, which was removed in each case. A point upon which Murphy
lays great stress is that there is httle or no depression immediately after
the perforation of the intestine and no collapse. Collapse is a late mani-
festation and is the expression of the denudation of the peritoneum of
its endothelial coat and absorption of infective material.

A second successful operation for perforation in typhoid fever
is reported by Bowlby.^ The patient was a boy, 10 years of age, who
suffered a relapse in the third week; on the fourth day of the relapse he
had a sudden fall of temperature and marked abdominal symptoms, with
great pain and sweating. Operation was performed, it was thought, 2
hours after the perforation occurred. A considerable quantity of almost
clear fluid was found in the abdominal cavity with a small collection of
fecal matter. The whole small intestine was greatly distended. The
perforation, the size of the head of a pin, was found about 2 feet from
the cecum. The ulcerating area was inverted with Lembert sutures of
silk. The abdominal cavity was given a dry toilet, a drainage-tube
introduced, and the wound partially closed. The patient was quite sick
after the operation, but recovered. A number of months after the opera-
tion the boy was in excellent health. This case and another already
published constitute Bowlby's experience in operations for typhoid per-
foration, and both have been successful. His success in both these cases
he largely attributes to the fact that in each the perforation occurred
after the fever was practically over and when the general condition of
each patient was relatively good. Bowlby closes with the suggestion that
in all cases in which perforation is suspected a surgeon should be called
in as promptly as possible.

Pettus,^ of the United States Marine-Hospital Service, describes a
successful late operation for gunshot wound of the intestines. A 32-
caliber bullet entered in the median line just over the pubic arch. The
patient walked about after the receipt of the injury and presented no
shock and complained of no pain or nausea. A catheter introduced into
the bladder brought away clear urine. The woimd was explored and it
was found that the buUet had injured the pubic arch, but there was no
evidence of its entrance into the peritoneal cavity. It was thought
advisable, under the circumstances, not to open the abdomen. The
patient did well for 24 hours, when his condition grew rapidly worse,
there being every evidence of peritonitis. Thirty-one hours after the
receipt of the injury the abdomen was opened and was found to contain
a quantity of bloody, flocculent semm and fecal matter. Seven ragged
perforations of the small intestine were found and closed. As closing
these wounds in the longitudinal direction would have seriously impaired
the caliber of the bowel, Pettus sutured them transversely. In one
wound, if this had not been done a resection of the bowel would have
been necessary. A piece of the patient's trousers was found adherent to
the intestines near one of the perforations. The abdominal cavity was
thoroughly irrigated with normal salt solution until perfectly clean.
» Lancet, Jan. 10, 1903. ' N. Y. Med. Jour., Aug. 30, 1902.

112 GENERAL SURGERY.

Drainage was introduced through the pelvis and the wound closed. The
patient's condition during the latter part of the operation was very bad,
but he quickly rallied and made an uneventful recovery. The large
wounds of the intestine in this case were probably due to the flattening
of the bullet against the pelvic bone. The result in this case goes to
disprove the statement of so many authorities that operations performed
after 24 hours for gunshot wounds of the intestines are useless.

Vance/ of Louisville, reports 3 consecutive and successful operations
for gunshot wound of the abdomen. The first case was one in which
there were 4 intestinal perforations and an injury of the mesentery.
The patient made an uncomplicated recovery. The second case was one
in which the stomach and duodenum were perforated. This patient was
operated upon within 40 minutes after the receipt of the injury. But
one wound of the stomach could be found, — that in the anterior wall, —
and but one wound of the duodenum, a very oblique one. It is evident
that the ball entered the stomach, passed through the pylorus, and
injured the duodenum in its exit. The peritoneal covering of the duo-
denum was injured for quite a distance. After suturing the duodenal
wound a flap of the lesser omentum was fixed over it. The patient
returned to his home perfectly well on the fifteenth day after the opera-
tion. The third case was that of a boy 13 years of age who was seen
a number of hours after the receipt of a gunshot wound of the abdomen.
He was suffering from great shock, due to loss of blood, and at the time
of operation exhibited all the symptoms of profuse hemorrhage. Opera-
tion in this case seemed almost hopeless; nevertheless, it was undertaken.
There was a large wound of the stomach where the bullet had evidently
cut out a section of the anterior wall. There was also a buttonhole
through the left lobe of the liver, which, however, was not bleeding.
About 3 feet from the cecum there were 3 wounds of entrance and 3
of exit in the ileum; also 2 wounds of the mesentery dividing large
mesenteric vessels, which bled profusely. All of the wounds were re-
paired and the abdomen was irrigated and drained. He ultimately
recovered. Vance is impressed with the necessity in these cases of
operating at the earliest possible moment. In this connection, also, he
reports a stab-woimd of the abdomen in which the ileum presented a
very extensive wound nearly severing the bowel, and also a wound of the
mesentery. After the control of the bleeding from these wounds blood
continued to come from the neighborhood of the spleen, which had evi-
dently also been injured. Gauze packing controlled this, however, and
the abdomen was closed. The patient recovered.

Six cases of rupture of the intestine with 4 recoveries are re-
ported by Lund, Nicholls, and Bottomley,^ of Boston. The first 3 cases
in the series were operated upon by Lund. In the first case the small
intestine was torn from its mesentery for about 3 inches, and in the
center of the bowel, which was denuded of its peritoneum, there was a
large perforation. This patient received his injury from a fall from a
bridge. He was operated upon 24 hours after the receipt of the injury

1 N. Y. Med. Jour., July 26, 1902. ^ Boston M. and S. Jour., Nov. 27, 1902.

DISEASES OF THE PERITONEUM AND INTESTINES. 113

and soon after his admission to the hospital. The damaged bowel was
quickly excised and an anastomosis was made with a Murphy button.
The patient died 2^ hours after the operation. The second case was one
of rupture of the small intestine due to the kick of a horse. Operation
in this case was performed 16 hours after the accident, and the patient
recovered. The rupture in this case was about the size of a lead-pencil
and was partly closed by the pouting of the mucous membrane through
it. The third case was also one of rupture of the small intestine due to
the kick of a horse. The operation in this case was done 9 hours after
the injury, and the patient recovered. The fourth case, operated upon
by Nicholls, was one of rupture of the ileum due to the kick of a horse.
Operation was done 3 hours after the injury, and the patient recovered.
The fifth case, operation by Bottomley, presented all the signs of diffuse
general peritonitis and showed a perforation in the jejunum opposite the
mesenteric attachment. This patient died 72 hours after operation.
The interesting feature, and the one which makes the case unusual, is
that neither from the patient's story nor from that of the witnesses,
nor from external sign, could any evidence be obtained of direct con-
tusion of the anterior abdominal wall. The patient was knocked down
upon a flat surface by being struck on the back just below the shoulder-
blade by the shaft of an approaching patrol wagon. The sixth case, also
operated upon by Bottomley, and which recovered, was that of a boy
8 years of age, who was run over by a wagon. The rupture in this case
was at about the mid-point of the ileum, 1 inch from its attachment to
the mesentery. The mucous membrane was pouting through the everted
edges of the opening and had prevented the escape of much fecal matter.
It is stated that the one thing which means most to both surgeon and
patient in these cases is the length of time which is allowed to elapse
from the hour of accident to the hour of operation. Beyond the fourth
or fifth hour every additional moment of delay adds greatly to the danger
of a fatal issue.

An instructive case of laceration of the bowel without external
evidence of injury is reported by Claybrook.* The patient, a muscular
young man, was caught between the bumpers of cars. After the injury
he walked 50 yards and was then put upon a stretcher. He was slightly
pale and complained of pain in the abdomen. There was no vomiting
and no shock, the pulse-rate ])eing 72. There was no bruise or abrasion
of the skin of the abdomen, but the abdominal muscles were very rigid
and tenderness was marked. On examination with the stethoscope there
was complete arrest of peristalsis and the heart and respiratory sounds
could be easily heard as low down as the hypogastrium. A diagnosis of
rupture of the alimentary tract was made and operation was immediately
performed. Wlien the abdomen was opened, a large quantity of blood
escaped. An examination of the abdominal contents showed the small
intestine completely severed at the duodenojejunal junction and the
mesentery at this point torn through to the base. The hemorrhage
came from torn mesenteric vessels. The bowel was anastomosed by
1 Virginia Med. Semi-Monthly, June 12, 1903.

114 GENERAL SURGERY.

means of sutures, the abdominal cavity thoroughly flushed out and
closed without drainage. The patient made an uneventful recovery and
2 months later resumed his duties as a brakeman. In addition to
pain, tenderness, and rigidity, together with thoracic respiration, Clay-
brook believes the complete absence of peristalsis as revealed by the
phonendoscope, and the transmission of the heart and respiratory sounds
so as to be audible over the whole abdomen, to be of the greatest diag-
nostic value. The presence or absence of shock cannot be relied upon,
as it is often absent in the worst cases until sufficient hemorrhage has
occurred to produce it, and, on the contrary, it is at times profound after
a simple contusion of the abdominal wall.

Brewer^ reports 9 cases illustrating some important points in the
diagnosis and treatment of abdominal contusions associated with
visceral injuries. He states that "pain, tenderness, and muscular rigid-
ity are often the only symptoms during the first few hours after the re-
ceipt of the injury, and the occurrence of these three symptoms following
an abdominal traumatism should be regarded as a positive indication for
an exploratory laparotomy. To delay exploration for the occurrence of
other more characteristic and localized symptoms is but to invite dis-
aster, as the resistance of the individual after the receipt of the severe
visceral injury diminishes with every hour of delay, and the only hope
of his being able to withstand the added shock of a severe surgical opera-
tion is to inaugurate the treatment at the earliest possible moment."
If the presence of free gas or fluid in the peritoneal cavity can be deter-
mined, the indication for exploration is all the more imperative. Brewer
recommends treatment of extensive lacerations of the spleen by pressure
and gauze packing rather than by splenectomy. He believes that it is
equally as effective in arresting hemorrhage; it is accompanied by less
shock; it saves time and preserves an important organ. [We are in
accord with the opinion here expressed, believing that the spleen is
sometimes sacrificed because of the ease with which it can be removed.
In some cases the simple method of packing will suffice.] Attention is
called to the fact that even after the severest lesions surprisingly slight
shock may be present during the first few hours, and we must not judge
of the gravity of the injury by the degree of the initial shock. Success
in operating upon these cases will depend upon speedy work, perfection
of technic, and ability to administer at any moment the most vigorous
stimulation. Brewer observed in several cases accompanied by severe
intraperitoneal hemorrhage, exhibiting comparatively shght evidences of
shock, that as soon as the peritoneum was incised and the intraabdominal
pressure was reheved, the patient passed rapidly into a state of profound
collapse. He therefore advises the exposure of one of the large veins
of the arm before the abdomen is opened in order that a sahne infusion
may be promptly employed.

A. Neumann^ reports a case of rupture of duodenum resulting from

contusion of the abdomen. The patient was a man who fell 16 feet,

striking his abdomen upon the top of a barrel. Operation was performed

1 Ann. of Surg., Feb., 1903. ^ Deut. Zeit. f. Chir., Bd. Ixiv, No. 7, 1902.

DISEASES OF THE PERITONEUM AND INTESTINES. 115

6 hours after the injury and the perforation of the bowel was closed
by sutures. The patient suffered from severe peritonitis after the opera-
tion, but finally recovered. The author presents a review of all the
cases of contusion of the abdomen occurring during the past 20 years
in the service of Hahn at Friedrichshain. During this period 133 cases
of contusion of the abdomen were treated and 61 presented some serious
visceral injury, the intestine being the one most frequently involved (21
cases). If sufficient interval of time elapses between the inauguration of
the force and the impact to allow of contraction of the abdominal muscles,
the chance of visceral injury is greatly decreased. Usually the intestine
is crushed or torn from its mesenteric attachment. There are no symp-
toms which point absolutely to intestinal perforation. Shock is a most
variable symptom. The most characteristic sign is absolute rigidity of
the abdominal wall. The case reported by Neumann is the only one
occurring in this series which recovered after operation. In order to be
successful, operation must be performed early.

Robert G. Le Conte^ takes for the subject of his annual address on
surgery delivered before the Philadelphia Academy of Surgery, the diag-
nosis of intestinal injury following abdominal contusion. Dealing
thoroughly with the subject and illustrating his remarks with numerous
results of cases, he concludes: (1) That a moderately assured diagnosis
of grave injury must be made before operation is undertaken, or we will
open many abdomens to find the trauma confined to the abdominal wall.
In a series of 100 consecutive cases of abdominal contusion as they
enter a general hospital, perhaps 30 or 40 will have received a gra^'e
injury demanding operation, while the other 60 or 70 recover without any
operative procedure. For the sake of argument, the author is willing to
grant that if the abdomen is immediately opened in each one of the 100
cases there will result a smaller percentage of deaths than if the surgeon
waits for some other symptoms of intestinal damage. But can we call
such radical and empirical treatment the science of surgery? The author
states that if he were one who always, without exception, advocated
immediate operation in appendicitis as soon as the diagnosis is made,
he could with greater force urge immediate operation in all cases of
abdominal contusion, for the seriousness of the two conditions is scarcely
comparable in his opinion. The teaching of many of the modern writers
when they urge operation in all cases presenting pain, rigidity, and local
tenderness seems too radical, for we have various kinds of pain and ten-
derness, and different degrees of rigidity, and many times these symp-
toms are due to injury of the abdominal wall alone. Had he followed
such teaching, he should have opened the abdomen in 6 cases here re-
ported, for each of them presented pain, localized tenderness, and rigidity,
and yet they all recovered without an exploratory operation. He be-
lieves, then, that we should wait for some symptom or symptoms indica-
tive of intestinal injury. (2) In the presence of shock a diagnosis of
intestinal injury cannot be made, no matter how profound the shock
may be or how slowly reaction takes place. We may diagnose hemor-
'Ann. of Surg., April, 1903.

116 GENERAL SURGERY.

rhage, which would lead to an immediate operation, and at the same
time presume the presence of a lacerated gut, but primary shock is of
itself no aid to our diagnosis. Therefore we should wait for reaction to
take place. (3) No one symptom is pathognomonic of intestinal injury,
but the two most reliable are gradually increasing rigidity and facial
expression. In the next group are placed deep and perhaps radiating
abdominal pain, respiration which becomes more and more thoracic, vom-
iting after the shock has ceased; distention, increasing pulse-rate, and
secondary fall in temperature. The order in which they are mentioned has
no significance, for any one or two of these symptoms may be prominent
to the exclusion of the others. (4) Any individual who has received an
abdominal contusion sufficiently severe to call for medical services de-
mands also the most careful and constant watching in order that the
surgeon may detect at the earliest possible moment the appearance of
grave symptoms. It is not meant that we should wait for these symp-
toms to become so pronounced that a positive diagnosis is assured, for
then operation is for the most part too late. There is a position, how-
ever, midway between operating on every case and waiting for an assured
diagnosis, where we can say that, owing to the gradual appearance of
certain symptoms, we have fair reasons to think the intestinal tract may
be injured, and that under such circumstances an immediate operation
will give the patient the best chance. In such a case it must not be
forgotten that perforation may take place hours or even days after the
injury. Lastly, as our individual experience increases, we gain the power
to place a more just value upon the symptoms present and to perceive
the grave symptoms in their early stages. In other words, we gain in
acuteness of perception, and there is scarcely any injury to the body
which requires this more for a successful result.

Three cases of rupture of the intestine without severe external
injury are reported by Tornqvist.^ The first case is that of a man 20
years of age, whose jejunum was ruptured by a kick of a horse. The
patient was operated on 11 hours after the injury and death occurred
from general peritonitis 7 days later. In the second case, that of a man
25 years of age, who had been kicked by a horse, the operation was
performed 6 hours after the receipt of the injury, and a rupture of the
jejunum found. This patient recovered. The third case is that of a
boy of 16 in whom the lower part of the ileum was ruptured by a blow
on the abdomen from a stone about the size of a fist. This patient was
operated upon about 8 hours after injury and made a good recovery.
The following symptoms are considered characteristic of a ruptured in-
testine: (1) The rapid rise in pulse-rate occurring immediately after the
injury and steadily increasing. This is especially important in the ab-
sence of other symptoms, indicating intraabdominal hemorrhage. (2)
The rapidity with which the general condition of the patient grows
worse. (3) The increasing zone of dulness in the region of the injury.
(4) Rigidity of the abdominal wall and the appearance of pain and ten-

1 Nordiskt Medicinskt Arkiv, 1902, vol. xxxv, Heft 1, No. 2; Amer. Med.,
Nov. 22, 1902.

DISEASES OF THE PERITONEUM AND INTESTINES. 117

derness. In the treatment of these injuries Tornqvist advocates imme-
diate cehotomy with cleansing of the peritoneal cavity by sponging and
the use of free drainage.

Ager^ discusses the case of a man aged 36 years who entered the
hospital, giving the history of diarrhea for a week, wliich had been
checked by a cholera mixture. The night previous to admission he had
taken a dose of castor oil. He rapidly grew worse after admission, and
developed symptoms of appendicitis. An operation was decided upon.
At the time the patient's temperature was 104° and pulse 106. A con-
gested appendix was removed, and, although there was evidence of
intestinal perforation, the patient's condition prevented further search
for the cause of the trouble, and the operation was hastily completed.
The patient died 12 hours later, and an autopsy revealed general peri-
tonitis with adherent small intestine. When the adhesions were sepa-
rated, a living lumbricoid was found. Later a small round perforation
was found in the small intestine, about 10 inches from the cecum. The
mucous membrane at the point seemed healthy except for the clean-cut
perforation.

A contribution to the study of intraabdominal omental torsion
is presented by J. F. Baldwin,^ who reports 2 interesting cases in this
connection and discusses the predisposing causes of intraabdominal tor-
sion. If the pedicle is so situated as to furnish a perpendicular axis for
rotation, torsion will be more apt to occur. If a perpendicular axis is
afforded by the pedicle proper and also by an adhesion at the bottom,
torsion will be still more apt to take place. That a congenital malforma-
tion may give rise to such a pedicle is shown possibly by Wiener's case,
and quite positively by the author's. It is by no means necessary to the
production of torsion that the pedicle should be particularly small. "In
the 6 cases reported by Wiener, the diagnosis in 4 was simply that of
strangulated hernia. In one of the others the symptoms led to a diag-
nosis of appendicitis, and in his own to that of an intraperitoneal abscess.
In Baldwin's case the diagnosis of a mild but progressive appendicitis
seemed clearly warranted. In all the cases the gravity of the symptoms
was recognized and prompt operation resorted to." In the author's first
case operation was done for an ill-defined mass which could be felt in
the right inguinal canal and extending down to the bottom of the scro-
tum. On opening the hernial sac, which extended to the testicle, a
small piece of omentum was found occupying the sac, but adherent only
to the bottom. This adhesion was separated, and on pulling down the
omentum a mass soon appeared, which was drawn out with considerable
difficulty. It proved to be an omental tumor 5 or 6 inches long and
more than an inch in diameter, with a smooth exterior, and looking not
unlike a piece of bowel. On bringing it out, it was found connected
with the rest of the omentum by quite a narrow pedicle. This pedicle
was ligated and the tumor removed. On examining the specimen, it
was found that after separating a few adhesions which kept it in shape,
the mass could be spread out into quite a normal-looking piece of omen-
» Jour. Am. Med. Assoc, Feb. 28, 1903. ' Ann. of Surg., Dec, 1902.

118 GENERAL SURGERY.

turn. From the history and appearance there could be no question that
this mass had from time to time occupied the hernial sac, but that re-
duction, while complete so far as the mass was concerned, was incom-
plete, owing to the adhesion of the strip of omentum to the bottom of
the sac. This case does not represent one of torsion of an omental
tumor, but throws some light upon the formation of such masses. The
second case reported is that of a man, 47 years of age, who was operated
upon for mild but progressive appendicitis, there being little doubt as
to the diagnosis. Abdominal tenderness and rigidity were both promi-
nent. When the abdomen was opened, a mass was encountered and
withdrawn through the abdominal wound, which proved to be made up
of omentum rolled up so as to make a distinct tumor and having a very
small pedicle, not larger than a knitting-needle, twisted upon itself eight
times. The entire mass was about the size of a large fig. The pedicle
was ligated and the tumor removed. The appendix was then more care-
fully examined and its distal portion found obliterated. Examination of
the specimen showed it to be made up of ordinary omentum, but rolled
together and adherent so as to make a distinct tumor. When the ad-
hesions were separated it could be spread out and then just about covered
the palm of the hand.

Von Mikulicz^ presented to the American Surgical Society what he
called small contributions to the surgery of the intestinal tract. He
first discussed briefly cardiospasm and its treatment. Cardiospasm is
a term the author has applied to a dilation of the lower portion of the
esophagus which results from occlusion of the cardiac orifice of the stom-
ach due to muscular spasm, and which is characterized by difficulty in
swallowing either liquid or solid food, until in the last stages only a
very small amount of food can reach the stomach. Since employing the
esophagoscope von Mikulicz has observed 20 cases. This affection can
only be definitely diagnosed by means of the esophagoscope. In many
of the cases carcinoma of the cardiac orifice will be suspected. The
author presented skiagraphs showing the value of the x-ray in diagnosti-
cating the condition. A primary cardiospasm is spoken of in which no
other condition is demonstrable, and a secondary cardiospasm which has
occasionally been observed in cases of carcinoma of the cardiac end of
the stomach. Two cases out of 14 of primary cardiospasm were followed
by secondary malignant growth. In each case the growth was found
in the esophagus above the dilation. In regard to the treatment of
cardiospasm, washing of the esophagus to remove the decomposing
residue can only relieve the inflammation. In the severe cases patients
must be fed through a stomach-tube. This can be easily done, as the
patient soon learns' to pass the tube. If this method fails, a gastric
fistula must be established. The author has tried many methods of
dilating the cardiac orifice. In one very bad case he opened the stomach
and stretched the cardiac opening thoroughly. Three months have
elapsed since this operation, but the patient is still thoroughly comfortable
and able to take solid food. A second topic presented is that of peptic
* Boston M. and S. Jour., June 4, 1903.

DISEASES OF THE PERITONEUM AND INTESTINES. 119

ulcer of the jejunum. This is a condition which has been observed
only as a sequel to gastroenterostomy. Fifteen such cases have been
encountered by the German surgeons. According to the experience of
these men, the ulceration occurs only after anterior gastroenterostomy
performed by the Wolfler method, and when the operation is performed
for benign affections of the stomach, such as gastric ulcer or pyloric
stenosis. It .does not follow the posterior gastroenterostomy of von
Hacker. The general picture of the disease closely resembles that of
gastric ulcer, hence most cases were formerly regarded as a recurrence
of the original trouble. Pain is a prominent symptom. Resection of the
bowel has been performed in a few cases, but there is a strong tendency
to renewed ulceration. In one of his own cases von Mikulicz states that
after resection a new ulcer formed 10 cm. from the site of the first. He
reports a case also of anterior gastroenterostomy performed for congenital
pyloric stenosis in a child 3 months of age, in which 2 months after
operation there developed multiple jejunal ulcers which caused death
through profuse intestinal hemorrhage and peritonitis. The development
of jejunal ulcers can be explained only by the prolonged presence of
gastric juice which reaches the jejunum without having been diluted and
neutralized by bile and pancreatic secretion. One of the lessons to be
drawn from the facts stated is that surgeons should no longer perform
anterior gastroenterostomy, at least not for benign affections of the
stomach. The third part of the author's paper has to do with the
operative treatment of severe forms of invagination of the intestine.
He reports an interesting case of invagination of the ileum, cecum, and
colon in which the cecum was protruded from the anus. In this case a
portion of the intussusception was brought through an abdominal wound
and carefully sutured to its edges. A long incision was. then made
through the outer bowel to the intussusceptum, which consisted of two
tubes of intestine, one contained within the other, the outer being colon,
the inner, ileum. The outer and inner layers of the intussusceptum were
cut away step by step and deep catgut sutures were immediately put
in to close the peritoneal pocket as soon as it was open. This patient
recovered. The same method was employed with equal success in the
second case. The latter portion of this valuable contribution deals with
the operative treatment of malignant growths of the large intestine.
Because of the large mortality from peritonitis which follows primary
resection of the large intestine from malignant growths, von Mikulicz has
for a long time advocated the two-stage operation. The results of this
method are infinitely better than those following primary resection. Of
24 cases operated upon, but 4 died after the operation, and none of
these deaths can be attributed to the method of procedure, one having
died 11 days after operation, from pulmonary embolism; another, a week
after, of pneumonia; a third, 6 weeks after operation, of general car-
cinomatosis; and a fourth, within 2 days, of peritonitis. The primary
operation consists in the enucleation of the tumor, the removal of the
lymphatic glands, and the withdrawal of the mass through the wound.
The loop of bowel is stitched to the parietal peritoneum and the ab-
dominal wound is partially closed. When the abdominal cavity is com-

120 GENERAL SURGERY.

pletely shut off, the tumor is excised and an artificial anus is estabhshed
which is closed 3 or 4 weeks later.

F. Gregory Connell^ discusses through-and-through intestinal
sutures at some length, quotes numerous authorities, and reports a
number of additional cases operated upon. His conclusions are as fol-
lows: "(1) The suture that aims to include but a portion of the bowel-
wall is dangerous: (a) because it is liable to fail to include any of the
sub mucosa, in consequence leaving a weak stitch ; (b) because, if including
any of the submucosa, it is almost certain to penetrate the coat, leaving
a stitch open to the dangers of capillarity. (2) By utilizing a through-
and-through suture the danger of yielding is excluded. (3) By employ-
ing a suture that is knotted in the lumen the danger of capillarity is
diminished. (4) It is acknowledged that the most appropriate place for
the knot when all coats are perforated is in the lumen of the bowel. (5)
It is undeniable that when the submucosa has been perforated acciden-
tally the knot ought to be placed inside. (6) It is also undeniable that
many so-called Lembert stitches perforate the submucous coat, and thus
convert an intentional nonperforating into an unintentional perforating
suture. (7) Undeniable, too, that owing to the extreme tenuity of the
submucous coat (one-sixth of the thickness of the needle which is to
'penetrate, but not perforate' it) we are utterly unable to differentiate
between a perforating and nonperforating Lembert stitch. (8) The logi-
cal conclusion is that the ideal location for the last and all knots in an
enterorrhaphy is outside of the peritoneal cavity, in the lumen of the
bowel. (9) As a chain is no stronger than its weakest link, it is of prac-
tical import that the last one or two stitches be also perforating and
knotted in the lumen. (10) The diaphragm by its valve-like action is
of great value in the prevention of leakage. (11) The tying of the knot,
according to the method described above, does not interfere with the
establishment of firm union or tend to leakage. (12) The side-knot, or
'square' stitch, in rendering a retaining suture unnecessary, is superior
to the top-knot, or 'circular' stitch."

James H. Dunn^ reports i6 cases of intestinal resection, in 9 of
which a Murphy button was used and in 7 of which simple sutures were
employed. Of the 9 cases in which the button was used, 3 were fatal,
1 clearly because no resection should have been undertaken. In one the
larger button was used in an end-to-end anastomosis of the sigmoid, and
although the patient was in extremis, it is quite possible that he might
have recovered if the suture had been used. This is the only case in
which the author has to regret the method of anastomosis chosen. One
patient died 6 weeks after operation, with extraperitoneal suppuration
in the abdomen and nephritis. There is no reason to believe the method
of anastomosis had anything to do with the result. Of the 7 cases in
which suture alone was employed, 6 recovered and 1 died from collapse
within an hour. Four of these 7 anastomoses were done with the Con-
nell suture. The author's conclusions are as follows: (1) Suture is the
most indispensable and generally applicable method of anastomosis in

1 Amer. Med., Jan. 24, 1903. ^ Jour. Am. Med. Assoc, May 20, 1903.

DISEASES OF THE PERITONEUM AND INTESTINES, 121

Fig. 26. — Lundliolin's forceps for intestinal ana.stomo.sis. a, Longitudinitl groove.s on inner surfaces
of the blades, forming a rectangular tunnel closed at one end, when forceps are locked; b, transverse
grooves extending around outer surface-s of both blades; c, sharp-pointed sliding stylet, to be introduced
into the tunnel formed by the grooves in order to cut the intervening visceral wall; rf, blunt sliding
stylet to be heated and introduced into the tunnel after cutting is done, thereby preventing eventual
hemorrhage (Jour. Am. Med. Assoc, Sept.. 27, 1902).

Fig. 27.— Lundholm's method of intestinal
anastomosis, showing first steps of operation. One
blade of forceps has pierced gastric wall and is
held securely in position by tightening and tying
the puckering ligatures in' one of the transverse
grooves. This also protects from possible leakage
of stomach-contents. The other blade, in tlie
operator's right hand, is held ready to be pushed
through into the lumen of the intestine in the
center of the pucker. In order to guard against
accidental penetration of both intestinal walls,
the anterior wall is held up steady by thumb and
index-finger of operator's left hand (to the left on
the figure), and also in the same manner to the
right by an assistant (Jour. Am. Med. Assoc,
Sept. 27, 1902).

9 S

Fig. 28. — Lundholm's method of intestinal
anastomosis. Shows the upper side of the forceps
after it has been introduced and locked. The two
blades of the instrument hold the gastric and in-
testinal walls in juxtaposition, pressing them
firmly together. The original i)uckers are seen
tied around the blades. A continuous silk suture
(white) going through all the layers and also a
superficial catgut (black) are sewed over the ui)per
surface of the instrument. Note that the ends of
both silk and catgut sutures are left long to be tied
with the other ends of the same sutures when
suturing is completed all around the anastomosis
and instrument removed. The forceps are held
by an assistant and the fingers of the operator's
left hand are holding the parts to be sutured
somewhat tense over the instrument, thus very
materiallv aiding the placing of the sutures
(Jour. Am. Med. Assoc, Seiit. 27, 1902).

122

GENERAL SURGERY,

intestinal resection. (2) The Murphy button is equally useful, if not pref-
erable, under certain conditions, but very inferior under others. For the
end-to-end union of segments of normal small intestine, or the end-to-side
anastomosis of healthy small and large bowel, it gives results unexcelled
by any other method. In unions of the larger intestine it is so far inferior
to suture as to be practically contraindicated. Pathologic changes in
the small intestine or its mesentery which render the perfect application
of the button difficult or such as would probably disturb the course of

Fig. 29.— Lundholiu's method of intestinal an-
astomosis. Rep resent sunder side of the instrument.
The silk suturing is completed to the point X,
where it is tied, but not cut, after which three
loose stitches are placed around the instrument,
ending at the starting-point. The catgut suture
is completed to the point *, where it is also tied
and left long. The sharp-pointed stylet is pushed
into the tube formed by the two longitudinal
grooves in the blades, thereby severing tTie inter-
medial visceral walls and also the two purse-string
ligatures which were placed primarily around
each blade (Jour. Am. Med. Assoc, Sept. 27,1902).

Fig. 30.— Lundholm's method of intestinal
anastomosis. The instrument is removed. Tlie
primary puckers around each blade of the instru-
ment, which were cut by the sharp-pointed stylet,
are picked up by a dissecting forceps, /. The
edges of perforation produced by the instrument
are to be inverted, the stitches already placed
tightened, and the two ends of tlie silk suture
tied together (Jour. Am. Med. Assoc, Sept. 27
1902).

heahng, should be united by suture. (3) Of suture methods, that of
F. Gregory Connell is incomparably the best; is, in reality, the simplest;
a single row of continuous suture, all wdthin the gut, the most likely to
be even, strong, and tight, with the smallest and most even diaphragm,
admits of the easiest and most perfect deahng with the mesenteric border
and is capable of a simple invariable technic. (4) It is especially de-
sirable to choose the fewest and simplest means compatible with the best
work, because intestinal operations occur at rare and irregular intervals

DISEASES OF THE PERITONEUM AND INTESTINES.

123

as emergencies in the hands of many surgeons, and the little conveniences
which enter into highly specialized operations of repeated daily execution
are for the most part worse than impracticable."

Lundholm^ describes a new instrument for intestinal anastomosis
the use of which is easily understood by reference to the illustrations
(Figs. 26-32). He has employed the instrument in 6 cases, 5 of which
were gastroenterostomies and 1 a lateral anastomosis of the intestine.
In 4 of the stomach cases an enteroanastomosis was also made. All of
the patients recovered. The author's conclusions are as follows: "Any
kind of lateral anastomosis is rapidly performed, about h hour being
generally sufficient. The size of the anastomosis opening can be made
larger or smaller, as the need may be, by pushing the blades more or less

Fig. 31. — Liindholm's method of intestinal
anastomosis, showing the silk suturing corapleled.
The last two or three catgut stitches are then
finished and the two ends of the catgut tied to-
gether (Jour. Am. Med. Assoc, Sept. 27, 1902).

Fig. 32. — Lundholin's molhod of inte.stinal
anastomosis. The anastomosis completed. The
intestinal anastomosis is perf<)rme<l in exactly tin;
same manner as gastro-eiiterostomv (.lour. Am.
Med. Assoc, Sept. 27, 1902).

deeply into the bowel before the forceps are locked. Leakage of visceral
contents during the operation is, with ordinary care, nearly impossible.
With the instrument in the bowel the sewing can be done with ease very
rapidly and substantially. It leaves no foreign body in the bowel to be
expelled afterward. A surgeon witli limited experience in intestinal
work can, with this instrument, perform lateral anastomosis with com-
parative safety. Postoperative hemorrhage from the stomach is pre-
vented by crushing of the tissues with the forceps, by the suturing and
the cauterization of the cut edges. No hemorrhage has so far occurred '
in any of my cases."

A case in which nearly 8 feet of gangrenous intestine was resected
' Jour. Am. Med Assoc, Sept. 27, 1902.

124 GENEIL\L SURGERY.

is reported by George R. Harris.^ The patient was suffering from
general peritonitis at the time of operation. Gangrenous intestine
resulted from constriction by a band. The mesentery as well as the
bowel -was necrotic at several points. There was a small perforation in
one part of the intestine. The gangrenous portions of both intestine
and mesentery were removed and an anastomosis was made between
the cecum and the distal end of the small intestine. The patient vom-
ited persistently after the operation for some time, but this symptom
was greatly relieved by gastric lavage. The Murphy button with which
the anastomosis was made was found in the rectum on the twenty-fourth
day and removed. Except for the fact that the abdominal wound be-
came infected, the patient made a good recovery. A list of 35 cases in
which great lengths of intestine have been resected accompanies the
report.

Roswell Park^ reports a case of successful removal of 265 cm. of
gangrenous intestine. The case was one of gangrenous appendicitis
involving in the gangrenous process a large portion of the small intestine
and cecum. The inflamed bowel was adherent to the cecum and appen-
dix. There were four large areas of bowel-wall which were in a gan-
grenous condition and threatened perforation. The uppermost point of
this kind was a great distance from the cecum. After the adhesions
were separated the question presented itself whether it was best to do
several resections or to take out the entire diseased bowel and make one
anastomosis. The latter course was decided upon, the ileum being
anastomosed by means of the Murphy button with the ascending colon.
The remaining ileum and a large portion of the cecum were excised and
their ends inverted. The patient was very septic at the time of opera-
tion, but, except for a fecal fistula which discharged for 3 or 4 months
and then closed, he made a good recovery. The button was not passed
until 4 months after operation, and it was then that the fecal fistula
closed. The patient was recently heard from and was in the best of
health in every respect. The bowel removed measured 265 cm. (8 ft.
9 in.). Park presents a list of 16 cases besides his own in which more
than 200 cm. of bowel has been removed. In a case of Obalinski the
bowel removed measured 365 cm. (12 ft. 2 in.). This patient died
promptly after the operation. Of the patients, 15 recovered although
from 205 cm. (6 ft. 10 in.) to 320 cm. (11 ft.) was excised.

Emanuel J. Senn^ presents an experimental and clinical study
relating to the transplantation of the omentum in operative treat-
ment of intestinal defects, with the following conclusions: (1) Trans-
plantation of omentum over defects in the stomach is an established
operation. (2) Transplantation of omeritum over intestinal defects is
recommended, but is still in the developmental stage. (3) Transplanta-
tion of omentum over defects in the cecum gives better results than in
any other portion of the intestinal tract. (4) Transplantation of
omentum over defects in the small intestine should only be done after

1 Med, Rec, Oct. 11, 1902. ^ Buffalo Med. Jour., April, 1903.

3 Jour. Am. Med. Assoc, April 18, 1903.

DISEASES OF THE PERITONEUM AND INTESTINES. 125

fixation of the segment of intestine to the abdominal wall. (5) Gauze
drainage should be resorted to, excluding the general peritoneal cavity.

Pollard^ reports an unusual and interesting case of matting of the
intestines for which he performed a successful double enterectomy.
A large amount of the small intestine was matted together and firmly
adherent to the sigrnoid. It was necessary to remove the whole mass of
the small intestine, measuring about 3 feet, and a number of inches of
the sigmoid flexure. An end-to-end anastomosis by means of sutures
was employed in each instance. The patient made a good recovery.

The creation of an artificial valvular fistula in the cecum for the
treatment of chronic colitis and a similar opening in the jejunum
as an adjunct to certain operations on the stomach is described by
C. L. Gibson,^ who refers to the cases operated upon by Bolton,^ and
also the method of employing the appendix for irrigating the colon, as
suggested by Weir. In a case in which Gibson operated, the patient
lived only 8 days, dying of tuberculous enterocolitis. Although the
irrigation was begun through a misinterpretation of directions on the
first day after operation, it was carried out without infection of the peri-
toneal cavity, as the autopsy showed. The operation which Gibson
recommends is exactly that which Kader uses in performing gastrostomy.
The second portion of this paper deals with performing jejunostomy after
the same manner in certain cases of operation upon the stomach. This
is done in order to enable the patient to receive nourishment at once
without any disturbance of the stomach. The suggestion of this opera-
tion is only tentative, its application being limited and its results, imme-
diate and remote, debatable. Gibson reports a case in which he removed
a large part of the stomach, anastomosing the duodenum and remaining
portion, bringing up a loop of the jejunum, and establishing an opening
into it such as described. This patient, however, died on the third day,
from peritonitis starting in the lesser peritoneal cavity, evidently due
to infection during the operation, the suture lines of the anastomosis
being found in excellent condition. There had been no leakage around
the jejunal opening. The advantage of using the method of Kader is
that the opening will close in a few days if the tube is withdrawn.

Robert F. Weir,* in advising the estabhshment of artificial anus at
the cecum or ascending portion of the colon in cases of persistent and
intractable colitis for the purpose of thorough irrigation of the bowel,
refers to a case in which he brought the appendix into the wound and
after fastening it there opened its extremity and introduced a catheter
through it into the cecum. Irrigation through the appendix in this case
resulted in recovery. If only we are sure that the appendix is patent,
it need not be opened until adhesions have formed. The advantage of
the method is its simplicity and the ease with which the appendix can be
removed and the fistula closed.

Willy Meyer^ reports "a case in which he has employed the method

» Lancet, March 28, 1903. ^ Boston M. and S. Jour., Sept. 25, 1902.

"YEAn-BooK, 1902. ^ Med. Rec, Aug. 9, 1903.

5 Med. News, June 27, 1903.

126 GENERAL SURGERY.

described by Weir for the purpose of irrigating the colon. The opera-
tion is termed appendicostomy. The patient was a woman, 53 years
of age, who was suffering from extensive ulcerative colitis involving also
the rectum. She was in no condition to stand any extensive operative
procedure, and the simple operation of bringing the appendix through
the abdominal wall and suturing it in this position was carried out. To
ascertain that the organ was patulous, it was immediately opened and
a bougie was introduced into the cecum. It was then constricted with
a suture which remained in place until the first irrigation of the bowel was
carried out, 24 hours later. Great improvement followed the irrigations
with nitrate of silver solution, and the appendix made an excellent fis-
tulous opening through which it was easy to introduce a tube and through
Avhich nothing passed from the intestine. In this operation there is no
probability of the appendix becoming acutely inflamed, but if it does so
it can be dealt with very easily. Meyer expresses his intention of em-
ploying this operation in cases of ileus due to cancer of the large intestine
in which it is desirable to relieve the obstruction before attempting a
radical operation. The advantages of such a procedure are enumerated
as follows: "(1) Saving of time ; (2) reducing the possibility of infection,
since the distended bowel would be opened only after the closure of the
peritoneal cavity; (3) obviating the necessity of an additional surgical
intervention to close the opening leading into the intestinal tract, the
same as is derived from inversion."

Hale White and Golding-Bird^ present the subsequent history of 3
cases of colitis in which right lumbar colostomy was performed several
years ago. The first case was one of membranous colitis of 20 years'
duration occurring in a woman 36 years of age. A right lumbar colos-
tomy was done on May 13, 1896, and 1 year later the artificial anus was
closed without difficulty. The improvement during this year was very
great, the patient suflfering no bad symptoms and gaining flesh. In
November, 1898, or 18 months after the closure of the artificial anus, the
patient was living an ordinary life and was active in her habits and was
taking moderate exercise. It was necessary, however, for her to take
aperients to open her bowels. Nothing was heard from her from this
time until February, 1902, when she had relapsed from her improved
condition, a return of symptoms taking place in December, 1898. The
second case also was one of membranous colitis. The patient was a bar-
maid 31 years of age. She was operated upon March 3, 1898. The
artificial anus was not closed for 2h years, during which time the patient
remained in perfect health, resuming her work 6 months after the opera-
tion and subsequently continuing it without interruption. The patient
twice refused an offer to have the artificial anus closed, as she feared a
return of the membranous colitis. In November, 1901, when the arti-
ficial anus had been closed for more than a year, the patient was in per-
fect health, and a careful examination was madfe of all bowel movements,
which, however, were found perfectly normal. The third case was that
of a man, 35 years of age, who had suffered from chronic colitis for 7 years.

^ Clin. Soc. Trans., xxxv.

DISEASES OF THE PERITONEUM AND INTESTINES. 127

The same operation as in the other cases was performed in December,
1898. Some difficulty was encountered in closing the artificial anus in
this case, only partial success accompanying three attempts. In Feb-
ruary, 1902, the sinus remaining from the last operation had closed
spontaneously and the patient was in perfect health. The cause of the
failure in the first case to permanently relieve the condition the authors
attribute to the fact that the artificial anus was closed too soon. It
must also be borne in mind that the patient had suffered from mem-
branous colitis for 20 years and at the time of operation was a chronic
invalid. It is thought that posterior colostomy is much to be preferred
to a cecostomy. The artificial anus in the cecostomy is controlled with
difficulty as compared to the posterior opening and is much more difficult
to close. It is thought that the method of making a small valvidar
opening in the cecum, as has been suggested by Gibson and employed by
Bolton and others, is not to be recommended, particularly for the treat-
ment of membranous colitis, since in the authors' opinion irrigation in
these cases does more harm than good. It is also thought that the
method practised in the cases reported is much to be preferred to that
of anastomosing the ileum to the sigmoid; first, because when such an
anastomosis is made the irritating contents of the ileum passing at once
into the rectum will probably produce chronic diarrhea; secondly, some
of the contents of the small intestine will be sure to regurgitate from the
sigmoid flexure into the colon and so keep up the colitis; and, thirdly,
the implantation will in many instances not be below the whole of the
diseased area.

Littlewood^ presents an interesting and instructive discussion of
malignant disease of the colon and reports 14 cases in which he has
performed colectomy with 10 recoveries. His remarks are based on
26 cases of cancer of the colon which have come under his care during
the past 4 years. All of these growths were columnar carcinomas. In
referring to the diagnosis, it is stated that probably in all cases, when
carefully inquired into, there will be found a history of increasing diffi-
culty in getting the bowels opened. In order to make an early diagnosis
of malignant disease, or in order to exclude it, the medical man should
endeavor in every case of constipation to find the cause of the trouble
before prescribing a remedy. The development of constipation after a
life of regularity in this respect, and especially if the constipation comes
on in attacks associated with colicky pains and the presence of blood and
mucus in the motions, should cause suspicion, and a careful examination
of the rectum and anus should be made. The cases of malignant disease
of the colon are divided into two classes — those in which a definite tumor
is present, and those in which there is a constricting ring of growth which
it is often impossible to discover by palpation. The larger growths are
more likely to be found in the cecum, the hepatic flexure, and the trans-
verse colon. The most frequent seat of cancer is at the flex^ures. The
larger the growth and the nearer it is to the cecum, the less likelihood
there is of obstruction, since the fecal matter is more fluid at this point

' Lancet, May 30, 1903.

128 GENERAL SXTRGERY.

and since the larger growths are less liable to contract and produce nar-
rowing of the caliber. Where no growth can be felt, and yet there is
strong reason for suspecting its existence, an exploratory incision is
justifiable. Littlewood did this in one of his cases and it was the earliest
case of malignant disease of the colon on which he had ever operated.
Regarding the use of enemas, it is stated that the author is acquainted
with 2 cases of fatal peritonitis due to a malignant ulcer bursting into the
peritoneum during the administration of an enema. Age may be of
value in deciding a diagnosis, but it must be remembered that malignant
disease may occur in the young. The youngest patient in the present
series was 28 years of age. The only treatment of malignant disease of
the colon is enterectomy. Littlewood performs this operation by con-
trolling the intestinal contents with Doyen clamps fixed near the point
at which division is to be made. A strip of redundant mucous mem-
brane is excised from each divided end of the bowel and a continuous
suture of catgut is passed through the muscular and serous coats for one-
half the circumference. This is followed by a continuous suture of the
mucous membrane alone which passes around the entire circumference.
When it is completed, the first suture is again taken up and completed.
Two rows of sutures are thus employed, one in the mucous membrane
and one in the muscular and serous coats. They are each of either
chromic or formalin gut and are interrupted at two or three points by
knotting so as to prevent narrowing of the lumen of the bowel by traction.
The opening in the mesentery is closed by applying three or four catgut
ligatures which include both of the cut edges. This procedure prevents
the possibility of perforating a mesenteric vessel which sometimes occurs
when a needle and thread are used to suture the edges of the mesentery.
After the completion of the anastomosis the omentum is wrapped around
it if possible and the abdomen is closed without drainage. When an
end-to-end anastomosis cannot be accomplished a lateral anastomosis
should be made. In cases of complete obstruction in which the exact
position of the growth cannot be ascertained Littlewood prefers to open
the abdomen in the middle line sufficiently to admit the hand and arm.
The intestine is not allowed to escape while the hand makes a careful
search for the point of obstruction. The search should be begun at the
top of the rectum and carried around the large intestine to the cecum.
After the growth has been found the liver and other organs should be
carefully examined for secondary deposits. A preliminary colostomy
should be performed and later an enterectomy. This was done in 3 cases
of the present series, 2 of which recovered. Another plan which can be
practised in the presence of an acute obstruction is the withdrawal of the
loop of bowel with the growth, its fixation in the wound, and its subse-
quent removal. This was done in 2 of the cases here reported; in each
case the bowel and growth were removed a fortnight after the first opera-
tion without an anesthetic. Both patients are now living, the first
having been operated upon in June, 1899, and the second in October, 1901.
If the growth is not removable, or if there are secondary growths, a
lateral anastomosis can be formed or a permanent artificial anus estab-

DISEASES OF THE PEEITONEUM AND INTESTINES. 129

lished. Brief reports of the 14 cases operated upon are presented in a
table.

Keith^ makes the nature and anatomy of enteroptosis the subject
of three Hunterian lectures. He claims: (1) that a knowledge of the
respiratory movements of the viscera gives the key to the manner in
which they are fixed and placed within the body ; and (2) that with any
marked deviation in the action of the muscles of respiration there is a
disturbance in the visceral movements, resulting in displacement and
disorganization of function. Keith says that when the respiratory
balance is upset the viscera of the chest as well as the abdomen are dis-
placed downward, resulting in the condition of enteroptosis. In many
of these cases the displacement of but one organ is noticed; yet, if
careful examination is made, it will be shown that all the organs are dis-
placed, but to a less degree. This paper is a lengthy one and deals largely
with the anatomy and function of the various muscles and their develop-
ment, as wtII as the location and fixation of the various viscera. It is
numerously illustrated, which illustrations do much toward making the
author's text clear. Ptosis of the liver and stomach arises from the
relaxation of the abdominal muscles, which maintain the visceral shelves
on which these organs rest, or from constriction of the cavity by clothing.
This point is excellently illustrated by a cut which represents the waist
and viscera of a woman, 45 years of age. After death the waist was
reduced from 26 to 22 inches, the tissues hardened, and the result repre-
sented in the cut obtained. The author devotes considerable attention
to the various agents which aid in the fixation of the kidney. Displace-
ments of this organ are brought about by compression of the thorax
with clothing, by the partial collapse of the thoracic wall following chest
and spinal disease, and by the permanent contraction of the diaphragm
which follows a relaxed or paretic condition of the abdominal walls.
Keith accounts for the infrequent displacement of the left kidney by the
fact that the very freely movable splenic flexure of the colon acts
as a safety-valve when the region is constricted. He shows how easily
it is displaced to the left and downward by a full stomach. In addition,
the left kidney is bound to the spleen, and the spleen is bound to the
diaphragm. On the right side the arcuate fibers draw down the heavy
liver against the kidney, whereas on the left side it is only the fundus of
the stomach that is drawn down. Attention is called to the fact that in
infants there is no difference in the position of the kidneys in the two
sexes. It is shown that the kidney may be displaced upward as well as
downward by lacing, according to whether a woman maintains a high or
a low waist. In closing, fixation of the intestinal tract, its movements
and displacements, are briefly considered. In discussing the fixation
of the intestinal tract the subject is looked at from the point of view of
comparative anatomy. The intestinal displacement may be due to the
diminution of the costal portion of the body-cavity, the subcostal viscera
being thrust down upon it, or to the want of support afforded by the
muscular wall of the stomach.

' Lancet, March 7 and 14, 1903.

130

GENERAL SURGERY,

RECTUM AND ANUS.

Mackay/ of Melbourne, reports 2 cases of foreign bodies in the
rectum of infants. The first patient was a male child 2 j^ears of age
who was admitted to the hospital with marked distention of the abdomen
and suffering from great pain. For the previous 3 months the child had
been cross and ailing. He was not weaned, but nevertheless ate every-
thing given him. The abdominal walls were so tense that when the
child was anesthetized nothing could be made out by palpation. An
examination of the rectum revealed a glove-button which was acting like
a valve and closing the narrow anus. It was removed with a scoop, A

Fig. 33. — Mitchell's operation for hemor-
rhoids. A pile is clamped in a long narrow-
bladed forceps— Kocher's artery forceps answers
admirably (Brit. Med. Jour., Feb. 28, 1903).

Fig. 34. — Mitchell's operation for hemor-
rhoids. The redundant mucous membrane and
pile are cut away with scissors. A curved needle
threaded with catgut hardened in formalin is
then inserted immediately above the clamp and
the end of the catgut secured by a knot (Brit,
Med. Jour., Feb. 28, 1903).

collection of beads, cherry-stones, plum-stones, and pieces of road metal
was then removed, and an enema brought away a large quantity of
normal fecal matter. The abdomen became flaccid and the patient
comfortable. Three days later, however, a large doughy mass was felt
in the right hypogastrium. The child was again anesthetized and several
pounds of fecal matter were removed by washing through the high rectal
tube. This fecal matter contained plum-stones, cherry-stones, chaff,
egg-shell, pieces of straw, and quantities of undigested food and fruit
skins. The second case was that of a male child 2f years of age who was
admitted to the hospital straining with pain. The child had been born
with an imperforate anus and a small opening had been made. An

^ Intercol. Med. Jour, of Australasia, May 20, 1903.

RECTUM AND ANUS.

131

examination with the finger revealed a plum-stone plugging the anal
opening. The anus was dilated and two plum-stones were removed.
The opening was enlarged by several radiating incisions. The child has
had no further trouble.

S. Lewis ^ reports 8 cases of anal fissure which he has cured by re-
peated applications of a saturated solution of potassium permanganate
followed by the introduction of suppositories of anusol. The ulcerated
area is first anesthetized with a 6 % cocain solution applied on a cotton
pledget for 15 minutes. Occasionally the sphincter has been stretched
with a bougie, but this is seldom necessary.

Fig. 35. — Mitchell's operation for hemor-
rhoids. A continuous suture is rapidly applied
round the clamp (Brit. Med. Jour., Feb. 28,
1903).

I'"ig. 36. — Mitchell's operation for hemor-
rhoids. The clamp is withdrawn (this can be
done without the slightest difiiculty) and the
.suture tightened, leaving a vertical line of con-
tinuous sutures within the rectum. The upper
end of the ligature, which is left long for the
purpose, should be held tirnily in the left hand
while the lnwer end is being tightened, so a.s to
prevent puckering. Each pile is treated simi-
larly in turn (Brit. Med. Jour., Feb. 28, l'.»03).

A. Rose^ reports minutely a case of rectal fistula complicating
hemorrhoids which was cured by passing through it carbonic acid gas.
Marked improvement was noticed after one or two treatments, and in a
very short period of time the fistula was entirely closed.

A. B. Mitchell,^ of Belfast, recommends the simple operation for
hemorrhoids which is illustrated in the accompanying cuts (Figs. 33-
36). The advantages of the method are its control of hemorrhage and
the formation of a linear scar.

John O'Conor* is an ardent advocate of the Whitehead operation in
the treatment of hemorrhoids. He has employed the method in 150
operations. No death has occurred in this series and in only 5 instances

1 Med. News, May 20, 1903.

3 Brit. Med. Jour., Feb. 28, 1903.

2 N. Y. Med. Jour., Jan. 31, 1903.

* Boston M. and S. Jour., Feb. 26, 1903.

132 GENERAL SURGERY..

did any appreciable contraction follow. Contraction occurred in his
earlier cases where injudicious encroachment on the skin was made. He
has applied the operation to all kinds of patients and in not a single
case has a relapse occurred. It is maintained that no excessive hemor-
rhage takes place during the operation if it is properly performed. Dur-
ing the past 12 months O'Conor and his colleague Phelps have operated
upon 26 cases and the average time of operation was 12^ minutes; the
maximum time was 20 minutes (only one case) and the minimum 5
minutes. This result is opposed to the frequent text-book statements
that the operation is objectionable because of the long time required
for its performance. The author employs a slight modification of the
original operation, and describes his technic as follows: "(1) Artery-for-
ceps are applied to the four cardinal points of the roset, or if the case
be nonprotrusive, the forceps are applied at same points about ^ of an
inch from skin margin. The assistant by making traction on two adjacent
forceps removes the rugose condition, and brings the line of junction of
skin and mucous membrane readily into view, while I divide around
^vith scissors about ^ of an inch from skin. (2) The mucous membrane
is next separated from underlying structures by passing the left index-
finger into rectum, which acts as a most efficient guide, while, with a
blunt dissector, and an occasional snip of a scissors, the mucous cuff is
raised, and separation carried well above pilous zone. So far there is
generally very little hemorrhage, but if any should occur it is imme-
diately ligated with catgut. Care is necessary during this part of the
operation not to injure the sphincters by any reckless scissoring. If the
mucous membrane is divided deep enough at the commencement, the
blunt dissector and fingers do the rest. (3) By the four artery-forceps
originally applied, the cuff of mucous membrane is drawn outward, and
it is transversely divided above pile area. In doing this it is most neces-
sary to determine the extent of each scissors snip by the amount of
hemorrhage, every spurting vessel must be at once caught up in forceps,
and by working round in this manner it is surprising how little blood
is lost. When the cuff has been removed, each bleeding point is ligated
with catgut. I usually retain a few forceps in position after ligation, as
they are useful during the next move; namely, approximation of mucous
membrane to skin. (4) All hemorrhage having been effectually arrested,
the part is well irrigated with warm salt lotion, and the mucous mem-
brane is attached to skin by a continuous catgut suture." The key to
success is not to draw this suture too tight. A tight suture causes
necrosis of tissues. Under no circumstances should the suture be em-
ployed to control hemorrhage. All bleeding should be arrested before
the suture is introduced. Careful cleansing of the part after operation
is employed. In his recent operations O'Conor has abandoned the wide
dilation of the sphincter; the muscle is only stretched sufficiently to per-
mit the hemorrhoids to come fully into view.

Metcalf,^ of Detroit, advocates a plan of treatment for hemorrhoids
based upon an experience of more than 700 cases with operation during
1 Jour. Am. Med. Assoc.., Sept. 20 1902.

RECTUM AND ANUS. 133

the last 10 years. The method employed depends upon the fact that
the arterial supply of internal hemorrhoids comes from above the vessels
entering parallel with the gut, and the tendency of these arteries when
cut is to retract within the loose tissue of the tumor. The vein extremi-
ties can be cut without danger of hemorrhage. This refers to uncom-
plicated internal hemorrhoids, which the author believes always arise
between the fephincters. In those few cases in which they extend above
the internal sphincter the danger of hemorrhage is greater and the ligation
of arteries is occasionally necessary. In the operation the bivalve specu-
lum of Pratt is used, and it is so adjusted that the tumor presents between
the separated blades. The mucous membrane covering the pile is stripped
off on either side until the veins are thoroughly exposed. These are then
clipped off with scissors. When the veins have emptied themselves the
tumor will have disappeared unless there is a quantitj^ of fibrous tissue,
which, when present, should be cut away to the level of the vessels.
If a vessel bleeds it is grasped with artery-forceps. The remaining hem-
orrhoids are treated in the same manner. The largest arteries are found
one anterior and one on either side near the center. When all the hemor-
rhoids have been exposed and evacuated, the sphincters are gently and
thoroughly dilated and bleeding points are looked for, and, if found, are
ligated with fine catgut passed through the tissue as a stitch. The thor-
ough divulsion of the sphincter is a potent factor in lessening the venous
hemorrhage. A plug of iodoform gauze is then introduced and allowed
to remain until the patient complains of some pain, usually before con-
sciousness completely returns. The plug is then taken away and its
removal clears away any small clots which may have formed. After-
ward the parts are dressed with sterile gauze compresses wrung out of
water as hot as can be borne. These compresses lessen the tendency to
spasm. Morphin is seldom required in female patients. The bowels are
not opened until the fifth day, by which time the wounds are covered
with epithelium and there is no infection from the passage of fecal matter.
When the whole circumference of the rectum is diseased and prolapsed,
amputation of the redundant mucous membrane is advisable. The
secret of success in this operation is to avoid the removal of any skin.
If this is not done, the skin is drawn within the grasp of the sphincter
and the patient suffers a great deal of pain. The same after-treatment is
carried out. This operation is indicated in about 5 % of the cases
operated upon. The results have been most satisfactory.

Lofton^ describes in detail a case of hemorrhoids which he treated
by repeated injections of hot salt solution with a most satisfactory
result. The patient received the first injection in April, 1900. Eight
hemorrhoids were treated in this manner. From 20 to 30 drops of very
hot salt solution were injected into each tumor. Little or no pain was
experienced from the injection. After the operation the patient walked
3 miles to her home and the next day worked in the field. At the end
of a week examination showed the hemorrhoids sloughing. In 4 weeks
the wounds were healed. In this same manner 17 cases of hemorrhoids
1 Med. Rec, March 14, 1903.

134 GENERAL SURGERY.

have been treated with the same good results. In his later cases, by
using a metal syringe, Lofton was able to inject boiling water.

An extensive discussion of the treatment of prolapse of the rectum
is presented by A. E. Halstead/ who reaches the following conclusions:
" (1) All cases of prolapse of the mucous membrane alone can best be
treated by resection of the protruding mucous membrane and suture of
the cut end to the skin of the anus, as in Whitehead's operation for
hemorrhoids. In mild cases clamping and cauterizing linear folds of the
prolapse is sufficient to effect a cure. (2) In recent reducible prolapse of
all coats of the rectum, removal of the cause if possible, with massage,
gymnastics, and appropriate internal medication to improve the patient's
general condition, should be first tried. If these fail, amputation or
intraabdominal suspension is indicated. (3) In young children operative
treatment of prolapse is seldom required. The removal of the cause,
which can usually be accomplished, with rest in horizontal position,
tonics, and massage, will in the great majority of cases cure the patient.
Among the most frequent pathologic conditions which bear a direct causal
relation to prolapse in children are intestinal catarrh, rachitis, phimosis,
and stone in the bladder. (4) In old irreducible or in recent strangulated
cases, the only treatment is amputation by the method of Mikulicz. (5)
In old irreducible prolapse, or in recent cases where a fair trial of pallia-
tive remedies has been given, we have the choice of two methods —
amputation or intraabdominal fixation. At the present time no authori-
tative statement can be made as to the value of colopexy. It possesses
the following advantages : it is not dangerous, it is easily performed, and
when it is not successful it does not leave the patient in any worse con-
dition than before. Inguinal colostomy should never be performed except
when some special indication exists — e. g.. when prolapse is associated
with colitis which does not yield to treatment, or when stricture or
malignant diseases are present. Simple catarrhal inflammation of the
prolapsed rectum does not justify opening the colon. (6) Rectopexy, if
employed, should be used only in the lesser degrees of prolapse of the
rectum. In invagination of the rectum and colon it is of no value. In
any case its disadvantages and dangers outweigh its good points."

Stephen Paget^ describes a case of prolapse of the bowel with loss
of control following perineal excision of the rectum for cancer in a
patient 65 years of age. The condition was relieved by the submucous
injection of paraffin. At the time of operation the patient was wearing
a plug to control the bowels, but it only imperfectly accomplished its
purpose. Since the excision 7J years had elapsed. The patient was only
comfortable at night when the support was not used. In spite of the
support the prolapse would come down. The control of the bowel was
very deficient and the patient's life was rendered miserable. The pro-
lapse amounted to about 2 inches of healthy mucous membrane. The
patient was anesthetized and paraffin was injected at several points under
the mucous membrane. Two hard round nodules were raised, one lateral
and one posterior, about ^ inch in diameter and ^ or | of an inch in

» Medicine, June, 1903. ^ Brit. Med. Jour., Feb. 14, 1903.

RECTUM AND ANUS.

135

height. Before the injection the bowel easily admitted 3 fingers and no
sphincteric action could be discovered. After the injection but one finger
could be introduced. There was no pain or tenesmus after the operation
and only very trivial discomfort for a few hours. About a month has
elapsed since the operation and there has been no return of the prolapse
and no escape of the bowel-contents. The patient is perfectly comfort-
able and has no difficulty in keeping himself clean. It is possible that
sooner or later another injection may be needed, but there is at present
no reason to expect this. " The points to be noted are that the paraffin
must be injected immediately under the mucous membrane of the pro-
lapse, not outside the bowel, but into the fold of everted mucous mem-
brane; that numerous punctures must not be made, but only one or two,
lest a vein should be wounded; that the prolapse, with the nodules of
paraffin in its submucous layer, must be put back at once, and kept back ;

Fig. 37. — Robson's operation for incontinence of feces due to relaxed or paralyzed spliincter ani.
a, Anus. The doited area .sliows the wound pulled open, the arrows showing the direction of traction.
The third illustration shows the anus reduced in size, and the wound closed by sutures (The Practi-
tioner, Feb., 1903).

that the bowels must be kept inactive for several days after the operation ;
and that the patient must be kept in bed for 10 or more days till the
tissues are thoroughly contracted."

A. W, Mayo Robson^ describes an operation for incontinence of feces
due to relaxed or paralyzed sphincter ani, and details a case in which
he performed the operation with most satisfactory result. The operation
consists in making a semilunar incision at the junction of the skin and
mucous membrane around the anterior half of the anus. This is deepened
to about I or ^ an inch ; the upper and lower margins are then separated
by being drawn apart so as to make the semilunar slit into a lozenge-
shaped cavity, as shown in the accompanying iUustration (Fig. 37).
This cavity is closed by bringing together the sides by means of buried
catgut sutures and the skin by silkworm-gut sutures. This leaves a
straight wound which is entirely external to the bowel; and it not only

» Practitioner, Feb., 1903.

136

GENERAL SURGERY.

diminishes the size of the anus, but also restores the power of the sphincter

muscle.

Emil Ries^ discusses the treatment of extensive rectal strictures and

describes in detail an
operation which he per-
formed 5 years ago.
There are 3 dangers
which result from the
treatment of extensive
rectal strictures. They
have their origin in the
septic field of operation,
the changed anatomic
relation of parts, and
from the menace of re-
currence. Reference is
made to the frequent
extensive adhesions
about the rectum and
also to the not unusual
occurrence of abscesses
and fistulas in the peri-

Fig. 38.— Ries's operation for the treatment of extensive rectal
strictiire.s. Condition before operation, ^j, Peritoneum ; .s.«, stric-
ture of sigmoid ; r.s, stricture of rectum ; i.f.r, internal fistula ; r.v.f,
rectovaginal fistula; u.t, urethral tear; li.s, urethral stricture (N.
Y. Med. Jour., Dec. 13, 1902).

rectal tissues. These
complications render the operative treatment of this condition extremely
difficult and dangerous and the likelihood of recurrence much more prob-
able. The really severe

cases of rectal stricture '^/- ■^-' *

never yield to treatment
by colostomy or linear
proctotomy. Such cases
require plastic operations
on the continuity of the
bowel by which the fecal
current is conducted
throughout a long
healthy bowel. The two
methods heretofore usu-
ally employed are end-to-
end anastomosis after re-
section of the diseased
portion and side-to-side
anastomosis without re-
section. In uncompli-
cated strictures the first
method is often satisfac-
tory, but its performance is frequently extremely difficult and is sometimes
impossible. The side-to-side anastomosis of Bacon, which is accomplished
1 N. Y. Med. Jour., Dec. 13, 1902.

Fig. 39. — Ries's operation for the treatment of extensive rec-
tal strictures. Condition after operation, r.s, Rectal stricture;
s.s, stricture of sigmoid (N. Y. Med. Jour., Dec. 13, 1902).

RECTUM AND ANUS. 137

by pulling a loop of intestine above the stricture down to a point below the
stricture and joining them with a Murphy button, is only applicable if the
stricture is not very extensive and the bowel above it is extremely mov-
able. The case operated upon by Ries was a woman aged 25 who 7 years
previously had acquired syphilis. At the time of operation she suffered
from a rectovaginal fistula, a stricture of the rectum at the internal site
of the fistula, and, as was discovered when an attempt was made to
excise this stricture, a second stricture of the sigmoid. The pathologic
conditions are well illustrated in the accompanying illustrations (Figs.
38 and 39). The patient at the time of operation was much emaciated
and pale, and weighed but 82 pounds. An attempt was made to excise
the stricture of the rectum and cure the rectovaginal fistula, but when
the surgeon tried to draw down the portion of rectum above the stricture
he found it impossible because of a second stricture at the sigmoid, which
could be easily felt by a finger introduced into an opening made in the
posterior culdesac. The abdomen was then opened, the sigmoid divided
above the point of stricture, and the proximal end carried down through
the opening in the culdesac and into the rectum jiearly to the anus.
The healthy gut fitted snugly into the opening in the culdesac and in
the incision in the anterior rectal wall, so that no sutures of the peri-
toneum were used. The extremity of the gut was attached to the rectum
below the rectal stricture by 4 silkworm-gut sutures. Before doing this
work, however, the distal end of the sigmoid had been inverted and the
abdomen closed. The rectovaginal fistula was excised and the posterior
vaginal wall sutured. The patient recovered in spite of some infection
of the wound and rapidly improved after the operation, being able to
return to her home 19 days later. She was seen some 5 years after the
operation, wheti she had gained 58 pounds and weighed 149 pounds.
Passages were natural and there was no discharge of mucus and she had
no incontinence. Rotter, of Berlin, has published 3 operations similar
to this, which he calls sigmoideorectostomy. His first operation was per-
formed about a month after the operation just described by Ries, but
before the latter had published anything about his case.

Sir Chas. Ball,^ of Dublin, delivered the Erasmus Wilson lectures before
the Royal College of Surgeons, taking for his subject adenoma and
adenocarcinoma of the rectum. In his first lecture he deals with
simple, multiple, and congenital adenomas. It is difficult to differentiate
clearly between benign adenoma and malignant adenocarcinoma. So long
as the epithelial proliferation is small and of superficial development it
may be looked upon as benign, but if it pierces the basement membrane
and infects the submucous layer and muscular coat or involves the tissues
external to the bowel-wall we are obliged to look upon it as malignant,
as it presents all the clinical characteristics of malignancy. Digital ex-
amination in some cases will enable us to cUfferentiate between the benign
and malignant forms with confidence, the superficial character or softness
and the mobility of the simple adenoma being obvious, while in the case
of malignant growth its hardness and fixation indicate its malignancy. In

1 Brit. Med. Jour., Feb. 21, 28, and Mar. 7, 1903.
10 S

138 GENERAL SURGERY.

most instances, however, a microscopic examination alone will define the
true nature of the growth. It is shown that local irritation will fre-
quently cause the development of simple adenomas, as is seen in cases
of prolapse of the rectum in young children and as when a like condition
takes place after colotomy. The term "polypus" applied to the peduncu-
lated adenoma is strongly objected to. Treatment of the benign adenoma
is very simple, and consists in ligation if pedunculated and excision if
sessile. Among the congenital sacral growths which are frequently met
with there is one variety which shows distinct evidence of having origi-
nated in adenomatous tissue. Although occasionally these tumors are
directly connected with the rectum, in the majority the relation to the
coccyx and sacrum is much more intimate and the tendency to growth
is more outward than inward, although Ball refers to one case in which
the growth was entirely inside the pelvis. The mechanical effects pro-
duced by pressure of unusually large adenomas occasionally give rise to
important symptoms, such as intestinal obstruction and retention .of
urine, and they may also seriously obstruct parturition. These complica-
tions, however, rarely arise except in connection with the embryonic
adenomas.

The second lecture presents a discussion of adenocarcinoma. There
are two distinct types of this disease: one a flat nodule in the mucous
and submucous tissues, spreading somewhat rapidly and occurring more
commonly in comparatively young patients. The other is more super-
ficial, does not grow so rapidly, contains more fibrous tissue, and by
contraction interferes with the caliber of the bowel. This variety occurs
in older patients. The symptoms of cancer of the rectum are carefully
detailed and marked emphasis is laid upon the urgent necessity for early
local examination in all cases of chronic diarrhea. The successful treat-
ment of rectal cancer depends upon early diagnosis. When the growth
becomes fixed and the lymphatics are involved, the chances of a successful
removal become greatly lessened. The lymphatics at the back of the
rectum are the first to become involved, and then those along the great
iliac vessels are implicated. Metastatic growths are seen usually in the
liver, although they have occasionally been observed in the lung and
elsewhere. Wherever found, they reproduce accurately the original type
of disease. Associated with adenocarcinoma it is not uncommon to
meet with polypoid growths, and it is thought probable that these neo-
plasms are the result of the direct irritation of the discharge from the
cancerous mass. Occasionally cancer of the rectum undergoes colloid
degeneration, and it is this variety which is liable to be mistaken for
tertiary syphilis. When the rectum is examined the most careful investi-
gation should be made of the abdominal organs. It is important to
learn whether or not the growth is movable, as upon its degree of mobility
will depend both the prognosis and treatment. The greater the fixation,
the greater wiU be the involvement of the glands and the less the likeli-
hood of complete removal.

In his third lecture Ball discusses the surgical treatment of cancer of
the rectum. He advocates the most thorough preparatory cleansing of

RECTUM AND ANUS. 139

the bowel, both above and below the growth. This is accomplished by
the administration of purgatives for a number of days before operation
and by the use of the tube passed beyond the growth. If it is impossible
because of the constriction thoroughly to empty the bowel above the
disease, a preliminary colotomy should be done. If thorough cleansing
is possible, colostomy is unnecessary. It is recommended that the
perineal excision should be confined to those cases in which the growth
is limited to the anal region. In operating upon rectal cancer the best
results will be obtained in those cases in which the growth can be with-
drawn through the anus as if an intussusception had occurred. The
sacral route is the one which Ball favors, and he prefers to remove the
coccyx and a portion of the sacrum if necessary rather than to form an
osteoplastic flap. The best results in these cases will be obtained where
after the excision of the growth the proximal portion of the bowel can
be invaginated into the distal portion and attached at the anus. This
invagination is done after the entire mucous membrane of the lower
portion has been removed. It is believed that the abdominal route for
removing rectal cancer will become more and more popular, as it permits
the removal of the entire growth as well as the involved glands.

C. H. Mayo^ describes the evolution which has taken place in the
treatment of cancer of the rectum. The following is a summary of
the main objections to the operations of the past: (1) Ineffectual removal
with local recurrence, so common in the perineal type. (2) The extensive
mutilating character of the Kraske method before operative conditions
were known. (3) The frequent failure of all methods of union of the
proximal and distal portion^ of the bowel. (4) The frequent formation
of stricture, either cicatricial or cancepous, following operation, necessitat-
ing inguinal colostomy. (5) The straightening and tension of the sig-
moid destroyed it as a fecal container. (6) That sentiment and not
chance has proved the main reason for continuing to place an uncon-
trollable anus in a comparatively inaccessible situation. The combined
intraperitoneal and perineal method is advised by C. H. Mayo. This
permits the surgeon to suit the procedure to the individual case. He can
either radically remove the tumor and glands, or he may simply do a
colostomy. When there is total removal, the proximal portion of the
bowel, namely, the sigmoid, can be brought out of the abdomen in the
left iliac fossa through the gridiron opening of McBurney, giving a fair
control of the bowel and not destroying the function of the sigmoid as a
fecal container.

W. Watson Cheyne^ divides the treatment of cancer of the rectum
into doing nothing, performing colostomy, and removing the affected
portion of the bowel. When nothing surgical is done, the treatment is
directed to the relief of symptoms as they arise and the adoption of a
variety of palliative expedients. The cases suitable for this kind of
treatment are those in which there are fungating masses, chiefly growing
from one side of the rectum, as distinguished from those in which the
growth encircles and constricts the bowel. Colostomy removes the risk

» Jour. Am. Med. Assoc, April 25, 1903. ^ Brit. Med. Jour., June 13, 1903.

140 GP]NERAL SURGERY.

of obstruction and relieves somewhat the tenesmus and pain and cer-
tainly the liability to hemorrhage. But Cheyne does not think it does
much to retard the growth of the cancer. Because of the unpleasantness
of an artificial anus the performance of colostomy in an early stage when
the patient is still comparatively comfortable is not advisable. The
question of radical treatment depends on the probabilities of getting rid
of the disease by excision and on the risks which will be run in the at-
tempt. Wherever there is a fair probability of ridding the patient of
his disease, at any rate for a considerable period of time, and if it can
be done without undue risk to life, this operation should be proposed
in preference to colostomy, and the decision should be left to the patient.
In the majority of cases there is nothing inherent in the form of cancer
which occurs in the rectum that contraindicates an attempt at radical
operation. Nor is there anything in the situation which renders com-
plete removal particularly difficult in suitable cases. In his own experi-
ence the author has had a number of patients remaining alive and well
for periods extending up to 9 years since operation. The proportion of
suitable cases which come under observation is less than in cancer of
the breast and extremities. Cheyne has estimated that only 20 % of
the cases which present themselves to the surgeon will be found suitable
for a radical operation. Excision is much to be preferred to colostomy
in all cases in which there is a fair chance of removing the disease. The
operation should only be imdertaken in patients who are in a fair state
of health, who are likely to stand a severe operation and, it may be,
a prolonged convalescence, who are suffering from no other organic
disease, and in whom there is no extension of malignancy to other parts
of the body. The chief local contraindication is fixation of the bowel
at the site of the growth due to infiltration of the whole thickness of
its wall. The one exception to this is fixation to the vagina, since the
posterior wall of this organ can be removed with the growth. The high
situation of the growth is not considered a contraindication, since such
growths can be removed by the abdominal or the combined abdominal
and perineal routes. Three questions are raised in regard to the method
of operation. The first is as to the advisability of performing preliminary
colostomy. It is thought that only in exceptional cases is this pro-
cedure called for. The chief value of colostomy is in the cases in which
end-to-end suture of the divided bowel is carried out, but by varying
the method in which the bowel is united from an end-to-end suture to
an invagination of the upper into the lower portion the force of this
argument is very much diminished. One disadvantage of preliminary
colostomy is the time which elapses between its performance and that
of the radical operation. As to the question of the best method of
reaching the growth, Cheyne refers to the four chief methods which are
employed, — the perineal, the sacral, the vaginal, and the abdominal or
combined abdominal and perineal. In the majority of cases the sacral
method is the most suitable. The perineal operation does not give the
necessary amount of room in dealing with the disease, and especially with
the affected glands. In discussing the operation of Quenu, the author

RECTUM AND ANUS. 141

prefers to remove the affected portion of bowel above a clamp, invaginate
and stitch the lower end of the bowel, and leave it in position, while
the other end is brought out of the groin and the ligature about it left
in situ for 2 or 3 days if possible. There is no great advantage in dis-
secting out the lower part of the rectum and it adds considerably to
the shock and loss of blood. The third question which is dealt with is
the avoidance of sepsis and methods of dealing wuth the divided bowel.
The surgeon should avoid any examination of the rectum at the time of
operation; he should have ascertained all to be gained from such an
examination on a previous occasion. Cheyne always stitches up the anus
tightly so as to prevent any escape of material from it during the course
of operation. Where it is possible, the diseased portion of the rectum
should be brought outside of the wound before the bowel is divided, as
the risk of infection is very much reduced when this is done. Cheyne
generally employs prophylactic injections of antistreptococcic serum. In
cases in which the distal and proximal ends of the rectum can be approxi-
mated it is thought much wiser to remove a portion of the mucous mem-
brane of the proximal end and invaginate the distal end. This gives a
surer union and one which is less likely to leak and infect the wound.
Where anesthesia is not possible, a sacral opening is preferred, but in
doing this the open end of the bowel is not stitched to the skin wound.
By means of a ligature the divided end of the bowel is kept outside of
or at the wound and covered with a piece of dressing, and the wound
is then closed with silkworm-gut sutures. The skin around the point of
exit is stitched to the muscular coat of the bowel as far above the divided
end as possible. If possible, these steps are all taken before cutting off
the lower end of the rectum with the tumor. The chief objection to
the procedure of leaving the bowel constricted by the ligature is that
the escape of gas from the bowel is completel}' prevented and some
patients suffer a good deal from flatulence. Cheyne, however, has never
found it necessary to divide the ligature in order to relieve the patient.

Geo. W. Roberts* deals with sigmoidoproctectomy for cancer of
the rectum and reports 3 cases in which this operation was performed.
In each case the control of the bowel was very good by means of a hard-
rubber cup and bandage. The author's conclusions are as follows: " (1)
The accepted methods of operating for cancer of the rectum correspond
in lack of thoroughness to the old-fashioned amputation of the breast,
supplemented by removal of a few enlarged lymph-nodes from the axil-
lary space. This operation has been supplanted by the superior technic
of Halstead, and a more radical method of dealing with cancer of the
rectum, which includes removal of the sacral lymphatics, is indicated
with equal clearness. (2) In very few cases of rectal cancer indeed is
it possible to remove completely even the primary growth from below,
for it appears that many inches above the ending of the macroscopic
growth cancerous tissue is still found in the mucous membrane. We
cannot conceive of the complete removal of the infected glands from
the sacral hollow by any of the vaginalperineal, or sacral operations.
1 Med. Rec, March 21, 1903.

142

GENERAL SURGERY.

(3) While no one should underestimate the misfortune of an artificial
anus, it should be remembered that sphincteric control is frequently lost
after severe rectal operations even though the anus is preserved, that in
this case the opening is very disadvantageously located for mechanical
control, and that an artificial anus constructed as described is practically
perfect. (4) We believe that in the vast majority of rectal cancers the
above — or some equally radical procedure — should be executed if the
patient is to receive the benefit of modern, instead of obsolete, surgical
principles. (5) This procedure presupposes a perfect surgical technic
and rapid but painstaking work, and especially would we emphasize the
great importance of completing the abdominal work before attacking the
perineal portion of the operation."

J. Rawson Pennington^ describes tube-shields and speculums which

he has made for the
purpose of treating
cancer of the rectum
and other cavities by
means of the x-rays.
Formerly Pennington
employed Caldwell's
tube and a metallic
shield and tissue cot of
his own device. These
he has lately discarded,
and employs the ordin-
ary Crookes tube cov-
ered with the shield
shown in the accom-
panying illustration
(Fig. 40). A handle
is attached to the
shield, and directly op-
posite the handle is a
flange over which the
rectal speculum fits. The ordinary Crookes tube is so much more power-
ful than the Caldwell tube that its adaptation to rectal use is a great
advantage. The rectum should be carefully cleansed and a small pledget
of cotton should be placed in the speculum to prevent the secretions
from soiling the tube.

Fig. 40.— Tube-shields and speculums for treatment of cancer of
rectum and other cavities by means of a;-rays. a, Crookes tube;
b, hemisphere separated ; c, speculums ; d, obturator.s; e, tip of the
liandle, and / flaoge for attaching the speculums (Pennington, in
Phila. Med. Jour., Dec. 13. 1902).

APPENDICITIS.

Eccles,^ in discussing the anatomy and pathology of the vermiform
appendix, refers first to the variations in the mesoappendix, particularly
as regards its length. He emphasizes the fact that it is when the aperture
of the appendix is closed that trouble is apt to ensue, and not when it is
unusually large. As a rule, the aperture is from 2.5 cm. to 3.5 cm. in-

» Phila. Med. Jour., Dec. 13, 1902. ' Lancet, March 14 and 21, 1903.

APPENDICITIS. 143

ferior and posterior to the ileocecal opening. Referring to Treves's
suggestion that a muscular contraction of a portion of the rectus upon
palpation of the abdomen may produce a sensation to the examining
hand similar to that of the appendix, Eccles says that in some cases at
least he thinks the tissue felt is the contracted anterior longitudinal band
of cecum, which contracts under manipulation. Because of the large
amount of lymphoid tissue in the submucosa of the appendix this organ
has been called the intestinal tonsil. Eccles next points out the char-
acteristics of a normal appendix. He states that it is impossible to say
that an appendix is normal until a microscopic examination has been
made of its mucous membrane. Regarding the function of the appendix,
he believes it to be in part absorptive and in part secretive. As to the
etiology of appendicitis, he believes that in every case the disease is caused
by bacteria. The various forins of bacteria found in a diseased appendix
are referred to. Primary tuberculosis of the appendix is decidedly rare.
Actinomycosis of the appendix does occur, though it is of rare occurrence.
The various pathologic results of inflammation of the appendix are re-
ferred to, including secondary abscess. In speaking of the association
of appendicitis with joint lesions, it is stated that when the two condi-
tions accompany one another, the arthritis should be looked upon as
wholly secondary to the appendicitis, in the nature somewhat of a sub-
acute pyemia. The joint-affection and the appendicitis are not coinci-
dently due to the same general infection. Appendicitis associated with
pregnancy and parturition is not rare. When appendicitis occurs during
the first three months of pregnancy, the safest course to pursue is to
operate. Abortion at this period is not nearly so serious a complication
as it would be later on. When there is strong reason to suspect inflam-
mation of the appendix, it is better to explore than to temporize. When
the inflammation has been allowed to progress to perforation or gangrene
of the appendix, the mortality is at least 70 %. Eccles claims, there-
fore, that it is wiser to operate upon even the suspected cases in preg-
nancy at the earliest possible moment. If miscarriage does take place
as the result of operation, there is much less danger than would accom-
pany such a circumstance if an abscess were present. The author does
not approve of emptying the uterus before operating upon" the appendix,
because if pus should have formed it is probable that the alteration in
the position of the uterus subsequent to its contraction might open the
abscess and flood the peritoneal cavity with pus. And, besides, by
operating upon the appendix and not emptying the uterus, the life of the
child may be saved. Appendicitis occurring during the puerperal state
may be mistaken for sepsis situated in the uterus or its appendages, but
a differential diagnosis can be made by a careful examination of the
pelvic organs and of the lochia. The prognosis at this period is not so
grave as when appendicitis occurs during pregnancy. Eccles discusses
appendicitis in relation to life insurance, believing that it deserves greater
consideration at the hands of the medical examiner. When there has
been more than one attack of appendicitis, he would not pass the appli-
cant unless the appendix has been successfully removed. Innocent

144 GENERAL SURGERY.

gro^i:hs of the appendix are extremely rare, though a number of un-
doubted cases have been reported. The author has collected 14 cases
of primary carcinoma and 3 of primary sarcoma of the appendix. Eccles
closes with a discussion of hernia of the vermiform appendix, showing
that this is much more frequent than was formerly supposed, and that,
when the appendix is situated in a hernial sac, it is prone to become
inflamed and is frequently strangulated. The diagnosis of an appendix
alone in a hernial sac is extremely difficult.

An interesting historical article on appendicitis with special refer-
ence to the essay of Melier, which was published in 1827, is presented
by Thomas H. Manley.^ A large part of MeUer's memoir is translated
and the cases he reports given in detail. It is quite evident from the
description of the symptoms and postmortem findings in a number of
cases recorded that Melier understood and was the first to demonstrate
the pathologic changes occurring in inflamed appendices. Melier states
that Villiermay was the first to call the attention of physicians to disease
of the appendix, but the presentation of the subject to the profession is
certainly due to Meher.

Djeulafoy^ urges early operation in all cases of appendicitis and
reports in detail a case showing the tlanger of late operation. The
patient was a young man, 23 years of age, who had suffered from acute
gangrenous appendicitis. Operation was performed on the fourth day.
The urine contained albumin, granular casts, leukocytes, and biliary pig-
ment. It was quite evident that he was suffering from septic infection.
When the abdomen was opened, the appendix was found gangrenous,
and there was a small collection of fetid pus behind the cecum. There
was no indication of peritonitis. The patient's condition gradually grew
worse, and he died on the fourth day in a comatose condition, and on this
day he had frequent attacks of hematemesis. A necropsy was made
and many points of hemorrhage in the mucous membrane of the stomach
and intestine were discovered. The peritoneum was almost normal.
The kidney presented subacute degenerative nephritis, and the centro-
lobular liver-cells showed granulofatty degeneration. Dieulafoy calls
attention to the fact that in this case primary symptoms were not severe,
but the dose of toxin produced at the point of infection was sufficiently
powerful to cause death. The only way of avoiding serious operative
complication due to septic intoxication is by early operation. The
operation should be done so early that symptoms of infection and in-
toxication do not have time to develop. The author states that in all
cases with operation before the third day recovery has resulted in those
in which operation was performed; during the third day there was also
recovery, but in some of them grave complications developed. Opera-
tions after the third day show many fatalities due to infection.

A number of cases, 20 in all, showing the results of blood examina-
tion in cases of appendicitis are presented by Longridge.^ His con-
clusions correspond to those of Cabot, Da Costa, Joy, Wright and others.

1 Med. Rec, July 19, 1902. ' Bull, de I'Acad. de M6d. dc Paris, July 8, 1902.

' Lancet, July 12, 1902.

APPENDICITIS.

145

The advantage of the leukocyte count in these cases is that it shows
whether or not the morbid process is increasing. More important than
the quantitative count is the quahtative count of the leukocytes, since
an increase in the polymorphonuclear cells out of proportion to the other
elements is indicative of progression. No leukocytosis is found in cases
of mild catarrhal appendicitis, in cases of fulminating appendicitis in
which no resistance is offered, or in cases of long-standing abscess.

Holman^ reports an interesting case of appendicitis which was fol-
lowed within a few months by cholecystitis. Six months prior to the
attack of appendicitis the patient had an attack of typhoid fever and

Fig. 41. — Eastman's appendix forceps with shields attacbed (Jour. Aui. Med. Assoc, Oct. 11, 1902J.

Fig. 42. — Eastman's appendix forceps with shields detached (Jour. Am. Med. Assoc, Oct. 11, 1902).

typhoid bacilli were found in the material evacuated from the gall-
bladder. The patient recovered from both operations except that 2
weeks after the second operation when the wound had closed he had an
attack of pain resembling hepatic colic. The wound was opened and
the ducts were explored with a negative result. He then recovered.
After the operation he complained occasionally of left epigastric pain,
and some months later had a distinct attack of intense left-sided epi-
gastric pain with tenderness, distention, coated tongue, high tempera-
ture, rapid pulse, and respiration. These symptoms subsided under
treatment and were thought to be due probably to pancreatitis.

J. R. Eastman^ describes an instrument which facilitates the removal
' Amer. Med., March 21, 1903. Uour. Am. Med. Assoc, Oct. 11, 1902.

146

GENERA.L SURGERY.

of the appendix by means of the cautery. It is a simple forceps to the
blades of which can be applied shields which protect the cecum and
surrounding tissues from the heat of the cautery, and also tend to keep
back the small intestine. After the cauterization is complete the shields
can be removed and pursestring sutures or Lembert sutures introduced
for the inversion of the stump. The advantages of cauterization over
ligature are set forth: the immediate sterilization of the stump and the
control of hemorrhage. The use of the forceps is shown in the accom-
panying illustrations (Figs. 41-43).

Howard A. Kelly ^ treats of the advisability of removing the ap-

Ciiv^'^'X

Fig. 43. — Eastman's appendix forceps with detacliable shields for the arrest of pus and intestinal
contents from appendix verm, and for the protection of intestinal serosa from the heat of the cautery
(Jour. Am. Med. Assoc, Oct. 11, 1902).

pendix when the abdomen is opened for other reasons, and has com-
municated with a number of American surgeons to learn their practice.
He reaches the following conclusions: " (1) The appendix should always
be examined and its condition noted whenever the abdominal cavity is
opened for any reason, provided no additional risk is involved. (2) The
opinion of the majority of surgeons in this country is against the removal
of a perfectly healthy appendix, 44 to 26 being the proportion shown in
his investigation. (3) The opinion of the large majority of surgeons is
in favor of removing an appendix which is even slightly adherent to other
structures, 60 to 7 being the proportion shown in his investigation. (4)
The fact that the appendix is normal in appearance does not prove that
1 Jour. Am. Med. Assoc, Oct. 25, 1903.

APPENDICITIS. 147

it contains no fecal concretions, for he has found them in a number of
instances. Their presence is sufficient reason for the removal of an
apparently healthy appendix, (5) After removal of the right ovary
the stump should always be covered with peritoneum in order to prevent
the risk of adhesion to the appendix. A long and free appendix should
invariably be removed."

The subject of appendicitis, particularly its acute forms, is dealt
with by MacDougall, ^ who presents his personal experience and observa-
tion. By reviewing his own and the experience of others in the British
hospitals he shows that appendicitis, although not a new disease, is
largely increasing both as regards frequency and severity. This state-
ment is fortified by the records of a number of the large hospitals of
Great Britain. The tendency to recurrence or relapse is much greater
than formerly. In view of the facts just stated, MacDougall's attitude
toward the treatment of appendicitis has undergone considerable change
during recent years. In the acute grave case of appendicitis he recom-
mends immediate operation. He states that the acuter the initial
symptoms, the greater is the gravity of the case. He says that the char-
acter of the pulse is of greater value than its rapidity; very high tem-
perature in the beginning, with a rapid small pulse and symptoms notably
local, demand quick operative interference. These cases require the most
careful nursing and recording of symptoms during their early stages.
The facial expression is of great diagnostic and prognostic value. Costal
respiration, especially in males, is of considerable importance. In the
acute forms of this disease the absence of a palpable tumor in the right
iliac fossa should not lead to conservatism when the other symptoms are
present. Given a rigor, intense abdominal pain, vomiting, a quick,
small pulse, a high or a depressed temperature, a hard contracted abdo-
men with a point of maximum tenderness within the right iliac sphere,
or one marked by the same local conditions with spreading tenderness,
short costal respiration, and a drawn face, the safety of the patient de-
mands an immediate operation. The writer sounds a warning about
being deceived by a so-called period of repose, a condition which often
results from gangrene of the appendix. Even at this period, when the
graver symptoms have been modified, the local symptoms are usually
sufficiently marked to prevent an error. Leukocytosis may be of some
value except in the very acute cases. MacDougall presents the history
of a number of cases illustrating his remarks, and discusses briefly the
differential diagnosis of appendicitis. He refers to a condition called
peritonism, resulting frequently from delayed or suddenly arrested
menstruation which produces congestion of the whole pelvis and which
has occasionally so closely simulated appendicitis as to cause the surgeon
to operate. In this condition the swollen abdomen lacks the tenderness
characteristic of inflammation. Commencing basal pleurisy of pneu-
monia will frequently simulate appendicitis. A careful examination of
the chest is sufficient to put one straight. When opium must be given
for pain in acute appendicitis, it should be given by suppository or as an

» Lancet, Feb. 23, 1903.

148 GENERAL SURGERY.

injection of laudanum into the rectum. To open the bowels in this con-
dition an enema should be used and not a laxative.

John O'Conor^ deals with the treatment of appendicitis, using as a
basis for his remarks a series of 140 cases. He advocates strongly the
removal of the appendix at the primary operation and refers. to 3 cases
in which he has operated for secondary attacks of appendicitis w^hen
simple incision and drainage have been done at the first operation. He
does not believe that the formation of an abscess results in the oblitera-
tion of the appendix. Unless the patient's condition is immediately
alarming, the adhesions should be separated and the appendix removed
at the primary operation. The key to the treatment of purulent appendic-
itis is early operation and an incision which permits of thorough in-
spection of the parts. One of O'Conor's reasons for advising early
operation in all cases of acute appendicitis is the fact that it is impossible
to tell the exact pathologic condition Avhich is present. The author's
attitude is freely fortified by reference to cases. [That an abscess may
be followed by obliteration of the appendix we know. Even in an ab-
dominal operation performed long after the drainage of an abscess the
appendix was found to have been destroyed.]

Lucas-Championniere^ recommends early surgical intervention in
appendicitis and recounts numerous cases to show the deceptive char-
acter of symptoms. Pathologic conditions of extreme gravity may
exist without indicative symptoms. The danger of a fatal infection
from leaving an inflamed appendix is greater than that of disseminating
the infection at the time of early operation. Failure after prompt
operation is usually due to the gravity of the infection and not to the
extension of the peritonitis. In every case of appendicitis the author
maintains that extension of the infection is just as liable to take place
as the subsidence of the acute symptoms. He urges in every case the
early removal of the cause of the infection.

Broca^ discusses the treatment of appendicitis, his views being based
upon his personal experience. The author endeavors in this communi-
cation to reduce the indications for immediate operation in acute appen-
dicitis. His mortality during a period of 4 years when he operated at
once in cases of acute appendicitis was 33 %, whereas when this same
class of cases was treated less radically the mortality fell to 13 %. In
cases of diffuse septic or suppurative peritonitis it is impossible to sepa-
rate with certainty those in which operation will fail and those in which
it may be successful. The author, however, is in favor of operation
except when a patient is moribund. In cases of general infection due to
pylephlebitis wuth or without peritonitis, Broca is opposed to operation
because the patient is in no condition to stand the shock of the anesthetic
and the operation. He thinks that in these cases the injection of senun
offers a sure prospect. Even in such cases when there is an effusion in
the right iliac fossa, unless it is known to be pus, an expectant plan of
treatment is advocated in order that the appendix may be removed

1 Lancet, Aug. 16, 1902. ^ j^^^ je Chir., No. 9, 1902.

3 Jour. m6\. de Brux., No. 37, 1902.

APPENDICITIS. 149

during quiescence. It is necessary, however, in such a case that the
patient be under the constant care of a skilled practitioner. If this
cannot be had, immediate operation should be done. The interval
operation should be performed in every case in which there have been
two clearly diagnosed attacks of appendicitis, and after a single attack,
if it was severe and if suppuration was threatened. The appendix should
not be removed until 5 or 6 weeks after the subsidence of the attack.

C. B. Lockwood^ discusses the diagnosis and treatment of appen-
dicitis. He believes that most of the difficulties in the diagnosis and
the treatment are due to insufficient knowledge of the morbid anatomy
of the condition. Usually the extent and intensity of the inflammation,
and whether it is progressing or receding, can be learned from the clinical
symptoms. The degree of pain and rigidity indicates the degree of in-
flammation. Sharp pain occurring at the end of micturition indicates
that the pelvic peritoneum is inflamed. It is an ominous sign when
vomiting occurs after the gastric contents have been voided. The
majority of cases of acute appendicitis run a favorable course. The
diagnostic value of the pulse, the temperature, and the respirations is in
the order given. The leukocyte count is not a safe guide as to the pres-
ence of pus. Rectal examination is of great value when the appendix
is located in the pelvis. Paralytic intestinal obstruction is seldom absent
when peritonitis has been established for some hours. Each case should
be judged upon its individual merits in regard to the question of opera-
tion, and when the surgeon is in doubt as to whether or not to operate
Lockwood advocates operation, and he thinks it is better to make a deter-
mined attempt to remove the appendix rather than to leave it behind.
Lockwood does not approve of the use of morphin and purgatives.
Enemas skilfully used afford relief and are unattended with any danger.

Moschocowitz^ presents a careful and exhaustive study of primary
carcinoma of the appendix and offers the following conclusions: "(1)
No exact figures can be given regarding the frequency of primary car-
cinoma of the appendix. It is certainly very rare, when compared with
the enormous frequency with which the inflammatory diseases of the
appendix occur. It is, however, not impossible that in time we shall
have to modify our opinion regarding this point, as it appears that
more and more cases are being reported, jjarticularly in the last few
years. (2) It appears that all "primary" carcinomas of the appendix
])egin in the mucosa. (3) It seems more than probable that all primary
carcinomas of the appendix take their origin in some preceding inflam-
matory process. (4) Primary carcinoma of the appendix is most fre-
quent at that time of life in which the inflammatory diseases of the
appendix are most frequent; and this accounts for the early age of most
of the patients reported. (5) Primary carcinoma of the appendix is
more frequent in the female than in the male; the cases reported admit
the ratio of 3 to 1. (6) If it shall prove true that ]:)rimary carcinomas
of the appendix originate in the inflammatory i)rocesses, it forms an
additional argument for removal of the appendix, once diseased."
1 Lancet, Dec. 13, 1902. ^ Ann. of Surg., June, 1903.

150 GENERAL SURGERY.

D. S. D. Jessup/ in discussing primary carcinoma of the vermiform
appendix, refers to 13 cases collected from literature on the subject and
reports a case of his own. In the author's case the patient was a woman
36 years of age who had had 2 children and 5 abortions. She had suf-
fered with pain in the left inguinal region since the last abortion, and
operation was performed for disease of the uterine adnexai When the
abdomen was opened there was found a cyst of one ovary, and this
was opened. The appendix was found bound down with adhesions, was
removed, and the patient made an uneventful recovery. Upon examina-
tion the appendix was found to be 6 cm. in length and bent at a right
angle at the junction of the middle and outer thirds. There was also a
constriction at this point, and beyond this a dilation 1 cm. in diameter.
The proximal two-thirds measured 5 mm. in diameter. In the dilated
portion the muscular coat had a thin sheU-like appearance and the space
within was occupied by a tumor-mass of firm yellow tissue.

Harte and Wilson^ discuss primary carcinoma of the appendix
and report 2 cases, one with operation by Harte and the other by
Le Conte.

Deaver and Ross^ present a review of 416 cases of appendicitis
with operation at the German Hospital of Philadelphia in the year 1901.
Of this number there were 279 acute cases and 137 chronic cases. The
death-rate in the acute cases was 15.3 %. In the 137 chronic cases
there was but one death, a mortality of 0.7 %. This death resulted from
acute intestinal obstruction. A mass in the right iliac fossa was demon-
strated clinically in 104 cases. In 299 acute cases pus was encountered
174 times; necrosis of the appendix and cecum and small bowel, 145
times; perforation, 84 times. In 11 adults there was a general purulent
peritonitis, and all of these died. A general infection is much more com-
mon in children than in adults, but is not nearly so fatal. In 154 cases
drainage was used. The appendix was removed in all but 7 cases. It
had sloughed off at the cecum in 3. Postoperative obstruction of the
bowels occurred in 10 cases, in all of which operation was performed
and in 4 of which there was recovery from a second operation. The
condition was recognized early in every case and operation instituted at
once. Fecal fistula appeared in 11 cases. Of these, 4 closed spontane-
ously; in 1 there was operation with recovery; 6 patients left the hospital
with fistula, one of them returning later for operation and was cured.
This complication took place in late cases. The authors think it fair
to presume that in a good proportion of the cases, if not in the majority,
there had been previous attacks of appendicitis. The time elapsing be-
tween the onset of symptoms and the operation was as follows: Five
hours in 2 cases, 8 in 2 cases, 12 in 5 cases, 14 in 1 case, 16 in 2 cases,
18 in 2 cases, 20 in 1 case, 24 in 18 cases, 30 in 1 case, 36 in 4 cases, 40
in 35 cases, 50 in 1 case, 3 days in 29 cases, 4 in 25 cases, 5 in 18 cases,
6 in 12 cases, 7 in 29 cases, 8 in 9 cases, 9 in 5 cases, 10 in 13 cases, 11
in 5 cases, 12 in 4 cases, 14 in 24 cases, 19 in 1 case, 3 weeks in 11 cases,

1 Med. Rec, Aug. 23, 1902. 2 ^ed. News, Aug. 2, 1902.

* Jour. Am. Med. Assoc, Dec. 13, 1902.

APPENDICITIS. 151

7 in 1 case, 8 in 1 case, 10 in 1 case, 6 months in 1 case. Of the fatal
cases with operation in the first attack, there are several important facts
to be noticed. In one case the death was attributed to the accidental
breaking open of the wound and subsequent intestinal obstruction and
peritonitis. In another case, with operation within 24 hours, there
existed at the time of operation a general purulent peritonitis. The other
patient had been ill with the disease from 48 hours to 2 weeks. All but
one had abscess and most of them necrosis. The one exception was the
patient who died of uremia on the sixteenth day after operation. An-
other had, in addition to an appendiceal abscess, a carcinoma of the
cecum. Death took place on an average of 5.4 days after operation,
excepting in 2 cases. Of the deaths, 86 % were due to peritonitis. The
11 cases of general purulent peritonitis which were operated upon and
died were beyond surgical rehef when admitted to the hospital. The
various symptoms presented by these cases are discussed and the line of
treatment followed indicated. The authors conclude by stating that in
every case of appendicitis operation should be performed in its earliest
stage, deferred operation meaning protracted convalescence and invalid-
ism or death.

In dealing with the mortality in appendicitis, its cause and limita-
tion, Ochsner^ takes as the basis for his paper 337 cases of appendicitis
treated in the Augustana Hospital during the year 1902. The point
which the author lays the greatest stress upon in the reduction of the
mortality in this disease is the starvation treatment in those cases seen
late in the disease and in those seen early in which the result of an imme-
diate operation would be doubtful. In other words, the cases selected
for this treatment are the worst ones. Of the 337 cases, 192 were acute
and 145 chronic. Of the acute class, 81 suffered from perforative or
gangrenous appendicitis with more or less extensive peritonitis, but 13
of these had diffuse peritonitis at the time of admission. Of the 81
patients having perforative or gangrenous appendicitis, 37 were operated
upon immediately and 44 were treated for a period varying from 4 days
to 5 weeks by the starvation method before operation was performed.
Of the 111 patients with acute appendicitis without perforation, 107 were
operated upon immediately and 4 were treated expectantly. These 4,
however, it was thought were suffering from perforative appendicitis at
the time of their admission. Also among the 37 cases of perforative or
gangrenous appendicitis which were operated upon at once there were
several in which Ochsner expected to find the infectious material still
confined to the appendix. The author's attitude toward the starvation
treatment is explained in the following: "The form of preliminary treat-
ment described above was employed in all of those cases in which my
former experience had taught me that the immediate operation would
be followed by a high mortality, a class of cases which come to the surgeon
on the third, fourth, fifth, sixth, and seventh days after the beginning of
the attack with severe distention of the abdomen, tense abdominal mus-
cles, a bad facial expression, marked nervousness, pulse above 100,
1 Med. News, May 2, 1903.

152 GENERAL SURGERY.

persistent nausea or vomiting and always a history of having received
cathartics and some form of liquid nourishment by mouth." The follow-
ing summary shows the mortality of this large series of cases; included in
it are two patients who were not operated upon and who died : " Entire
number of cases with operation, 337; number of deaths, 7; mortality
2 % + . Entire number of acute appendicitis, 192; number of deaths, 6;
mortality, 3 % + . Entire number of chronic appendicitis, 145 ; number
of deaths, 1; mortality, 1 % — ." A brief history of the fatal cases is
presented. The following are the conclusions reached after a discussion
of the whole subject of treatment: "(1) The mortality in appendicitis
results from the extension of infection from the appendix to the peri-
toneum or from metastatic infection from the same source. (2) This ex-
tension can be prevented by removing the appendix while the infectious
material is still confined to this organ. (3) The distribution or extension
of the infection is accomplished by the peristaltic action of the small
intestines. (4) It is also accomplished by operation after the infectious
material has extended beyond the appendix and before it has become
circumscribed. (5) Peristalsis of the small intestine can be inhibited by
prohibiting the use of every form of nourishment and cathartics by
mouth and by employing gastric lavage in order to remove any sub-
stances of food or mucus from the stomach. (6) The patient can safely
be nourished during the necessary period of time by means of nutrient
enemas. (7) In case neither food nor cathartics are given from the be-
ginning of the attack of acute appendicitis and gastric lavage is em-
ployed, the mortality is reduced to an extremely low percentage. (8) In
patients who have received some form of food and cathartics during the
early portion of the attack and are consequently suffering from a begin-
ning diffuse peritonitis when they come under treatment, the mortality
will still be less than 4 % if peristalsis is inhibited by the use of gastric
lavage and the absolute prohibition of all forms of nourishment and
cathartics by mouth. (9) In this manner very dangerous cases of acute
appendicitis may be changed into relatively harmless cases of chronic
appendicitis. (10) In my personal experience no case of acute appendici-
tis has been fatal in which absolutely no food of any kind and no cathartics
were given by mouth from the beginning of the attack. (11) The mor-
tality following operations for chronic appendicitis is exceedingly low.
(12) Were peristalsis inhibited in every case of acute appendicitis by the
methods described above — absolute prohibition of food and cathartics
by mouth and vise of gastric lavage — appendectomy during any portion
of the attack could be accomplished with much greater ease to the
operator and correspondingly greater safety to the patient.

" I would make the following suggestions for the treatment of appen-
dicitis with a view of reducing the mortality: (1) Patients suffering from
chronic recurrent appendicitis should be operated during the interval.
(2) Patients suffering from acute appendicitis should be operated as soon
as the diagnosis is made, provided they come under treatment while the
infectious material is still confined to the appendix, if a competent surgeon
is available. (3) Aside from insuring a low mortality this will prevent

APPENDICITIS. 153

a series of complications, mentioned elsewhere in this paper. (4) In all
cases of acute appendicitis without regard to the treatment contemplated
the administration of food and cathartics by mouth should be absolutely
prohibited. (5) In case of nausea or vomiting or gaseous distention of
the abdomen, gastric lavage should be employed. (6) In cases coming
under treatment after the infection has extended beyond the tissues of
the appendix, especially in the presence of beginning diffuse peritonitis,
conclusions four and five should always be employed until the patient's
condition makes operative interference safe. (7) In case no operation is
performed neither nourishment nor cathartics should be given by mouth
until the patient has been free from pain and otherwise normal for at
least 4 days. (8) During the beginning of this treatment not even water
should be given by mouth, the thirst being quenched by rinsing the
mouth with cold water and by the use of small enemas. Later small
sips of very hot water frequently repeated may be given, and still later
small sips of cold water. There is danger in giving water too freely.
(9) All practitioners of medicine and surgery, as well as the general
public, should be impressed with the importance of prohibiting the use of
cathartics and food by mouth in patients suffering from acute appendici-
tis. (10) It should be constantly borne in mind that even the slightest
amount of liquid food of any kind given by mouth may give rise to
dangerous peristalsis. (11) The most convenient form of rectal feeding
consists in the use of 1 ounce of one of the various concentrated liquid
predigested foods in the market, dissolved in 3 ounces of warm normal
salt solution introduced slowly through a soft catheter, inserted into tlfe
rectum a distance of 2 to 3 inches. (12) This form of treatment cannot
supplant the operative treatment of acute appendicitis, but it can and
should be used to reduce the mortality by changing the class of cases
in which the mortality is greatest into another class in which the mor-
tality is very small after operation."

Parker Syms^ reports 9 deaths which constitute his mortality in
operations for appendicitis during the past 13 years. Of these, 5 were
of the type of acute gangrenous appendicitis rupturing into the peritoneal
cavity without adhesions; 3, of the type of perforating suppurative
appendicitis without adhesions or with incomplete adhesions in which
there was free pus in the peritoneal cavity with acute general peritonitis
or with progressive suppurative peritonitis. In one case there was a
circumscribed abscess, and this is the only case in which a fatal ter-
mination was not expected and predicted. A study of the histories of
these cases shows that in nearly all of them there had been previous
attacks of appendicitis from which an apparent recovery had taken place,
or that the patients had had symptoms to which they had paid but
slight attention, but which would easily have been recognized by a
skilled diagnostician. These facts point to the necessity of early opera-
tion in every case of appendicitis. The palliative treatment should only
be employed in those cases in Avhich an experienced surgeon will feel
comparatively sure that the patient is progressing to a prompt recovery,
» Jour. Am. Med. Assoc, Dec. 13, 1902.

lis

154 GENERAL SURGERY.

and in which he may look forward to a safe postponement of the operation
to the time of the interval. The author describes his method of operating
in the different types of appendicitis. In cases of localized peritonitis
with or without abscess, after protecting the general abdominal cavity
the diseased area is thoroughly cleansed with hydrogen dioxid and drain-
age established. In such cases the question of the removal of the appen-
dix arises. Syms removes the organ much more frequently than formerly
— in fact, in nearly ever}^ case ; but he feels that there are cases in which
it would be safer to desist from such an attempt rather than to persist.
In cases of fulminating appendicitis with general peritoneal involvement
every portion of the visceral and parietal peritoneum should be cleansed
with thorough sponging and then the entire cavity thoroughly irrigated
with hot salt solution. If the patient's strength will permit, the intes-
tines should be systematically washed outside the abdomen. [Like Syms,
we remove the appendix in almost every case; but, like him, we feel that
in some cases it should not be removed.]

Homer Gage^ presents an interesting analysis of 300 cases of appen-
dicitis in which he has operated previous to 1901, and in the majority
of which he has had recent communications regarding the ultimate
results of the operation. Of the 300 cases, 240 operations were done in
the course of an acute attack; the mortality of these was 15 %. In 143
cases the appendix was removed at the time of the operation, with a
mortality of 13 %; and in 67 it was not removed, with a mortality of
19 %. Recently Gage has removed the appendix much more frequently
than formerly, but still believes that there are some cases in which
simple incision and drainage are preferable. In 26 of the acute cases
there had been no successful effort at localization of the inflammation
and the entire abdominal cavity was irrigated. Of these patients, 8, or
nearly one- third, recovered. In 60 cases operation was done during the
interval between attacks, with one death. This death occurred early in
the series of operations and resulted because of an attempt to dispense
with drainage when there was a small amount of pus outside of the
appendix. Of the 228 cases whose subsequent history Gage has been
able to trace, 42 have complaints of one sort or another to make. Many
of these, however, are trifling and not in any way connected with the
operation. One patient suffered a great deal from pain in the scar after
an interval operation. This became so troublesome as to cause the
patient to give up her work as a teacher. The abdomen was reopened
and the omentum was found adherent to the scar. After it was separated
the patient suffered no more pain. In 2 cases fecal fistulas have failed
to close spontaneously; one has discharged for 7 years and another for
7 months. Both followed pus cases and in both the appendix had been
removed. Of the 228 replies, 19 report the existence of a hernia through
the scar. All of these were cases in which drainage had been employed.
The majority of the hernias occurred during the first 6 months after
operation. In 9 instances attacks simulating appendicitis occurred after
operation, and these cases are briefly recorded. In 3 of them the
^ Boston M. and S. Jour., Oct. 9, 1902.

APPENDICITIS. 155

appendix was not removed at all at the firsl operation, and in 2 others
it was very incompletely removed. Gage is at a loss to account for the
reappearance of the symptoms in the 4 cases in which the appendix had
been thoroughly removed.

In discussing foreign bodies in the vermifonn appendix James
Bell^ refers to the great rarity of true foreign bodies in the appendix
and states that when foreign bodies do enter the organ they are either
accidental occupants, or, if they give rise to symptoms at all, they do
so in a different way and do not, as a rule, at least, cause genuine appen-
dicitis. Bell reports an extremely interesting case of a young woman 22
years of age who received a blow in the abdomen from the back of a
chair and who developed abdominal symptoms about 50 hours after the
injury. During the interval she was able to go about the house and
attend to her work. At the end of this time, however, she began to
suffer severe pain in the abdomen. Bell operated upon the patient about
38 hours after the onset of abdominal symptoms. At this time she pre-
sented all the evidences of severe general peritonitis. It was thought
that the patient was suffering probably from a perforated gastric ulcer.
When the abdomen was opened, there was free gas and a flow of pus;
the whole cavity was filled with pus. There was no perforation of the
stomach nor was there any other lesion in the upper portion of the
abdomen. An incision was made over the appendix region, where a mass
was felt. The appendix stood upright and there was an opening near
its base as large as a 5-cent piece, partially blocked by a large faceted
gallstone more than h inch in diameter. A small stone, also faceted, lay
in the appendix beyond the larger one. The appendix was removed and
the peritoneal cavity was cleansed and drained. The patient did well,
but later developed symptoms of a pulmonary abscess, which could not
be located although an exploration was made. Later, pus was expec-
torated and the patient improved greatly, though at the time of the
report she was still feverish and weak. The abdominal condition was all
that could be desired. From the history obtained it is thought that the
foreign body had been in the appendix for a long time, probably 9 years,
and that a slight blow upon the abdomen was the initial factor in pro-
ducing a large perforation of the appendix.

Malcolm^ reports a case of fecal concretion on a black pin removed
after death from the vermifonn appendix of a child 6 yeal's of age.
The child's illness and death were very sudden and no physician saw
the patient. The appendix was gangrenous and ruptured.

The following conclusions are reached after a discussion of the toilet
of the peritoneum in appendicitis by G. R. Fowler:^ ''(1) In cases in
which the infection is confined to the appendix the surrounding peri-
toneum should be carefully guarded against infection from the opening
left in the cecum by the excision of the organ. (2) In cases in which
suppurative collections are present the cavity of the peritoneum should
be carefully guarded by gauze pads, which may be advantageously wet

' Phila. Med. Jour., Nov. 15, 1902. ' Lancet, July 5, 1902.

s Ainer. Med., June 20, 1903.

156 GENERAL SURGERY.

with 1 : 2000 sublimate solulion before breaking down limiting adhesions
in approaching the appendix. (3) As soon as the pus cavity is opened
the septic material should be rapidly sponged away and the neighborhood
cleansed with hydrogen dioxid. Following this the appendix should be
removed, after which the parts are subjected to a second cleansing pro-
cess. (4) Outlying infection of the peritoneum may, as a rule, be left
to take care of itself after the removal of the appendix and local cleansing.
(5) In peritonitis more or less generalized in the pelvic and enteronic
areas the method of procedure wiU depend upon the presence or absence
of markedly septic seropurulent material. When the latter is present,
it should be carefully sponged away. If only thin and sUghtly turbid,
this will usually suffice. If, however, this is more decidedly purulent,
and particularly if flakes of grayish, slate-colored lymph are floating
about in it, providing the patient's condition will permit of it, the infected
area may be forcibly flushed with saline solution and drained from the
direction of the pelvis, the force of gravity being utilized in 'the after-
treatment to encourage the flow of septic fluids from the enteronic to
the pelvic area. (6) In diffuse septic peritonitis the conditions are usu-
ally such as to prohibit prolonged interference, and the surgeon will, in
the majority of cases, be justified in interference only to the extent of
removing the appendix and cleansing locaUy. In selected cases flushing
the peritoneal cavity has advantages. The elevated head and trunk
position should be employed in the after-treatment whenever possible.
Favorable results from eventration can only rarely be claimed legiti-
mately. So-called 'scouring' of the peritoneal surfaces for the removal
of plastic lymph is a most unsurgical procedure. (7) Drainage, when
instituted, should be bj'' tubes of glass or smooth rubber. Massive gauze
packing or multiple and radiating gauze strips placed between the intes-
tinal coils is probably never of real service, and may be productive of
harm."

A case of appendicitis is reported by Damianos^ in which there was
transposition of the cecum and yet the predominant symptoms were
on the right side. The patient was a boy 18 years of age who entered
the hospital 2 days after the sudden onset of symptoms. These were
quite characteristic of appendicitis in a normally situated appendix.
Immediate operation was advised but declined. When the symptoms
had subsided, von Mosetig-Moorhof opened the abdomen through the
right semilunaris and encountered a mass of adherent small intestine
but no trace of the cecum or ascending colon. When the small intestine
was pushed to one side, pus escaped from the left side of the abdomen.
A second opening was then made on the left side. Here was found a
normal descending colon and sigmoid flexure, but immediately to the
right of it were the cecum and appendix, the latter surrounded by pus.
The appendix was removed and the cavity drained. The patient died
2 days later. At the necropsy the liver and stomach were found in their
normal positions. The cecum and small intestine were found to have
a common mesentery. Damianos refers to a number of reported cases
» Wien. klin. Woch., Aug. 27, 1902.

APPENDICITIS. 157

in which the appendix was situated on the left side, and yet in which,
just as in this case, the most prominent symptoms were on the right
side.

Jacobson/ of Syracuse, reports a unique case of what is called hemor-
rhagic appendicitis. The patient presented all the symptoms of acute
appendicitis with marked fever. When the appendix was removed, it
was found to present numerous areas of hemorrhage into its substance,
but there was no free bleeding into the cavity of the organ, which was
distended by a mucoid discharge. The wound was closed without
drainage and the temperature fell to nearly normal after the operation.
Two days later, however, the patient was seized with intense pain in
the left side of the chest and the temperature rose to 102°. Four days
after the operation she developed a hacking cough and raised a large
quantity of bright red blood. The same night she had a profuse nasal
hemorrhage. Next day a number of petechias appeared on the left leg,
while on the calves of both legs numerous ecchymoses were found.
There was never any hemorrhage from the bowels nor from the kidney,
nor was there any evidence of gastric hemorrhage. Epistaxis was re-
peated and the bronchial hemorrhage was very persistent. About 3
weeks after operation suprarenal extrax;t was administered and there was
a prompt cessation of the hemorrhagic manifestations and of the fever.
The patient recovered. This case seems to be clearly one of purpura
hemorrhagica, of which the first evidence was hemorrhage into the
appendix. Reference is made to the reported cases of purpura hemor-
rhagica in which there have been marked gastrointestinal symptoms,
but the author has been unable to find a case which corresponds to the
one here reported.

Two cases of appendicular black vomit are reported by G. R. Fow-
ler.^ Kirmisson was the first to call attention to black vomit in appen-
dicitis. The blood is usually partially digested. Fresh blood or coagu-
lated blood is rarely vomited. Accompanying vomiting of blood there
are present usually the symptoms of an intense general intoxication.
Vomiting of blood may develop after an operation or it may arise when
no operation has been performed. It also occurs in cases in which the
peritonitis is but slight. It has been observed also in strangulated hernia.
Seven cases of appendicular black vomit have been reported by Dieula-
foy; in all of these cases the symptoms occurred only after sufficient
time had elapsed to permit a general infection to take place. In 3 of the
fatal cases the violence of the hematemesis was such that death took
place from the entrance of blood into the lungs. In 2 others it was
produced or accelerated by anemia following the vomiting of large quan-
tities of blood. Two of the 7 cases recovered. In all of the appendicular
cases perforative appendicitis was present and in 2 there was diffuse
peritonitis. In the first case reported by Fowler operation was by R. S.
Fowler, and in this case there was general peritonitis with a perforated
appendix lying free in the abdominal cavity. There was scarcely any
postanesthetic vomiting. Black vomiting developed on the second day.
1 Med. Rec, Feb. 7, 1903. ' Med. Rec, April 25, 1903.

158 GENERAL SURGERY.

Examination showed this to contain blood. The condition was accom-
panied by no increase in the symptoms of peritonitis. Gastric lavage
was practised without avail and death took place on the sixth day.
There was no autopsy. In the second case operation was by the author.
An unusually large gangrenous appendix without adhesions was removed.
There was commencing peritonitis in the neighborhood. There was no
postanesthetic vomiting; black vomiting commenced 11 hours after opera-
tion and continued until death took place, 42 hours after operation and
66 hours following the commencement of the attack. The stomach
showed from 200 to 300 small ulcers about the size of a miUet-seed.
Sections of the stomach-wall showed frequent emboli. Staphylococci
were also found in the ulcers. There can be no question that these pro-
cesses were septic in origin. The view that the microorganisms were
transported to and produced thrombi and subsequent embolism in the
vessels is sustained, first, by the fact that in one of the sections there
was a focus of necrotic tissue in which the microorganisms appeared,
the vessels of the sub mucosa near this area containing recent thrombi;
and, second, in another section an embolus appeared involving a vessel
in the mucosa near its bifurcation, the vessel and its two branches con-
taining recent blood-clot.

In referring to the various causes of hematemesis Nitzsche^ reports a
case of hematemesis in appendicitis. The patient was a man 62 years
of age who suffered from a typical attack of appendicitis. Coffee-ground
vomit containing blood developed on the second day and the patient
died on the fourth day. At the postmortem examination a gangrenous
appendix was found in a partially walled off abscess and there were evi-
dences of general peritonitis. There was no thrombosis of veins. The
stomach and jejunum held a quantity of dark material containing blood.
The mucous membrane of the stomach showed innumerable small points
of ulceration partially covered with clotted blood. The ulcerations
involved the mucosa and submucosa. In one of the veins of the sub-
mucosa a i^artially formed thrombus was found. As the autopsy was
performed 3 hours after death it is impossible that the ulceration could
have resulted from postmortem digestion. Nitzsche believes that the
ulceration of the mucous membrane in these cases is of toxic origin. The
toxins reach the stomach either through the general circulation or in a
retrograde manner through the veins; they are taken up by the gastric
glands, and these in excreting them become ulcerated.

A. K. Gerster^ presents a valuable contribution on septic thrombosis
of the roots of the portal vein in appendicitis. The most common
cause of septic pylephlebitis is appendicitis. The condition is considered
rare by most authorities. Out of 1189 cases of appendicitis with opera-
tion at the Mt. Sinai Hospital in the past 10 years septic involvement of
the veins was encountered but 9 times. Septic thrombosis of the portal
vein and its feeders may be divided into continued thrombosis in which
the condition extends by continuity and in which the circumference of
the lower course of the portal vein is rarely involved, the blood passing

1 Deut. Zeit. f. Chir., Bd. Ixiv, 1902. ^ Med. Rec, June 27, 1903.

APPENDICITIS. 159

along between the attached clot and the vessel-wall; and detachment
of the thrombus with embolism and septic invasion of the systemic
system. The detachment of a septic embolus is determined by a number
of factors: (a) lack of firm adhesion of the thrombus to the walls of the
vessel; (6) loss of consistency of the thrombosis due to septic deliques-
cence; (c) mechanical forces acting from within or without the body, and
among these the author mentions manipulation, during operation. It
is believed that in many cases of appendicitis, particularly interval
operations, which are shortly followed by death and are supposed to be
caused by surgical shock, the death results from septic thrombosis and
the sudden introduction of a sufficient quantity of ichor into the circu-
lation to produce fatal toxemia. In discussing the symptoms and diag-
nosis Gerster states that chills accompanied by a rapid rise of tempera-
ture during the course of appendicitis, it matters not how mild the local
symptoms, may and usually do signify the entrance of septic material
into the portal and general circulation, and should be considered a sign
of the gravest import. When the condition becomes well established,
the patient evidently suffering from marked septicemia, the removal of
the diseased appendix and evacuation of pus may either accomplish no
good whatever or only result in a temporary subsidence of the symptoms.
The morbid process which has become established is beyond the line
where measures undertaken against the primary focus would exert a
curative influence. "Setting aside, therefore, both the unproved hypoth-
esis of surgical shock and of peritoneal sepsis, the results of our observa-
tions at the bedside, the operating room, and especially at the post-
mortem table irresistibly force upon our attention, as causative factors
of paramount importance, septic phlebitis and thrombosis of the roots
of the portal vein and embolic processes dependent upon their disinte-
gration." Special attention is called to the frequency with which this
dreaded complication results from operations done after the subsidence
of an acute attack of appendicitis, and it is suggested that in these cases
a most thorough postmortem examination should be made in order that
if possible the undeserved blame should be removed from the operator
who has had the misfortune to encounter a patient with a septic throm-
bosis which is ready to be detached and carried into the circulation on
the slightest provocation. "The gist of the matter as to the diagnosis
lies in these three propositions: (1) The presence of precedence of an
infectious process involving the abdominal contents. (2) The presence
of pyemia. (3) The implication of the liver." In order to aid diagnosis
Gerster makes the following suggestions: "(1) Demonstrate that the
existing pyemia or septicemia is not caused by any lesion within the pale
of the systemic circulation, and especially not by malignant endocarditis,
a task which is very hard, when not even a murmur is demonstrable to
indicate the presence of this treacherous malady. Note: A small but
important lesion pertaining to the area of the general circulation may be
easily overlooked. (2) Do not forget that the violent oscillations in the
temperature (from 105° to 96° F.), which are so characteristic of the
initial stages, become less and less typical as the disorder progresses. In

160 GENERAL SURGERY.

protracted cases the fever is of a constant and remittent type, the chills
disappear (Chvostek and Gerster), and the oscillations are merely accentu-
ated by profuse sweats. (3) Again and again search for the primary
septic focus in the belly. (4) Remember that the evidences of hepatic
trouble are often very equivocal. Though the liver is mostly somewhat
enlarged, local pressure, pain, and jaundice are often absent. The en-
larged spleen is not distinctive, nor do the stools offer anything charac-
teristic. (5) A persistent local pressure along the right rectus abdominis,
extending upward toward the epigastrium and accompanied by fever,
observed after an appendicitis operation, and with the abdominal wound
healing or healed, justifies a strong suspicion of continued pylephlebitis
if there are no signs of sacculated peritonitic abscesses." The prognosis
is very bad, but not altogether hopeless. The treatment must be largely
symptomatic. The occurrence of a chill in appendicitis is of the gravest
import, and should be considered to constitute a more urgent indication
for operation than even the signs of local peritonitis. The drainage of
the infected veins is also recommended. In this connection it is inter-
esting to refer to 2 cases here reported in which upon removing the
appendix the author found its veins and those of the cecum involved in a
septic thrombosis, and after thoroughly incising and evacuating them
both the patients recovered. This contribution is concluded by a report
of 14 illustrative cases.

Sonnenburg^ finds from examination of his records of 1000 operations
for appendicitis that lung complications developed in 5 % of the cases.
In the Moabit Hospital of Berlin 740 cases with operation were recorded.
Embolism and infarcts were discovered in 3 patients, 2 of whom re-
covered; in 5 cases of pneumonia 3 of the patients recovered; in 7 cases
of pleurisy and 1 of bronchitis aU the patients recovered. In his private
sanatorium 13 cases were reported; out of 260 operations, 3 cases of in-
farct and 9 out of 10 cases of embolism recovered. Of these complica-
tions, 12 occurred in operations undertaken during the attack of appendi-
citis, and only one in an operation during the interval. In 20 cases of
thrombosis the right leg was affected 9 times, the left leg 6 times, both
legs in 2 patients, the portal vein in 2 patients, and the vena cava in 1
patient. As to the reason of thrombosis and embolism in appendicitis,
Sonnenburg believes that in the great majority of cases the cause is in-
fection. The operation, by disturbing the inflamed veins, loosens a
thrombus which is thrown into the circulation as an embolus. This may
occur either at the time of the operation or, quite frequently, several
days later. [Gibbon lost a patient at the Pennsylvania Hospital a num-
ber of weeks after an operation for acute appendicitis from a pulmonary
embolus. The patient was a very anemic woman who for years had
suffered from a large uterine fibroid which completely filled the pelvis.
She developed a thrombosis of the left leg, but this promptly subsided
and the patient at the time of her sudden death was able to be up in a
chair every day. The cause of death was determined by postmortem
examination.]

» Arch. f. klin. Chir., 1902, Bd. Ixviii; Amer. Med., Dec. 13, 1902.

APPENDICITIS. 161

Under the head of some unusual cases of appendicitis, Robert F.
Weir^ presents brief reports of a number of interesting cases. The first
case is one of internal strangulation of the small intestine due to an
elongated and adherent appendix. The tip of the appendix was
attached to the side of the lumbar vertebras and under it was caught a
large loop of small intestine. The abdomen was opened, the appendix
removed, and the patient recovered. The next case before the operation
was supposed to be one of small strangulated hernia, but when an incision
was made the condition was found to be one of hydrocele of a hernial
sac. When the abdomen was opened, an acutely inflamed appendix
was found near the femoral ring. Before the operation the abdomen
was generally soft and free from rigidity, but there was a little tenderness
above Poupart's ligament; no more, however, than is often felt in a
strangulated hernia. The appendix when opened showed its walls and
its mesentery to be thickened and infiltrated with pus. In both this
case and the one preceding it there was absence of rigidity of the ab-
dominal wall, the presence of which is with justice looked upon as evi-
dence of peritoneal inflammation. The third case reported is one of
gangrenous appendicitis occurring in a hernial sac. The diagnosis
in this case was of strangulated or incarcerated hernia. Brewer operated
and removed a gangrenous appendix. The patient made an uncom-
plicated recovery. Another case operated upon by Brewer is also re-
ferred to in which a diagnosis of small ovarian cyst was made. This
patient, a woman aged 38, had been operated upon 5 years previous for
appendicitis, and it was supposed that the appendix had been removed.
Through the stretched cicatrix could be felt an elongated swelling 5 or 6
inches long, just outside the iliac artery and running forward toward the
anterior brim of the pelvis. This mass was movable but also tender on
pressure. When the abdomen was opened, the tumor was found to be
a cystic enlargement of the appendix measuring 4^ inches in length and
over 1^ inches in diameter. An interesting case of tumor of the cecal
wall following the removal of the appendix is reported. This patient
was also operated upon by Brewer. The patient had had a previous
operation in June, 1902, between attacks of appendicitis and the appen-
dix removed and the stump inverted, but was admitted to the hospital
in November, 1902, with symptoms of acute appendicitis. It was thought
that probably the appendix had not been removed at the first operation,
but this, it was learned, was a mistake. There was a small hard sensitive
mass to be felt in the region of the cecum under the cicatrix of the pre-
vious operation. When the abdomen was opened, no appendix was
found, but at its site there was a small hard tumor f inch in diameter
projecting externally and also into the lumen of the cecum. It was
excised and the al^domen closed. The mass was examined microscopic-
ally and pronounced to be a chronic inflammatory condition of the wall
of the appendicular stump. In order to avoid a similar occurrence it is
Weir's custom always to cauterize the mucous membrane of the appen-
dicular stump before inverting it.

1 Med. Rec, May 23, 1903.

162 GENERAL SURGERY.

Another case is reported in which a very short appendix, ^ inch long,
was productive of several sharp attacks of appendicitis. The

patient was operated upon in a quiescent interval and made a prompt
and permanent recovery.

An interesting case of appendicitis with general peritonitis is re-
ferred to in which operation was by Brewer. The appendix was gan-
grenous and ruptured and there was free purulent fluid throughout the
abdominal cavity. Thorough irrigation w^as done and a number of
gauze drains introduced. The leukocyte count in this case w^as 34,000.
On the second day after the operation there was frequent vomiting and
the temperature had reached 106.6° and the pulse 160. The urine was
scanty. The case looked hopeless, but the house officer was given per-
mission to try infusions of salt solution. This was repeated a number
of times and the stomach was washed out. The temperature gradually
subsided and the patient recovered. Weir states that in the Roosevelt
Hospital the suggestion of Barker has been followed of adding to the salt
solution 5 % of sterihzed glucose, and lately the suggestion of Crile of
adding 10 to 15 minims of 1 : 1000 solution of adrenalin chlorid.

The last case recorded is one of cancer of the appendix occurring
in a young man 23 years of age. The patient gave a history of 13 attacks
of appendiceal pain within 2 years. The appendix was found to be
strongly kinked and knobbed a little more than usual at the end ; it was
removed and microscopic examination proved that the tip of the appendix
contained a small mass of adenocarcinoma. The patient was observed for
more than 3 years, during which time there was no recurrence. With
the exception of the last 2 cases all of the patients referred to were treated
during the past 12 months.

Christian and Lehr^ present a contribution on subphrenic abscess
as a complication of appendicitis. Out of 4028 autopsies collected
from the Boston City, Johns Hopkins, and Rhode Island Hospitals there
were 86 deaths due directly or indirectly to acute appendicitis, and in
these 86 cases 7, or 8.13 %, showed involvement of the subphrenic region
by a purulent process, although in the strict sense of the word every case
was not subphrenic abscess. A report of each of these 7 cases is presented.
Five were males and 2 females. The ages varied between 11 and 50
years. In 4, Streptococcus pyogenes was present in several organs; in 1,
Bacillus coli communis; in the remaining 2 no cultures were taken. In
5 cases the appendix had been removed, leaving only a short stump; in
one the cecum and appendix with obliterated lumen were bound down
by fibrous adhesions, and behind the cecum was an abscess; in one the
appendix was bound down by adhesions, its distal half gangrenous and
riddled with perforations. Subphrenic abscess as a sequel to appendic-
itis may occur in one of the following ways: "(1) As a localized abscess,
a part of a general purulent peritonitis; (2) by extension of the diseased
process from the appendix to the subphrenic region by an intraperitoneal
route; (3) by extension of the diseased process by an extraperitoneal
route, either by way of the lymphatics or by infiltration through the
* Med. News, Jan. 24, 1903.

APPENDICITIS. 163

retroperitoneal tissues; (4) by way of the blood-current as part of a
general embolic septic process, or as a sequence of liver-abscesses which
are of embolic origin by way of the portal vein." The greatest number
of such abscesses originate by extension, the route depending upon the
situation of the appendix and the periappendicular process. It is claimed
that when the abscess is retrocecal there is greater liability to the forma-
tion of subphrenic abscess. Having reached the subphrenic' region extra-
peritoneaUy, the abscess may remain so or may become intraperitoneal.
Among the cases collected by Elsberg 27 % were extraperitoneal, 48 %
intraperitoneal, and 25 % of doubtful anatomic location. In 4 of the 7
cases here reported there was also involvement of the pleural cavity,
though in none of these cases was there perforation of the diaphragm.
The pleura may become involved in such cases in one of two ways : ( 1 )
By extension from a pneumonic focus or infarct in the lung; and (2) by
extension from the abdominal cavity, either by way of the lymphatics or
by erosion of the diaphragm.

Darling^ reports an interesting case of subphrenic abscess on the left
side following the removal of the appendix. The patient was a young
woman 21 years of age. When first seen she was apparently recovering
from an acute attack of appendicitis. The condition remained satisfac-
tory for 7 days, when there was a severe recurrence of pain with tenderness
and tumor in the right iliac fossa. The appendix was found embedded
in a mass of omentum, small intestine, and cecum. It was separated and
removed with some difficulty. There was no pus, although the appendix
was gangrenous and perforated. The patient did well until 10 days after
the operation, when she began to complain of pain in the lower part of the
abdomen and of difficulty in micturition. These symptoms continued
until it was evident that there was an accumulation of pus in the pelvis.
The patient was again etherized and a large pocket of offensive pus
drained. She left the hospital apparently well, but soon afterward began
to complain of pain in the left side high up under the ribs. Her discom-
fort gradually increased and general tenderness developed over the
region of the spleen, occasionally extending downward as far as the crest
of the ilium. There was no cough, but deep inspiration was painful.
The temperature was 102° and the pulse 110. I.ater, symptoms devel-
oped which made it clear that there was an abscess, but it was impossible
to tell whether it was above or below the diaphragm. A lumbar incision
along the outer border of the quadratus lumborum was made and a large
abscess-cavity evacuated. The patient ultimately recovered. The case
is particularly interesting because of the unusual situation of the abscess.
Dr. M. H. Richardson, who saw the patient during convalescence, stated
that he was inclined to regard the sequence as a coincidence, the two
suppurations being of independent origin. Although this may be true,
there was no other ascertainable cause for the subphrenic abscess.

W. Blair BelP reports an interesting case of appendicular abscess
which perforated the ileum and in this way nearly completely evacuated

1 Boston M. and S. Jour., July 17, 1902.

2 Liverpool Med.-Chir. Jour., Oct., 1902.

164 GENERAL SUEGERY.

itself. At the operation the abscess-cavity was found empty. The
perforation of the ileum was closed and the appendix removed. The
patient made an uninterrupted recovery.

Thos. S. Cullen^ reports a case in which he evacuated a retrocecal
abscess which developed 3 years after an operation for an appen-
diceal abscess in which the appendix was removed. The patient re-
covered.

Box and Wallace^ report a case of appendicitis in which the symp-
toms closely resembled those of typhoid fever and in which there was
evidence of a perinephritic accumulation of pus, which, however, could
not be discovered through a lumbar incision, and which ultimately rup-
tured into the colon at the hepatic flexure. The rupture produced pro-
fuse intestinal hemorrhage. The pus passed by the bowel was only
small in amount and was hardly detected as such; the occurrence of the
hemorrhage only tended to complicate the diagnosis, which was not made
until the autopsy.

F. D. Donaghue' discusses briefly appendicitis complicating preg-
nancy, and reports a case in which a gangrenous appendix was removed
when the patient was 3^ months pregnant. She did not miscarry but
was dehvered at term. The Uterature of a similar case is referred to.
[Gibbon operated upon a patient at the Pennsylvania Hospital who was
4 months pregnant and who was suffering from an enormous appendicular
abscess. The appendix was removed and the abscess-cavity drained.
The patient aborted on the third day, but ultimately recovered.]

Edward Ricketts* discusses puerperal appendicitis and reports sev-
eral cases and reaches the following conclusions: "(1) Puerperal appen-
dicitis is as distinct as salpingitis, with or without pus. (2) It can be
diagnosed and differentiated from a puerperal septicemia due to other
causes. (3) Many cases of peritonitis arise from the infected appendix,
and not from the results of pregnancy and child-birth. (4) The reason
that puerperal appendicitis has been overlooked explains why it is
claimed that appendicitis is more frequent among males than females.
(5) With puerperal appendicitis recognized, the disease will be found as
often among women as among men."

HERNIA.

Coley^ presents an interesting report on the results of 1000 opera-
tions for the radical cure of inguinal and femoral hernia performed
between 1891 and 1902. To date, the author has performed 1075 opera-
tions for hernia. The later ones were performed too recently to furnish
data from which to draw conclusions. The exact number of cases here
classified is 1003; inguinal, 937 cases — male 756, female 181; femoral,
66 cases. Of the patients 317 were over 20 years of age. Coley states

» N. Y. Med. Jour., Dec. 27, 1902. ^ Lancet, June 6, 1903.

» Boston M. and S. Jour., Sept. 4, 1902.
< Virginia Med. Semi-Monthly, Nov. 21, 1902.
5 Ann. of Surg., June, 1903.

APPENDICITIS. 165

that operation on children is really more difficult than in adults, and does
not agree with the many authorities who state that any operation will
cure hernia in children. In proof of this statement he says that prior to
1890, in 20 operations performed upon children by the Czerny and Socin
methods, there were 50 % of relapses within a year after the operations.
Coley compares his cases to those occurring in the Albert-Hochenegg
clinic. From this clinic comes a report of 804 operations upon 473 pa-
tients. The inclination in this clinic is to operate upon both sides in
all cases. Coley's 1003 operations were done upon 911 patients.

For femoral hernia he employed the Bassini operation in 16 cases,
and the purse-string suture in 50 cases. In the last group there has not
been a single relapse. The cases in which the purse-string suture was
used were not selected, an(f Coley uses this method even in large hernias.
He performed 181 operations on the female for inguinal hernia with no
mortality and no relapse. In the female Coley does not transplant the
round ligament, but simply closes the canal over it. In the 67 opera-
tions for femoral hernia there was no mortality, and primary union was
obtained in every case but one, and this one furnished the only relapse
which has been observed. All but 9 of these cases have been traced;
46 were well from 1 to 10 years, and 34 from 2 to 10 years after operation.
He performed 14 operations upon 9 patients for direct inguinal hernia.
In most of these cases Coley transplanted the cord by the Bassini method.
Of 937 cases of inguinal hernia, the cord was transplanted according to
Bassini's method with kangaroo tendon for the buried sutures in 917
cases, with 10 relapses, or a fraction over 1 %. "In the entire series of
cases, 1003 in number, the end results were as follows: 647 were traced
and found well from 6 months to 11 years; 460 were well from 2 to 11
years." Attention is called to the fact that in the Vienna Clinic the
double operation, unless hernia definitely existed upon both sides, has
been abandoned since 1899. The author confirms by later statistics
his former conclusions that patients well one year after operation may
reasonably be expected to remain well, and that aiier 2 years they may
be considered permanently cured. A detailed statement of the relapsed
cases in this series is presented. The percentage of relapses after the
Bassini operation is slightly more than 1. There were 6 relapses in 20
cases of inguinal hernia in which the cord was not transplanted.

Regarding the technic of the operation, the author states that he
always places a: single suture in the internal oblique muscle above the point
at which the cord passes through. This is not a part of the Bassini
operation, but he believes it to be a decided aid in preventing relapses.
The wound is dressed with 10 % iodoform gauze and a spica bandage.
In children under 14 years of age he uses a plaster spica. The patient
is kept in bed 2 weeks and allowed to leave the hospital in from 2 to 3
weeks, but wears a spica bandage until 4 weeks have elapsed, after which
no support is worn. Kangaroo tendon was the suture material in prac-
tically all of these cases, and the author is a strong advocate of it. In
proof of the statement that a large proportion of the cases of suppuration
formerly attributed to catgut or imperfectly sterilized or buried sutures

166 GENERAL SURGERY.

are really due to other causes, chiefly to infection by the hands of the
operators or assistants, it is only necessary to compare the results of
wound-healing before and after the use of rubber gloves. In addition
to cleanliness, rapidity in operating and clean dissection, especially in
separating the sac from the cord without bruising the tissues or allowing
them to become infiltrated with blood, are most important. In the 1003
operations here reported suppuration occurred in 30 cases. In 21 of these
it was limited to stitch-hole abscess. Since the use of rubber gloves there
have been only 5 cases of suppuration in 4 years, and in about 400 cases.

Regarding the indications for operation, Coley states that it is
seldom advisable under the age of 4 years except in cases of strangulation.
After the age of 4 years in all cases in which a truss has been tried and
failed, or in which the presence of a reducible hydrocele prevents a truss
from holding a rupture, operation is advised. In adults the operation is
always advisable under the age of 50, unless there are strong contrain-
dications present. Between 50 and 70 years operation is advisable in
patients in good health if the rupture is with difficulty held by a truss.
The contraindications are: (1) serious organic trouble of the heart, lungs,
or kidneys ; (2) very large adherent irreducible hernia in stout individuals,
especiallv when the sac contains both intestine and omentum. The risk
of operation under the above circumstances is large and the chances of
permanent cure small. When the omentum alone is present in very large
adherent irreducible hernia in stout people, the danger is less, but never-
theless is worthy of consideration. Reference is made to several cases
in which the omental stumps in these cases has given late suppuration.

The mortality in Coley's series of 1003 cases is 2 deaths — less than
3^ of 1 %. The firet death was due to ether pneumonia in a child, and the
.second was in an adult with a large irreducible hernia, and resulted from
intestinal obstruction in spite of a second operation. Since this death
occurred, Coley has performed over 500 operations without a death.
Previous to 1890 the mortality was certainly not far from 6 %. In the
Vienna Clinic there were only 3 deaths and 804 cases. At the Johns
Hopkins Hospital there was but 1 death in 459, and at Carle's Clinic in
Rome there were but 2 deaths in 1400 operations upon 1285 patients,
and one of these was from pneumonia.

Regarding special varieties af hernia Coley has considerable to say.
He has operated upon 38 patients associated with undescended testis, and
in only one of these did he find it necessary or did he deem it wise to
remove the testis. Regarding the proper method of treating cases of
hernia with undescended testes there are considerable differences of
opinion, Coley, however, states that "believing in the physiologic
value of even an atrophied and probaljly functionless testis, I have made
it a practice always to preserve the organ, and have never removed it
except on two occasions." He does not advise operation in the majority
of hernias with undescended testis in children under the age of 10 years,
for the reason that in many cases the testes will later descend into the
scrotum spontaneously. When operation is done, he does not advise
the anchoring of the organ in the scrotum, but closes the canal by the

APPENDICITIS. 167

Bassini method, drawing the testes outside the external ring. In most
cases it will be found that the organ will later spontaneously come down
in the scrotum. An interesting variety of hernia, which is called the
inguinoperineal type, is described by Coley. In 8 cases he has found the
testis in the perineum, and in 6 of these cases the condition was associated
with hernia, and in 5 of these operation was done. In every case the sac
was a congenital one, and in 4 instances a portion of it was retained to
cover the testis, and a pouch was made for the organ in the scrotum.
Superficial inguinal hernia is really a variety of interstitial hernia, in
which the testicle is arrested just outside of the external ring and the
hernial pouch develops l)etween the aponeurosis and the external oblique
muscle and the skin. Coley has met with 5 cases, 2 in adults and 3 in
children. Hernia of the cecum was found alone in 10 cases; hernia of the
sigmoid in 3 cases, and in 8 cases a sliding hernia of the cecum was en-
countered. Hernia of the bladder was operated upon in one case. Coley
has operated upon 3 cases where there was tuberculosis of the hernial
sac, 2 in children and 1 in adults. Sixteen cases of strangulated and
femoral hernia have been operated upon, with 2 deaths. One death
occurred in the case of a femoral hernia which had been strangulated for
3 days and in which a resection of 7 inches of the intestine was made.
The other death occurred in an infant 6 weeks old with a strangulated
cecal and appendicular hernia. This child was moribund at the time
of operation. In the other 15 cases a radical operation was performed
and there has not been a single relapse. Primary healing occurred in
every case.

A general discussion of the radical cure of hernia, with a report and
analysis of 116 cases in which he has operated, is presented by Frank
Martin.^ The author reconnnends the radical cure even in patients of
advanced years, and does not consider age a contraindication. These can
be operated by either local anesthesia or by subarachnoid anesthesia.
The author has used the latter method in 4 cases, in one of which the
patient was 68 years of age, a confirmed alcoholic with marked cardio-
vascular changes, chronic bronchitis, and nephritis. The hernia was a
large irreducible one of 20 years' duration. No ill effects followed the
operation, and 18 months after it the patient was free from any evidence
of relapse. Cocain has also been used in a number of elderly patients.
A table of the cases operated upon is presented and several of the more
interesting cases discussed.

The implantation of silver filigree for the closure of large hernial
apertures is advocated by Willy Meyer. ^ The use of this material is
only recommended in those cases which cannot be satisfactorily treated
by one of the recognized methods because of the large hernial opening.
The net is made in various sizes and shapes to fit the different hernias.
It is roimd, oval, or quadrangular, with blunt corners for umbilical and
ventral heraias, and is sutured upon the aponeurosis of the abdominal
muscles bordering the opening. The net used for inguinal hernia is an
acute-angled triangle with the base turned toward the median line.

*Phila. Med. Jour., Nov. 22, 1902. ^ \nnals of Surgery, Nov., 1902.

168 GENERAL SURGERY.

There is a small aperture left in the base for the passage of the spermatic
cord. It rests upon the internal oblique above and is sutured to Poupart's
ligament below. Meyer has used the method three times with satisfac-
tion. The patients were all very stout and the local conditions gave little
promise of cure by the ordinary methods. One patient died of some
other condition and the two others have gone for periods of 18 and 8
months without relapse. There has been no serious inconvenience from
the presence of the truss.

J. A. Bodine^ recommends local anesthesia in the radical cure of
inguinal hernia. His remarks on the subject are based on 48 cases.
The secret of success in this work is cocainization of the hjq^ogastric
branch of the ileohypogastric, the inguinal branch of the ileoinguinal, and
the genital branch of the genitocrural nerves. These nerves possess inter-
communicating branches, and this fact explains why the operation may
be completed with comparatively little pain after cocainization of the
ileohypogastric though the other two are not identified. When operating
under local anesthesia, it is important not to carry the lower end of the
incision too far down, as when this is done vessels are sure to be divided
which will require ligation. When a bloodvessel is cut or tied in cocain
work, it produces acute pain. Of the cases here reported, 43 were non-
strangulated and 5 were strangulated. Many of the cases presented local
complications which required considerable time and manipulation. In 18
cases there was entire absence of pain; in 28 the pain may be character-
ized as moderate; and in 2 it was acute when the neck of the sac was
ligated. In 3 cases of double hernia which are classified as moderate in
pain the second side was done with local anesthesia at the patient's
request.

Alexander Lyle^ relates an experience with cocain in the radical
cure of hernia extending over 15 cases.

Eckstein^ reports 2 cases in which he has employed paraffin injections
for the cure of hernia. The first patient was a girl 18 years of age
who presented 2 small inguinal hernias. That on the right side had
(Existed for a year and a half and that on the left for only 2 weeks. Under
cocain-anesthesia between 4 c.c. and 5 c.c. of paraffin was injected into
the left external abdominal ring. Within a few days the right side was
treated in the same way. Each injection successfully occluded the in-
guinal opening and controlled the hernia. Since the operation the patient
has done heavy work, and an examination 2 months later showed that
both hernias were perfectly retained and the patient suffered no discom-
fort. She wore a truss on the right si(^e for a short time after the second
injection, but soon laid this off. The second case was a small umbilical
hernia in a boy 9 years of age. The patient suffered considerable pain.
When the hernia was reduced, the hernial ring admitted the tip of the
finger. In this case 6 c.c. of paraffin was used. The paraffin mass was
held in place for a few days by means of an adhesive strip, and the hernia
did not recur. [These two cases are the only ones with which we are

1 Med. Rec, Feb. 14, 1903. ^ N. Y. Med. Jour., May 30, 1903.

*Wien. klin. Rundsch., No. 48, Nov. 30, 1902.

APPENDICITIS. 169

acquainted in which this method of treatment has been employed, and
we feel that it should not be generally recommended, and that if it fails
it may interfere with a subsequent operation for the cure of the hernia.
We have had some experience with tissues infiltrated with paraffin, and
find them very difficult of manipulation.]

A summary of the history of the radical cure of hernia is given by
A. E. Benjamin,^ with a discussion of the modern methods of operating,
in which the author describes and illustrates an original modification of
Bassini's operation. The sutures employed for all the structures are of
silkworm-gut, so arranged as to be easily withdrawn. A great advantage
claimed for the operation is that there are no sutures for the tissues to
absorb, and as the sutures are tied over gauze rolls, the danger of necrosis
from too much constriction of the ti^ues is overcome.

Verhoef^ discusses the accidental wounding of the bladder in
operations for hernia, and reports 2 cases. In one of these a portion
of the bladder was in the sac, but in the second it was not. The bladder
is in danger of being wounded when the neck of the sac is being isolated,
ligated, and divided. It is pointed out that the internal surface of the
sac is in close contact with the bladder, and may in fact be closely attached
to this organ; therefore when the sac is forcibly dragged down for the
purpose of applying a ligature, the bladder may be included and injured.
When an unusually thick layer of fat which cannot be readily dissected
away from the sac is encountered, the surgeon should be on his guard
lest he injure the bladder. If the urine be quite free from microorgan-
isms and the wound be strictly extraperitoneal, Verhoef departs from the
usual practice under such circumstances and advises drainage of the
bladder with no attempt at suture. [It is difficult to understand what
advantage is to be obtained by drainage of the bladder as here recom-
mended. It would seem to us that its closure and fixation to the ab-
dominal wall with gauze drainage applied over the point of suture would
be a preferable procedure and render the subsequent completion of the
radical cure of the hernia easier.]

J. B. Harvie,^ under the head of hernial complications, reports an
interesting case in which the entire bladder was found in the hernial
sac. Before operation it was thought that the condition was one of
strangulated hernia compHcated by a hydrocele. The tumor was a large
one, but contracted in its center, giving an hourglass shape. The upper
part of the mass was tender, but the lower part was not so sensitive.
The patient had had a reducible hernia for 10 years, but had never worn
a truss. It became irreducible on the day before operation in an un-
successful attempt to evacuate the bowels, when the patient felt that
the hernial mass had suddenly become greatly increased. Attempts at
urination from this time on were frequent, but only a few drops were
passed. Subsequently he developed all the symptoms of strangulated
hernia. About 7 inches of gangrenous small intestine was found in the

^ Jour. Am. Med. Assoc, April 25, 1903.

2 Jour, de Chir. et Ann. de la Soc. Beige de Chir., No. 2, 1903.
' Amer. Med., April 4, 1903.
12 S

170 GENERAL SURGERY.

sac and resected, an anastomosis being made with the Murphy button.
The remaining mass was then examined and a small opening made in
it which showed it to be the bladder. Considerable difficulty was ex-
perienced in reducing this organ, but it was finally accomplished and the
patient made a good recovery. Other cases of hernia of the bladder which
have been reported are referred to.

Collier^ reports a case of a boy 2 years of age who was treated for
double congenital hernia. On the right side the bladder was found
in the sac, and on the left side the cecum and appendix. The interval
between the operations was 3 weeks. The hernias were both reducible,
but could not be controlled with a truss. The patient made a good
recovery.

Schiitz^ is a strong advocate of the operation for hernia of the linea
alba, even when the condition gives rise to no pain or trouble. The
only conditions under which operative treatment might be regarded as
contraindicated would be those in which the hernia is associated with
emaciation from chronic disease or with some disease of one of the ab-.
dominal viscera. The abdominal bandages made for the purpose of
controlling these hernias are generally unsatisfactory, as they usually
retain them for a short time only, and are not able to withstand coughing
or sneezing. The author is careful to call attention to the fact that the
pain and dyspeptic symptoms so often accompanying this form of hernia
may be of neurotic origin, and consequently may not disappear promptly
and completely after operation.

W. H. Conant^ deals with the question of operation for umbilical
hernia and pays particular attention to this condition occurring in stout
adults. His views are summarized as follows: "(1) Umbilical hernia in
children as a general rule gets well with the use of a truss. (2) Strangu-
lated umbilical hernia should be operated on like any other hernia. (3)
Radical umbilical hernia should be operated on if the patient will give
consent. Otherwise, a well-fitting truss should be constantly worn, day
and night. (4) Irreducible hernia should be operated unless there is
some marked contraindication, like serious lesion of the kidney or heart.
Age, and size of tumor need be no bar to an operation. (5) The prefer-
able operation should combine rapidity of operation with diminution of
shock, both by diminishing the hemorrhage and also the length of time
that the patient has to be under an anesthetic. (6) Cocain should be
used when ether is contraindicated."

Priestley Leech* presents the notes on a case of strangulated left
duodenal (retroperitoneal) hernia occurring in a young man 26 years
of age. The symptoms of strangulation were slow in development, but
within a few days became very marked. No cause could be found for
the obstruction, and as enemas and other treatment failed to relieve the
condition a laparotomy was resorted to. When the abdomen was opened,
the small intestine was seen to be moving under the mesentery and a
diagnosis of retroperitoneal hernia was easily made. The mouth of the

1 Lancet, June 6, 1903. =* Wiener Klinik, April, 1903.

3 Boston M. and S. Jour., Oct. 9, 1902. " Lancet, June 6, 1903.

APPENDICITIS. 171

sac looked obliquely upward and to the right, and the anterior and lower
margin was thickened and rigid. The finger could be passed into the
sac and about a yard of intestine was withdrawn; the abdomen was
closed and the patient made a good recovery. The author thinks that
a diagnosis of the condition might have been made had it been thought
of, since there were a history of two previous attacks of partial obstruc-
tion, the presence of a more or less central tumor, and pain paroxysmal
in character. Leech believes that the obstruction in this case was due
to a twist in the bowel, as it was certainly not due to constriction at
the mouth of the sac, since the finger could readily be introduced before
the gut was withdrawn and as there was no indication of constriction
of the bowel. The sac in retroperitoneal hernia is a congenital condition,
and probably always contains more or less intestine; should the amount
of intestine in the sac become increased and distended, or should the
intestine usually contained in the sac become more distended from some
indiscretion in diet, increased peristalsis occurs and twisting may easily
take place, leading to obstruction. As the inferior mesenteric vein lies
in the neck of the sac, one would hesitate to cut the margin ; and for the
same reason no attempt was made to close or to obliterate the mouth
of the sac. The author approves of the suggestion of Moynihan of
describing these hernias as left and right duodenal; at present they are
described under a great many different names.

Andrews^ describes a case of hernia into the fossa duodenojejunalis
which was discovered on the dissecting table. The whole of the small
intestine, with the exception of the lower 6 inches on the ileum, was
found in the sac. The subject was an old man.

Moschcowitz^ deals with inguinosuperficial hernia (Kuester) and
reports a very interesting case of this type. The patient was 28 years
of age. The left testicle had never descended ; it had occupied the position
just outside the external ring. After adolescence the testicle descended
about an inch, and its descent was accompanied by considerable pain,
which the patient learned to relieve by pushing the organ back to its
original position. Its descent and the accompanying pain became of
such frequent occurrence that the patient was advised to wear a truss,
the pad of which would lie on a plane above the testicle. It was found,
however, that this only increased his suffering, and he therefore reversed
the instruction which had been given him and wore the truss below the
testicle, and in this way derived great comfort. In spite of the truss the
testicle occasionally slipped below the pad. This accident was always
accompanied by sharp pain, which was relieved only when the testicle
was restored to its former position. The testicle slipped below the truss
26 hours before admission to the hospital and the patient was seized with
sharp pain in the left inguinal region which was accompanied by nausea.
When an attempt was tnade to restore the testicle, it was found im-
possible to do so. It was also noticed that there was a large swelling
above the testicle. Upon admission there was seen and felt a smooth,
ovoid, painful and tender mass about the size of a goose-egg parallel with
' Lancet, Jan. 24, 1903. ' Med. Rec, Jan. 10, 1902.

172 GENERAL SURGERY.

and above Poupart's ligament. The mass could be divided into two
portions, the inner and inferior being smaller, firmer to touch, and dis-
tinctly more tender. The upper and outer half presented distinct fluc-
tuation. A diagnosis of torsion of the spermatic cord was made and
immediate operation done. When the tumor was exposed it was found
to consist of two portions — the lower and anterior the testicle, and the
upper and posterior a hernia containing strangulated omentum and
considerable fluid. The testicle lay within the hernial sac. In other
words, the hernia was of congenital origin. A tunica vaginalis was formed
for the testicle from the sac and the testicle carried down into the scrotum
and fixed there. The sac was excised and a Bassini operation performed.
The wound healed primarily, and 8 months after operation there was no
evidence of a recurrence of the hernia. The reader is referred to the
classic article of Kuester, in which the condition is most minutely de-
scribed. Its rarity is showTi by the fact that the author has been able
to add to Goebel's collection (1900) of 14 cases but 3 others. The pre-
disposing elements in this variety of hernia are an undescended testicle
and an open processus vaginalis. [At the Pennsylvania Hospital during
the summer of 1903 Gibbon operated upon 2 cases practically identical
with that of Moschcowitz. There were symptoms of strangulation in
each, and the sac in one contained omentum and in the other a small
knuckle of bowel. The testicle was removed in each case and the patients
made good recoveries. These cases will be reported in detail later.
DaCosta operated on a similar case in the Jefferson College Hospital.]

A brief discussion of properitoneal hernia with a report of an inter-
esting case is presented by Howlett.^ The patient, a man of 48, was
admitted to the hospital having vomited for 5 days, during the last 2
of which the vomited material had been of stercoraceous character. The
patient gave a history of having been troubled with a "lump" on the
left side which presented itself midway between the anterior superior
spine of the ilium and the middle line. He said this lump disappeared
when he lay down. For its control he w^ore a belt. The left inguinal
canal seemed somewhat prominent, but the parts were soft to the touch
and no hernia could be felt. A large horseshoe flap with its base over
the internal ring was turned down and the internal ring thoroughly ex-
posed. The canal was found to be perfectly normal except for a mass
of varicose veins in the cord. On making pressure upward with the
finger-tips at the site of the internal ring a tense sac could be felt. The
abdominal wall was incised over it, and when the sac was opened some foul
bloody fluid escaped, together with a mass of gangrenous omentum. The
omentum was excised, and in the bottom of the sac was found a coil of
gangrenous bowel. The constriction at the neck of the sac was divided
and the healthy bowel drawn out. The gangrenous portion was resected
and an anastomosis made with a Murphy button and the bowel dropped
back into where was supposed to be the abdominal cavity. The patient
was in a very grave condition and 4 pints of saline solution was trans-
fused into the arm. Toward the close of the next day stercoraceous
* Quarterly Med. Jour., Aug., 1902,

APPENDICITIS. 173

vomiting recommenced, and in spite of stimulation the patient died 48
hom-s after the operation. A limited postmortem examination revealed
the interesting fact that there were two sacs, one which was opened at the
operation, and at the neck of which the previous obstruction had taken
place, and a second very large one, which was found between the peri-
toneum and the transversalis fascia, extending downward and inward
to the pelvis and side of the bladder. In this second cavity lay the re-
sected bowel and ligated omentum. The obstruction at the ring appeared
to be of recent date, and Howlett inclines to the view that it was caused
by the dragging on the omentum at the operation, resulting in plugging
of the ring, and thus giving rise to the second set of symptoms of strangu-
lation. The opening from the abdominal cavity into the larger internal
sac was quite large. Reference is made to the various forms of inter-
stitial hernia, and especially to Moynihan's work in this condition.

A. Webb Jones ^ describes a rare case of lumbar hernia which came
under his care. Such hernias protrude through the triangle of Petit,
that is, the interval between the latissimus dorsi and the external oblique
muscles. In many of the cases the abdominal wall at this point has been
weakened by the formation of an abscess. Jones's patient was a well-
developed male Soudanese aged 45. The hernia, which was on the right
side, had existed for 4 or 5 years, and lately had caused considerable
trouble from local pain and tenderness with constipation and dyspepsia.
The hernia was oval in shape and rather irregular in outline, extending
from the level of the iliac crest inward and upward toward the spine and
overlapping the lower three or four ribs. It gave the impression of being
composed largely of fat, but on reduction, which was easily accomplished,
a distinct gurgle was felt. The impulse on coughing was well marked.
In the left lumbar region there was a slight undue fulness that gave
rise to no symptoms, but it is thought it might be the forerunner of a
hernia on this side. Jones operated on the right side and removed a
large amount of fat and reduced the colon to the abdominal cavity.
The edges of the latissimus dorsi and external oblique were united with
silkworm-gut and the wound closed. The recovery was uneventful.
Mastin collected 25 cases of lumbar hernia. Three of the 25 cases oc-
curred in infants, but one of these followed an old psoas abscess. By
far the gravest characteristic, however, of this variety of hernia is its very
marked tendency to produce symptoms of local pain, constipation, or
even strangulation. Of the 25 cases referred to above, no less than 4
became strangulated, 5 are said to have been from time to time the cause
of vomiting, colic, or constipation, while 6 only are stated definitely to
have given no trouble; the rest are without details. One case was bi-
lateral and associated with an inguinal hernia. In two instances the
diagnosis was at fault and the bowel was damaged, the surgeon being
under the impression that he was incising an abscess. No sac was dis-
covered in the case here reported, and in only a few instances of those
reported was the presence of a sac noted.

Three cases of unusual hernia are reported by Sir Wm. J. Collins.^
» Lancet, Sept. 13, 1902. ^ Lancet, May 23, 1903.

174 GENERAL SURGERY.

Two of these were Richter's hernias. The third case was one of a woman
44 years of age who was admitted with what was supposed to be an ir-
reducible and painful femoral hernia. When the hernial sac was exposed,
the finger of the operator detected a sharp pointed foreign body, which
upon removal proved to be a piece of bone 1| inches long, varying from
i to ^ of an inch in width. This bone transfixed the sac. The sac was
removed, the wound was closed, and the patient made a good recovery.
There was no evidence of perforation of the bowel and there was no bowel
found in the sac at the time of the operation ; it is therefore impossible to
explain how the bone reached the position in which it was found.

Rake^ reports a case of strangulation of vermiform appendix in
the right femoral ring. The appendix became strangulated and sup-
purated, forming a large abscess which was incised. On the sixth day
after incision a sloughing mass presented in the abscess-cavity, was
removed, and was easily recognized as the appendix. A slight fecal
discharge kept the wound open for some time, but it finally healed.

Jeffery^ reports a somewhat unique case of hernia of the cecum
and appendix occurring in a child 2^ years of age. The hernia appeared
at the age of 2 months and was reducible until March, 1902. At this time
there occurred a somewhat acute inflammation of the contents of the
hernia, the mother stating that it became swollen, painful, and red, and
that later an abscess formed and burst externally, discharging quan-
tities of pus for about a fortnight. The child recovered with a fecal
fistula. The patient came under Jeffery's care in August, 1902, at the
age of 2^ years. The fistula opened in the right side of the scrotum.
The inguinal canal was opened and the hernial sac found to contain the
cecum and appendix. The internal site of the fistula was discovered in
the cecum near the base of the appendix. The bowel was freed from
adhesions, the appendix removed, and the edges of the fistulous opening
cut away and sutured. The patient made a good recovery.

The coexistence of hernia and hydrocele Vittorio Remedi^ has
encountered 25 times, and presents a careful study of the condition. In
the 25 cases which were carefully studied as to the relationship between
hydrocele and inguinal hernia only 3 did not show a hernial protrusion
into the vaginal process at the level of the internal inguinal ring. In an
earlier contribution Remedi stated that there existed a constant rela-
tionship between hydrocele and the incomplete obliteration of the vaginal
peritoneum. The 3 cases referred to refute this statement. The author
expresses the hope that other surgeons will observe the relationship be-
tween the two conditions and report their results. In order to make a
thorough examination the incision for hydrocele must be extended toward
the inguinal canal in order to determine whether the vaginal process of
the peritoneum is obliterated. If it is not, it should be excised in order
to prevent the occurrence of a subsequent hernia.

A. E. Barker^ in two clinical lectures discusses the results of opera-
tions for strangulated hernia and the treatment of gangrenous her-

1 Ann. of Surg., Dec. 1902. =* Brit. Med. Jour., Nov. 29, 1902.

» Gaz. degli Osped., March 8, 1903. " Lancet, May 30, and June 6, 1903.

APPENDICITIS. 175

nias by enterectomy. The first lecture is based upon a table of 406
consecutive operations performed for strangulated hernia at the Uni-
versity College Hospital. The figures presented show that the number
of cases operated on for strangulated hernia in this hospital has each
year increased, and that during the last 10 years the average number
has been just twice as great as it was 20 years ago. This is partly due
to the fact that taxis is now less frequently resorted to in severe cases
than formerly. In the first series of years taken 36 cases were treated
by taxis; in the second equal number of years, 52; in the third, 19; in
the fourth, 6; and in the last, none at all. Barker doubts whether in
any given case of strangulated hernia taxis ought ever to be employed
except in the very recent cases and among aged patients in a state
of great weakness. It is impossible until the sac is opened to tell the
amount of damage done to the intestine by strangulation, and even when
the sac has been opened the bowel is frequently put back in the belief
and hope that it is sound and viable, and yet death has frequently re-
sulted from perforation or peritonitis. The duration of the strangulation
has been shown to be an unsafe guide as regards the propriety of replacing
the strangulated bowel. Many of the cases in which it was comparatively
short have succumbed to peritonitis after reduction, while others have
recovered when the strangulation has lasted for days. Of the 406 cases
considered in this paper, 127 ended fatally, a mortality of 31.2 %. Con-
sidering these cases, however, in series of years, it is shown that the
mortality-rate has been reduced more than one-half during recent years.
This is not due to the fact that cases are sent into the hospital in better
condition, since the number of cases in which the condition of the patient
and bowel were so bad as to forbid anything more than an artificial anus
being made remains almost equal for each of the series of years, and was
exactly the same for the first and the penultimate. A study of the post-
mortem examinations made in the fatal cases operated upon shows that
death in the majority was due to general peritonitis spreading from the
reduced gut. Up to the summer of 1899 no single case of successful
enterectomy for gangrenous hernia appears. Since then to the end of
March, 1903, there have been 3 cases of artificial anus with 2 deaths,
and 7 cases of primary enterectomy with 4 deaths. Barker discusses the
treatment of gangrenous hernia at considerable length. The elements of
danger in a gangrenous hernia are enumerated as follows : " (1) The gut is
destroyed by necrosis over a greater or less surface and therefore it cannot
be returned into the abdomen ; (2) the dead portion is septic in the highest
degree; (3) the fluid of the sac, if there be any, is highly septic and may
run back into the abdomen and infect it if the constriction has been
divided before the sac has been well cleansed; and (4) the condition of
things within the abdomen is also fraught with risk." Attention is called
to the fact that the bowel above the constriction is loaded with retained
fecal matter which is virulent in proportion to the time it has been pent
up in a stagnant condition. The bowel is distended by this fluid often
to an enormous extent, is paralyzed, and frequently its structure is
altered, the mucous membrane being inflamed and even ulcerated from

176

GENERAL SURGERY.

the point of obstruction upward sometimes for a number of feet. It is
clear that the same infection will take place sooner or later within the
abdomen from the unbroken bowel above the constriction if the evacua-
tion of the retained fermenting feces be not provided for. Because of
this condition of the bowel Barker urges extensive resections, and also
that the bowel be thoroughly emptied. Absorption from the retained
contents is a great additional danger. The irritating properties of these
contents is shown in the inflammation of the skin which follows the
formation of an artificial anus. Although many surgeons recommend the
establishment of an artificial anus in cases of gangrenous hernia, Barker
rather advocates the performance of a primary resection and anasto-
mosis. At the University College Hospital in a series of years reaching
down to date, out of 20 consecutive cases of formation of an artificial
anus for gangrene only 2 ultimately recovered. In those cases of gan-
grenous bowel in broken-down individuals who are almost moribund the
law of establishing an artificial anus must stiU hold good, any long opera-
tion or any prolonged general
anesthesia being contraindi-
cated. But in those instances
in which the patients are in
tolerably good general condi-
tion, although the state of the
intestine is hopeless, it is
thought that a wide-reaching
resection of the bowel offers
the best prospect of recovery.
The author is glad to see that
the tendency to postpone op-
eration and the pernicious
practice of drenching cases
with strangulated hernia ^Aith
purgatives is less widespread than formerly. The most imminent
danger to the patient with a greatly damaged or actually gangrenous
loop of intestine lies in the condition of the bowel for the 3 or 4 feet
above the constriction. If this is simply put back or an artificial anus
made, the risks are enormous. The great point is to remove at once
the contents as well as the diseased bowel, and to make the suture
junction in relatively sound and clean gut. Attention is called to the
fact that it takes very little longer to excise a large portion of the bowel
than it does to excise a small portion. A number of cases are referred
to illustrating the author's attitude toward immediate primary resection.
It is Barker's custom in doing a resection to fold the bowel and its mesen-
tery upon itself and grasp the two layers of mesentery, as is shown in
the accompanying illustration (Fig. 44), with long Doyen forceps. The
distal end of the bowel is also clamped with the Doyen forceps and both
layers of mesentery then controlled and approximated by a number of
sutures. The distal end of the gut is then separated from the mesentery
and allowed to hang over the edge of the table and empty itself while

Fig. 44. — a, Constriction ; 6, proximal distended gut ;
c, distal contracted gut; d, mesentery ; e, Doyen's clamp
on both loops; /, Doyen's clamp on mesentery. The
folded loop here represented is for convenience of draw-
ing onlv a sliort one (Barker, in Lancet, May 30, and
June 6, 1903).

APPENDICITIS. 177

the remaining mesentery is divided. In this manner a large portion of
the bowel proximal to the constriction, and which contains the objection-
able material already referred to, is also thoroughly emptied. When this
is complete, a second Doyen forceps is apphed to the point of proximal
division and the diseased bowel removed and an anastomosis made by
two rows of sutures, one involving the muscular and serous coats, and
one the mucous coat. Since Barker began to employ this method of
procedure in 1899 he has done 7 enterectomies for gangrenous hernia;
and of these, 5 have recovered. One of the fatal cases died from obstruc-
tion due to an old fibrous band pressing on the bowel after its return.
The second death was due to a slowly developed peritonitis starting from
the remains of the infected sac, which unfortunately had not been drained
at the time of the operation, and which it was difficult to shut off by
suture from the abdominal cavity.

An analysis of no operations for strangulated hernia is presented
by William Thorburn.^ These patients were all operated upon in the
Manchester Royal Infirmary between 1889 and 1900. Of these, 55 were
inguinal, of which but 5 occurred in females; 37 were femoral, of which
but 3 occurred in males; 17 umbilical, 4 in males; and 1 ventral. Stran-
gulation was more common on the right side. The age varied greatly,
the oldest patient being 84. The youngest patient suffering from stran-
gulated femoral hernia was 21 years of age. One of the cases of strangu-
lated umbilical hernia occurred in a male infant 2 days old; this patient
recovered promptly after operation. The rarity of this condition is
referred to. Two of the successful cases in this series had been reduced
en masse before admission and were treated by median laparotomy. All
of the cases in the series contained intestine in the sac. In one case
of right inguinal hernia in a child the vermiform appendix and cecum
were found in the sac, and in one adult the entire cecum was present.
In no case were organs other than intestine and omentum found in the
sac. Gangrene or perforation of the bowel occurred in 10 instances.
The mortality of the whole series was 24.54 %. The author has collected
statistics of St. Bartholomew's, St. Thomas's, and the Middlesex Hospitals
for a number of years, and finds that the mortality-rate is practically the
same as his own, being 24.58 %. Attention is called to the fact that
in the author's series the first 55 cases showed a mortality of 29 %, and
the second 55 of only 20 %, and these figures are practically duplicated
in the statistics of the hospitals referred to. In 9 of the 27 fatal cases
the intestine was gangrenous or perforated by ulcers at the time of opera-
tion; and in 2 of these there was a general peritonitis. Of the remaining
18 cases, 4 were fatal within 24 hours from shock or intoxication. One
patient, a man aged 84 years, died on the eighth day from pneumonia.
Of the 10 infants and young children in this series, none died. In 8 of
the patients whose condition was very bad the intestine was merely
opened and left in the wound after division of the constriction; of these,
7 died. The 2 cases in which reduction en masse was performed, and
which were operated upon later through a median incision, recovered.
1 Brit. Med. .lour., April 25, 1903.

178 GENERAL SURGERY.

A successful operation for a strangulated femoral hernia of 52
hours' duration occurring in a woman 90 years of age is reported by
Neave.^ The patient made a good recovery in spite of the fact that the
operation was done Avithout any of the modern conveniences of aseptic
surgery.

A case of bilateral strangulated hernia in an infant 10 weeks old
is reported by Kellock.^ On March 8 the child was operated upon for
a strangulated right inguinal hernia. A hernia was found in the left
inguinal region 2 days later which was easily reduced. The child was
discharged from the hospital on the eleventh day after operation, but
4 days later was readmitted with strangulation of the left side. The
patient recovered from both operations.

A. B. MitchelP reports a case of a man 57 years of age upon whom
he operated for old-standing irreducible inguinal hernia which had
given rise to repeated attacks of obstruction. The mass was so large
that it w^as found impossible to reduce it. Its size was the result of an
overgrowth of fat between the layers of the mesentery. A resection of
all the intestine in the sac was then done and the portion removed was
afterward found to measure 6 feet. The patient made a good recovery,
and 16 months after the operation showed no evidence of a recurrence.

The literature of congenital hernia of the liver into the umbilical
cord is freely quoted in an article by J. W. BuUard,^ who also reports
a case of his own occurring in a male child w^eighing 3^ pounds. An
attempt at radical operation was made when the child was 12 days old,
but owing to extensive adhesions it was necessary to abandon the opera-
tion, and the child died 20 hours later. Reference is made to a number
of other cases, however, in which the operation has been successful. It
is maintained that it is advisable to do the operation in these cases as
soon after birth as possible, as delay, with the consequent changes in
the cord and the amniotic coverings of the sac, is likely to lessen the
chances of a favorable result.

DISEASES OF THE LIVER, GALL-BLADDER, PANCREAS,
AND SPLEEN.

Arnott,^ of St. Helena, reports a unique case of liver abscess occur-
ring in a child 2^ years of age, a time of hfe at which the disease was
supposed not to occur. The child was admitted with a history of a
neglected attack of dysentery. The stools were typically dysenteric in
character and the patient also presented signs of commencing tubercle
in the lung. Great improvemen:t followed the open-air treatment and
the dysentery disappeared. The temperature remained normal for 9
days, when it again rose and continued irregular. There was nothing
demonstrable in the chest to account for the temperature, but the liver
was greatly enlarged and tender. Vomiting became a troublesome

1 Lancet, Oct. 15, 1902. ' Lancet, July 5, 1902.

' Brit. Med. Jour., Sept. 27, 1902. * Amer. Med., Nov. 8, 1902.

5 Brit. Med. Jour., Jan. 24, 1903.

DISEASES OF THE LIVER, ETC. 179

symptom and the child was very much exhausted. A trocar was intro-
duced into the liver through the tenth interspace in the anterior axillary
line and 12 ounces of pus were withdrawn. The withdrawal of the pus
was followed by a drop in temperature from 103° to 99° and a cessation
of the vomiting. The abdominal distention also disappeared. Soon
after the operation the child developed typical tuberculous meningitis
and died 6 days after the opening of the abscess.

Captain Keble^ reports from India 4 cases of abscess of the liver
occurring in English soldiers, all of whom recovered. Of these patients,
3 were apparently suffering from malarial fever, but the fever would not
yield to quinin, and later the symptoms of abscess developed. In the
first case the only indications of liver-abscess were a fluctuating tem-
perature and sweats. In this case but slight enlargement of the liver
was noticed and there was no pain or tenderness. Pus to the amount of
10 ounces was evacuated through an incision made between the seventh
and eighth ribs in the anterior axillary line. In the second case the
diagnosis was very doubtful and the condition was not definitely diag-
nosticated until an aspirating needle was introduced into a pulsating
tumor which appeared just beneath the costal arch to the left of the
median line opposite the eighth and ninth cartilages. The liver was
not enlarged nor was it painful or tender, but 22 ounces of pus was
evacuated. The abscess in the third case was drained as in the first,
15 ounces of chocolate-colored pus being evacuated. In each of these
3 cases the abscess-cavity was washed out with mercuric chlorid solution.
The fourth case was one of liver-abscess which opened into the bowel,
and in this way recovery took place. [We would hesitate to wash an
abscess-cavity with mercuric chlorid solution because, in the first
place, the pus is often sterile in abscess of the liver, and if it is antiseptic
irrigation can do no possible good ; second, because even if the fluid con-
tains bacteria, the germicide will fail to destroy those in the abscess- wall ;
third, because the irritant germicide may break through encompassing
barriers and disseminate infection.]

Cohen and Gibbon^ report a case of tropical abscess of the liver
and present a brief discussion of the subject. The patient was a man 30
years of age who developed dysentery 3 years previous to admission,
while residing in South Africa, from which he did not recover until his
return to America. About a year before his admission to the hospital
the patient noticed a swelling in the hepatic region which accompanied a
recurrence of the bloody stools. The latter symptom continued inter-
mittently. The liver continued to enlarge, and it was on this account
that the patient applied for treatment. The hepatic enlargement was
enormous, extending from the fourth interspace nearly down to the iliac
crest. The patient complained of nothing save the discomfort due to
the size of the tumor. The elevation of temperature was insignificant
and there was no history of previous chill or fever. The leukocyte count
was 13,400. There was no tenderness over the liver, although there was
a point just below the edges of the ribs which seemed to fluctuate. The

» Brit. Med. Jour., Sept. 6, 1902. ^ Am. Jour. Med. Sci., Feb., 1903.

180 GENERAL SURGERY.

amebas were not found in the stools, although repeated examinations
were made. The character of the enlargement, its smoothness, and the
absence of tenderness and a sense of fluctuation at its most prominent
part caused hydatid disease to be seriously considered. The history of
dysentery, however, and the fact that the patient stated that an explor-
ing needle which had been introduced revealed pus seemed to indicate
an abscess. The Uver was exposed over its most prominent part, just
below the costal border, the peritoneum was not found adherent, and
there was no blood in the abdominal cavity. An aspirating needle was
introduced into the liver and a quantity of thick brown pus escaped.
The general abdominal cavity having been thoroughly walled off from
the point of puncture by large gauze pads, the abscess was freely opened
by means of the Paquelin cautery. An enormous quantity of pus was
withdrawn and the liver became so contracted that it was necessary to
make a second transverse incision extending from the first in order to
thoroughly drain the abscess. The patient made an excellent recovery
and has greatly increased in weight. The liver rapidly contracted.
Drainage was continued for about 3 months. No amebas were found in
the pus, although it was repeatedly examined. Attention is called to
the frequency of amebic dysentery occurring in American and English
soldiers in the tropics. The ameba can frequently be found in scrapings
from the abscess when not found in the pus itself. Although multiple
abscesses of the liver are usually of pyemic origin, the fact that about
one-half of the liver abscesses occurring in tropical countries are multiple
produces the belief that the ameba is more frequently responsible for
multiple abscesses than is generally supposed. The abscess may occur
at any part of the liver, but is most frequently situated in the right lobe
near the anterior or posterior border. If left to itself, the abscess will
break either into the pleural cavity, the lung, or the abdominal cavity.
Many cases have reached recovery after rupture into the lung. The
mortality of liver-abscesses without operation is between 90 % and
95 %. The treatment consists in thorough drainage through an opening
made either anteriorly, as in the case reported, or posteriorly after resec-
tion of one or more of the lower ribs. The aspirating needle should be
used only when the surgeon is prepared at once to operate in case pus is
found. Otherwise there is danger of infection of the peritoneum or pleura
by the withdrawal of an infected needle, and the possibility of the escape
of a small amount of pus if the abscess is very tense. The needle is of
the greatest value after the liver is exposed, when it not only discovers
the pus, but also may be employed as a guide to the knife or cautery.
The operation may be done either in one or in two stages, that is, imme-
diate drainage or secondary drainage after the liver has become adherent
to the parietes. Curetment of the abscess- wall seems questionable, and
care should be used in introducing a drainage-tube to see that the end of
the tube does not rest on the abscess-wall, since such pressure may pro-
duce necrosis and perforation at this point. The stitching of the liver
to the abdominal or chest wall does not seem necessary if the drainage-
tube is thoroughly surrounded by gauze. [In a case recently operated

DISEASES OF THE LIVER, ETC. 181

upon by Da Costa the left lobe was involved. The patient had never
been out of the United States, had never had dysentery or chronic diar-
rhea or typhoid fever. The leukocyte count was only 8000. There had
been no chills or sweats and the temperature was 100° in the evening.
He had lost much flesh and complained of pain and tenderness in the
hepatic region. The liver was much enlarged. The abscess contained
a quantity of chocolate-colored fluid which contained no amebas and
was sterile. Recovery followed drainage.]

Vachell and Stevens^ describe 2 cases of carcinoma of the liver,
each presenting interesting clinical and pathologic points. The first
patient was a negro 36 years of age who was treated in the Cardiff In-
firmary. The patient had worked until 8 weeks before his admission,
when he first noticed that his abdomen was swollen. He had no dis-
comfort whatever and there was no history of malaria, syphihs, or alco-
holism. He was deeply jaundiced. There was no fever. The abdomen
was markedly ascitic and- the liver was greatly enlarged, occupying the
whole upper part of the abdomen, was hard and nodular, but was not
tender. The patient sank rapidly and died 5 days after admission. At
the autopsy the liver was removed and found to weigh over 17 pounds.
The whole organ was involved in a malignant growth and there was no
adhesion to surrounding parts. All the other organs were quite normal
with the exception that there were 3 small white nodules on the visceral
pleura and a small nodule in one of the bronchial glands. Microscopic
examination showed an infiltrating spheroidal-celled carcinoma. The
brief duration of the illness is of interest, although the average duration
of primary carcinomas of the liver is but 12 weeks. The absence of other
symptoms than jaundice and ascites is also worthy of note and rather
exceptional. Primary carcinoma of the liver is rare, only about 4 % of
all cases of cancer of the liver being primary. Before assuming that
such a growth is primary, it is necessary to make a careful and detailed
search for a primary source in another part. The absence of fever in the
case reported was exceptional, as was also the freedom from pain and
tenderness. The second case was that of a man 56 years of age. The
interesting point in this case was that the malignant growth of the liver
had its origin in an exceedingly small primary growth in the pylorus.
This case illustrates the point which the authors wish to make, that it is
necessary to make a careful examination of other organs before assuming
that liver cancer is primary. The condition in this case very closely
resembled alcoholic cirrhosis. There was a marked history of alcoholic
excess; there was no jaundice, but well-marked ascites. The liver was
not palpable and there was an absence of both pain and tenderness.
There was slight hematemesis 3 days before death, but no melena.

Richard Jones^ reports a case of suppurating hydatid cyst of the
liver complicating pregnancy. The patient was a primipara 36 years
of age. During gestation she had periodic attacks of spasmodic pain in
her right side accompanied with vomiting and jaundice. The attacks
were sudden in onset and quickly disappeared. Previous to her preg-

' Brit. Med. Jour., Feb. 14, 1903. ' Brit. Med. Jour., April 11, 1903.

182 GENERAL SURGERY.

nancy she had had no symptoms at all. She was delivered at term and
did fairly well until the third day afterward, when she had an attack of
pain and chilly sensations. On the fourth day she had a distinct chill
and very acute pain in the right side with vomiting. There was nothing
to indicate hydatid disease except the situation of the pain. The liver
was plainly enlarged; the other abdominal organs were normal. Tender-
ness was marked in front and to a less degree at the side. The lower
half of the right thorax was dull and there was an absence of breath-
sounds. The intercostal spaces corresponding to the dulness were bulg-
ing. The hand placed over this area detected distinct crepitation. The
'cyst was exposed through the chest in the usual manner and the patient
stood the operation well. The cyst communicated with a large bile-
duct and the flow of bile was profuse and continuous. The patient's
death, which occurred on the fourth day, is attributed to this cause.

Kilvington^ discusses simple cysts of the liver, reporting several
cases which came under his observation, and reaches the following con-
clusions: (1) Most of them arise from dilated bile-ducts. (2) Mechan-
ical obstruction, such as results from tumors and cirrhosis, is not the main
cause, though it may assist other factors (these conditions are extremely
common, whereas liver cysts are rare). (3) Some cysts are admittedly
the result of a developmental fault, and he believes most of the large ones
have the same basis, though the change is only in part of the liver, and
progresses during extrauterine life. (4) The peculiar vascular and
cirrhotic condition of these livers is another expression of a congenital
error, and this obtains in the fetus and in some of the lower animals. (5)
The occasional origin in the bloodvessels cannot be denied, and the change
from blood-cysts to serous cysts is seen in other situations, and in nevi.
(6) The development from dilated lymph-spaces is possible, though he
cannot find the report of any case where this has been made out. (7)
The fusion of vacuolated liver-cells to form a large cavity is of dubious
occurrence. It is impossible for it to lead to the production of a space
bounded by a definite fibrous wall, and lined by a layer of nucleated
cells. The only change established as occurring when liver cells atrophy
and disappear is the occasional formation of an angioma.

A remarkable case of nail in the liver is reported by Livingstone and
Jubb.^ The patient, a man 64 years of age, was admitted to the hos-
pital for cancer of the rectum and died about 6 months later. The in-
teresting disclosure of autopsy was a nail in the left lobe of the liver,
which had penetrated the organ from below. The head of the nail
was almost flush with the under surface of the liver and was covered
with peritoneum. Judging from the somewhat extensive cicatrix on the
under surface of the liver, it was thought that the nail was probably
swallowed, and that, becoming jammed in an upright position at the
pylorus, it gradually made its way through the stomach-wall. No trace
of injury, however, could be found in any other organ than the liver.

^ Intercol. Med. Jour, of Australasia, Dec. 20, 1902.
2 Brit. Med. Jour., Sept. 6, 1902.

DISEASES OF THE LIVER, ETC. 183

The nail was an ordinary iron one, If inches in length. During life
there was no complaint of any other trouble than cancer of the rectum.

Keen and Fisher^ make an interesting report of a case of cirrhosis of
the liver 2 years after epiplopexy performed for ascites. The patient
was an Italian, ,32 years of age. He was operated upon 8 weeks after
the occurrence of the ascites and after having been tapped a number of
times. In performing the operation Keen irritated the upper portion of
the liver and spleen and the under portion of the diaphragm, and in
addition sutured the omentum to the abdominal wall. After the opera-
tion the fluid reaccumulated and the patient had to be tapped a number
of times. At the end of 6 months, however, the condition of ascites had
entirely disappeared, and there has been no recurrence at the end of 2
years. The patient has gained considerably in weight and color, but
still suffers excessively from pain in the splenic region. The spleen,
which was very large at the time of operation, is if anything larger since.
Although it has been suggested that this might be a case of Banti's dis-
ease, the other characteristic symptoms of this disease are not present.

Greenough^ presents an exhaustive study of the literature relating
to the surgical treatment of cirrhosis of the liver and has collected
and summarized 105 cases. He eliminates 17 cases in which Talma's
operation was done for ascites due to other causes than cirrhosis. Fol-
lowing is the author's summary of his paper: " (1) The condition known
as biliary cirrhosis, with enlarged liver, jaundice, and fever and without
ascites, is accompanied in a certain proportion of cases by an infection
of the bile-ducts. The drainage of the bile-ducts by cholecystostomy
is a proper operation for the relief of this condition when evidence of
infection is present and -symptomatic treatment has failed to effect
relief. (2) Of 105 cases of liver cirrhosis which presented the symp-
toms of ascites, 42 % were improved and 58 % not improved by
Talma's operation or one of its modifications. The mortality within 30
days was 29.5 %. Nine patients were improved in health 2 years after
the operation. (3) The nine cases of continued relief presented no
marked differences from the general character of all the cases. (4) The
cases in which the liver was enlarged gave a lower mortality and a higher
percentage of improvement than cases of atrophic liver. (5) Cases of
suture of the omentum between the layers of the abdominal wall gave a
lower mortality and a slightly higher percentage of improvement than
cases where only peritoneal surfaces were brought in contact. (6) Drain-
age increases the danger of septic infection and peritonitis and is to be
avoided. If necessary, tapping may be .done after the operation. (7)
The presence of adhesions or perihepatitis is of good prognostic import
as regards the success of the operation. (8) The number of tappings
before operation and the presence of edema of the feet and legs are of
less prognostic importance than the general condition of the patient, the
size of the liver, and the functional activity of the liver-cells. (9) Talma's
operation or one of its modifications is of proved benefit in a certain
limited number of cases of liver cirrhosis; primarily for the relief of

* Phila. Med. Jour., May 9, 1903. ' Am. Jour. Med. Sci., Dec, 1902.

184 GENERAL SURGERY.

ascites, and secondarily for the relief of other symptoms of portal con-
gestion. (10) The dangers attending the operation are mainly due to
the weakened resistance of the patient, rather than to the operation
itself. The selection of cases suitable for operation demands more judg-
ment than has been exercised hitherto. (11) The operation is not indi-
cated in cases of ascites due to causes other than cirrhosis of the liver.
(12) The operation is contraindicated in the presence of renal or cardiac
disease and when good evidence does not exist that sufficient functional
liver tissue remains to maintain life. It is also contraindicated when
complications exist sufficient in themselves to make the result of opera-
tion uncertain." [The operation should be performed early before the
development of chronic inflammation of the peritoneum.]

Arcoleo^ has performed the operation of Talma 8 times for ascites
due to cirrhosis of the liver. Three patients died shortly after the
operation; 4 patients were neither improved nor injured by the opera-
tion, and in these a temporary relief of symptoms took place. Two of
the patients were suffering from hypertrophic cirrhosis, and the operation
in these resulted in marked temporary improvement. This is probably
due to the fact that this form of cirrhosis is much less serious than the
atrophic type. It is shown that these results correspond practically
with those of a number of other surgeons. Mori presents an analysis of
37 cases: 13 patients died and 13 were cured; 10 remained stationary
and 1 improved. Mongour puts the immediate mortality of the opera-
tion at 35 % and Frieschi places it at 45 %. The number of cases which
have been operated upon is not yet sufficient to warrant the drawing of
any very definite conclusions regarding the value of the operation. All
operators are of the opinion that the operation should be done as soon as
ascites develops, and that the patients who are already markedly cachectic
and in bad condition should not be operated upon.

Thomas R. Neilson^ reports a case in which he performed Talma's
operation for the relief of ascites due to cirrhosis of the liver. The
report is made 21 months after operation. The patient was in a grave
condition at the time of operation and the ascites was very marked. He
showed prompt improvement after the operation and 21 months later
was in the best of health, having gained 23 pounds in weight.

Tansini^ reports a number of experiments upon dogs in which an
attempt was made to divert the portal circulation by direct union of
the portal vein with the vena cava. Of the dogs operated upon, 10 %
lived, and were under observation for a number of months, during which
time they became quite fat.

The present status of the surgery of the gallbladder and bile-ducts
is presented by William J. Mayo.* It is thought that the accepted per-
centage (5 %) of persons suffering from gallstones is too high, because
the statistics are taken largely from almshouses and large public hos-
pitals. The profession has grown so accustomed to looking upon colic
as the one symptom of gallstones that the more chronic manifestations

» Rif. Med., Feb. 11, 1903. ^ Phila. Med. Jour., May 9, 1903.

3 Centralbl.7. Chir., 1902, No. 36. * Med. Rec, Feb. 21, 1903.

DISEASES OF THE LIVER, ETC. 185

of cholelithiasis are frequently overlooked. The two elements which
cause latent calculi to become active are infection and mechanical inter-
ference with drainage. Infections in the gallbladder may die out, es-
pecially those resulting from the colon bacillus, but this is not to be
expected. It has been clearly shown that normal bile is free from micro-
organisms. It is taken for granted, however, that all cases of "slumber-
ing" gallstones contain bacteria encapsulated. The reputation of the
various medicinal springs probably rests upon the fact that the water
acts by keeping up a free circulation of bile which is so essential to the
well-being of the host. The active gallstones as long as they have periods
of latency are compared to the cases of chronic and relapsing appendi-
citis. Mayo favors the early removal of active gallstones. Of these
cases Mayo and his brother had operated upon 250 out of a total of 454
operations upon the bladder and ducts up to December 11, 1902, with
a mortality of less than 1 %. He has collected 2000 operations of this
kind in the hands of 6 surgeons without a single instance of the reforma-
tion of gallstones. Delay in these cases of active gallstones with periods
of latency breeds misfortune. Repeated infection with prolonged inter-
ference with drainage causes the walls of the viscus to become infiltrated
with inflammatory products, and the connective tissue formed inter-
feres with its elasticity under pressure and limits its power of contraction.
At this stage the pbstructing stone is forced through the cystic duct into
the common duct, there to remain or pass out into the intestine, or it
may become encysted in a thick-walled pouch composed of the remains
of the gallbladder, causing recurring attacks of inflammation. Adhesions
to surrounding structures may prevent fatal perforation, and spontaneous
discharge of the infected fluid and incidentally of the calculi may take
place. It is seldom that all of the stones are thus passed, and even if
they are the adhesions remaining may be a prolonged source of distress
to the patient. An operation at this stage is dangerous and the gall-
bladder can no longer be expected to return to the normal. It is in this
class of cases that cancer of the gallbladder is most likely to occur. In
the 454 operations referred to cancer of the gallbladder or bile-ducts
occurred in 21 cases (5 %), and in nearly all a distinct history of previous
colic was elicited. In every one of these cases in which the gallbladder
was examined stones were found. It is stated that in no case was opera-
tion performed upon a patient who had passed stones by the bowel that
the gallbladder did not contain more. In 49 cases stones were found in
the common and hepatic ducts. Infection of the liver-ducts is the cause
of death after operation in the majority of cases. This condition has
been termed "hepatargia" by Eisendrath, and indicates the cessation
of liver-function from degeneration of the parenchyma. In Mayo's
experience this has been the cause of death in nearly one-half the fatal
cases. The symptoms are chiefly nervous and usually sudden in onset
and rapid in their course. The only safeguard when infective cholangitis
is presented is the free drainage of bile to the surface. Cases are referred
to which have been operated upon and in which no stones were found
but only thick mucus and bile. There were 26 such cases in the present
13 S

186 GENERAL SURGERY.

series. The colics were undoubtedly due to plugging of the bile-passages
with the tarry material with which the gallbladder is filled. In each of
these 26 cases a careful but futile search was made for some other cause
for the symptoms, but none found. Mayo has recently written to each
of these patients to find out the present condition, and from the 23 letters
received 19 replies; of these, 15 wrote that they were well, 2 improved,
and 2 unimproved. Three died as a result of the operation, from hepa-
targia. This death-rate alone demonstrates that the infection is often
more active than in gallstone disease. The ideal operation of removing
the stones and closing the gallbladder is not approved, although it may
be done in those latent cases in which the stones are found during other
operations on the abdominal viscera. Whenever gallstones are in a
state of activity, drainage is the operation of choice, and this drainage
should be continued until the bile is normal. Gallbladders with thickened
walls, and especially if the cystic duct has been obstructed, are liable to
give trouble after cholecystotomy, and, if possible, the organ should be
removed. The cystic duct should be tied only when the liver-ducts
are entirely free from involvement. Drainage of the hepatic ducts when
involved can be had by leaving the cystic duct open. Mayo does not
think that Kehr's percentage of cases in which the hepatic ducts require
drainage is too high — namely, 37 %. A convenient method of draining
the cystic duct, and through it the hepatic ducts, is that which Mayo pre-
viously described. It consists in removing the fundus of the gallbladder
and the mucous membrane of the remaining portion. This gives all the
advantage of temporary hepatic drainage with the permanent benefits
of cholecystectomy. The other method, which consists in dividing the
cystic duct and leaving it open, does not compare in ease and safety with
the method recommended by Mayo. In stones in the common duct
drainage of the hepatic duct is essential. Mayo has lately practised the
plan of draining the common duct after the removal of stones, as was
first suggested by W. E. B. Davis. In 49 choledochotomies Mayo had
but 2 deaths. In the majority of these cases the duct and gallbladder
were both drained. The 454 cases which formed the basis of this paper
were operated upon by W. J. and C. H. Mayo. [A paper by the Mayos
is sure to be filled with valuable precepts of practical surgery and is in-
variably founded on a very large collection of thoroughly studied and
carefully tabulated cases.]

William J. Mayo^ presents a study of 534 operations upon the gall-
bladder and bile-passages with a tabulated report of 547 operated
cases.

An instructive dissertation on the diagnosis of gallstones is pre-
sented by Murphy.^ The pain of gallstones is divided into 3 kinds:
first, the acute inflammatory or infective type occurring in vinilent in-
fections and accompanied by involuntary muscular contraction of the
organ ; second, the aching, cumulative, tension type, which is not guarded
by abdominal tension, but defended by sudden muscular contraction
when pressure is made ; and third, the referred ache or pain which accom-

> Boston M. and S. Jour., May 21, 1903. ^ Med. News, May 2, 1903.

DISEASES OF THE LIVER, ETC. 187

panies either of the preceding kinds. There is neither sensitiveness to
percussion or pressure at the point to which the pain is referred. The
spasmodic type of pain termed colic occurs only when a foreign body is
being transmitted through a canal, the lumen of which is normally
smaller than the diameter of the foreign body. It is never produced by
either the overdistention of the gallbladder or the retention of bile and
mucus under pressure. As soon as the foreign body becomes stationary
the pain intermits. Murphy does not agree with Kehr that the colic
is due to inflammation of the gallbladder. It is thought that the passage
of the gallstone is due to the cumulative pressure behind and not to any
peristaltic wave in the biliary ducts. The fact is emphasized that colic
is absent in every type of biliary obstruction except that of foreign bodies,
such as calculi, clumps of mucus, etc. The nausea and vomiting of
biliary obstruction are reflex symptoms, and by their relaxing effect they
favor the dropping back of the stone into the gallbladder in obstructions
of its pelvis, and thus often terminate the attack. The vomiting may
last from a few minutes to several hours or days. A second variety of
reflex vomiting due to torsion, flexion, or valvular obstruction of the
cystic duct is mentioned. In this class the vomiting continues for days
with no severe pain and no colic, and is relieved by liberation of the
obstruction and escape of the gallbladder contents. When the abdomen
is opened for this condition, the gallbladder is usually enlarged and not
compressible. The fact is emphasized that hypersensitiveness of the
gallbladder is present in all varieties of infection and calculus obstruction,
but not in the neoplastic, torsion, flexion, cicatricial, or valvular obstruc-
tions. The most characteristic and constant sign of gallbladder hyper-
sensitiveness is the inability of the patient to take a full, deep inspiration,
when the physician's fingers are hooked up deep beneath the right costal
arch below the hepatic margin. The diaphragm forces the liver down
until the sensitive gallbladder reaches the examining fingers, when the
inspiration suddenly ceases as though it had been shut off. Attention
is called to the peculiar angularity of the temperature and the duration
of the complete intermissions, in both of which charac eristics it varies
from the curves with remissions found in other types of infection. Mur-
phy is a strong believer in Courvoisier's law: ''In 80 % of the cases of
obstruction of the common duct due to stones, there is contraction of the
gallbladder, while in 90 % of the cases of enlargement of the gallbladder
the obstruction is due to causes other than stone." In 86 % of the cases
operated upon by Murphy jaundice was absent as a symptom at the time
of operation and in the history given. Continuous jaundice throughout
the course of the disease indicates malignancy. Therefore, a large gall-
bladder with jaundice is indicative of malignant disease or cicatricial
contraction, and contracted gallbladder indicates a cholelith, in the per-
centage already mentioned. Murphy formulates the following law:
"(I) That jaundice due to gallstone is always preceded by colic; (2) that
jaundice due to malignant disease, or catarrh of the ducts accompanied
by infection, is never preceded by colic." When a large calculus pro-
duces disturbance by impaction in the cervix of the gallbladder, the

188 GENERAL SURGERY.

symptoms are pain, nausea and vomiting, pronounced hypersensitive-
ness, particularly when, in the examination, the fingers are hooked up
under the liver and the patient attempts to take a deep inspiration ; then
the pain becomes intolerable. In this variety there is no jaundice and
no elevation of temperature and the attack may subside with vomiting
which causes the stone to drop into the gallbladder. The cessation of
the pain after vomiting is considered very characteristic. When infection
of the gallbladder is associated with calculus, the disturbance produced
is in direct proportion to its virulence and tension. If mild it produces a
hypersensitiveness and no pyrexia unless the products of infection are
retained in the gallbladder under pressure by the impaction of a stone
in its gervix. It is in this variety that necrosis of the gallbladder and
rupture may take place. The symptomatic manifestations of infectious
cholecystitis without impaction of the stone in the neck of the gallbladder
or cystic duct are neither so severe nor dangerous as when the impaction
occurs after a virulent infection. In this condition the temperature
rises high, the vomiting is persistent, and the depression great. So
destructive is infection under these circumstances that the mucosa of
the gallbladder rapidly becomes gangrenous from the biotic and toxic
effect of the microorganisms and the pressure under which the products
of infection are retained. The next type of infection of the gallbladder
which is described is that which is characterized by recurring chills, high
temperature, and sweats, and which is most usually diagnosticated
malaria. There is an absence of pain, no colic, no jaundice, but oc-
casionally a mild discoloration of the sclera. The condition is usually
acute, and in Murphy's cases there has been enlargement and edema
of the gallbladder wall. The diagnosis is difficult, but the chills and
irregular temperature are characteristic. There is also one physical
manifestation which was uniformly present in all of Murphy's cases of
this type; it was the inability of the patient to take a deep inspiration
without pain when the physician's fingers were deeply pressed beneath
the right ninth costal cartilage. These attacks occur with or without
stone ; more frequently without. Acute phlegmon of the gallbladder may
possibly be confused with this condition. There is another class of cases
described, the contracted type of gallbladder with infection, with or
without preceding colic, but usually the sequence of primary calculous
disease. In this class the patient has recurrent attacks of chills and
high temperature with subsidence, remaining normal from a period Y&Ty-
ing from a few hours to as many months, when the same symptom-cycle
is again passed through. Here we have also the classic temperature
angle of cholangic infections. The gallbladder is contracted to a teat-
like process, indurated, deformed, and surrounded by adhesions. The
symptoms of stone in the common duct are in most instances quite
characteristic. Its arrest in the duct is sometimes followed by a dilation
of the duct on the hepatic side of the obstruction, which may become so
great that the stone is permitted to slide back and forth, giving rise to
the valve-like action of Fenger. Infection of the duct is very likely to take
place, and the patient then develops the manifestations of an infective

DISEASES OF THE LIVER, ETC. 189

jaundice with repeated chills and high fever characterized by inter-
missions. Once sepsis is manifested with a stone in the common duct,
there appears to be no cessation of the septic process, until the foreign
body is removed. "When the stone is arrested in the ampulla of Vater,
the drainage is frequently more free and the manifestations of sepsis less
marked, than when it is ^ inch or more from that point in the common
duct. When in the ampulla of Vater, we have the additional danger
of infective pancreatitis or fat necrosis. When in the course of a cal-
culous jaundice we have a sudden and extreme collapse, intense pain
without any gradual preceding increase of pain, it is right to assume
that the condition is due to a beginning fat necrosis, and not to a per-
forative peritonitis, nor to a progressive infective cholangitis. In the
fat necrosis there is no hyperleukocytosis ; with perforative peritonitis,
and the acute infective cholangitis there is a pronounced hyperleukocy-
tosis." Drainage of the gallbladder has a beneficial effect on the fat
necrosis even when the pancreas is not incised. When gallstones pro-
duce intestinal obstruction, they have usually escaped from the gallblad-
der through a perforation of its wall or of its ducts. It is rarely preceded
by jaundice, as stones of great size seldom find admission into the in-
testine through the common duct. There are no special symptoms by
which the obstruction of biliary enteroliths can be differentiated from
the obstruction of coproliths.

Brewer,^ after presenting in detail the differential diagnosis of
diseases of the gallbladder and ducts, considers the 3 chief symptoms
occurring in diseases of the gallbladder and ducts, namely, pain, tumor,
and jaundice. The occurrence of repeated attacks of acute paroxysmal
pain, in the upper right quadrant of the abdomen, strongly suggests a
lesion of the biliary passages. This suggestion is accentuated if the
attacks occur at night, or during fasting, and are accompanied by vomit-
ing and fever. If the pain radiates upward to the back and shoulder,
and if an area of tenderness exists under the free border of the ribs, the
diagnosis is still more probable. If in addition to the pain there is a
palpable and tender tumor in the gallbladder region with moderate spasm
of the rectus muscle, the case is probably one of cholecystitis. If tumor
is absent and jaundice is present, there is probably a stone in the common
duct. The development of a tumor preceded by a history of tumor
which is round, smooth, and elastic, and which lies immediately under
the abdominal wall below the ribs, moves with respiration, allows a certain
amount of movement, which cannot be made to disappear like a mov-
able kidney, and which is not accompanied by pain and fever, is in all
probability a gallbladder distended with mucus. If with such a con-
dition there is progressive jaundice, there is probably a non-calculus
common-duct obstruction. If such a tumor is sensitive to the touch
and accompanied by fever, pus is probably present. A tumor corre-
sponding to the above description, without pain, fever, or jaundice
at first, but presenting a hard, irregular surface, is in all probability
cancer. The occurrence of a mild transitory jaundice unaccompanied
' Boston M. and S. Jour., May 14, 1903.

190 GENERAL SURGERY.

by other symptoms suggests a catarrhal obstruction of the common duct.
Temporary jaundice with colic suggests the passage of a stone through
the common duct into the intestine. The occurrence of intermittent
jaundice, intermittent colic, and intermittent fever suggests a floating
stone in the common duct. The occurrence of continued jaundice,
with chiUs, fever, hepatic enlargement and tenderness, hypertrophy of
the spleen, and general sepsis, suggests an infective cholangitis. The
occurrence of a progressively increasing jaundice and enlargement of the
liver, with a previous history of colic, but without distention of the gall-
bladder, suggests an impacted stone near the papilla. The occurrence
of a progressively increasing jaundice, without pain or fever, but with a
tumor of the gallbladder, suggests common-duct obstruction from new-
growth.

Attention is also called to the facts that gallstones are rarely found in
young people, that they are most frequent in females, and that 90 % of
these have borne children. In common-duct stone the calculus is found
in 67 % of the cases in the duodenal extremity; in 15 % in the hepatic
extremity; and in 18 % in the middle portion of the duct. One-half of
all cases of common duct obstruction only are due to stone. In 70 % of
the cases of obstruction located in the neck of the gallbladder the pain is
referred to the right subscapular region, in 10 % to the left subscapular
region, and in 20 % to the precordia, sternum, right subclavicular region,
or neck. Jaundice is absent in from 80 % to 90 % of operative cases of
gallstone or duct disease. Jaundice preceded by colic is practically
always due to stone. Jaundice without pain is practically always due to
inflammation or new-growths of the ducts or to outside pressure. Mur-
phy is quoted as saying that during the presence of a calculous jaundice,
the sudden occurrence of acute epigastric pain, muscular rigidity, nausea,
vomiting and collapse, without leukocytosis, strongly suggests acute
pancreatitis occasioned by the presence of a stone in the diverticulum of
Vater.

Ehret^ discusses the diagnosis of the location of gallstones. It is
stated that when the stools continuously present a more or less bile-
stained character, and when in the intervals between attacks there is
little or no jaundice, the location of the gallstones may in most instances
be diagnosticated by a careful consideration of 4 symptoms — namely,
fever, jaundice, pain, "and the condition of the blood. When fever is
associated with gallstones, it indicates infection. The infection follows
interference with the onward flow of bile. Microorganisms are always
present in the biliary tracts, but become much more abundant as the
duodenum is approached; therefore a gallstone is more liable to give rise
to infection the further down the ducts it is situated. The fever, when
the infection takes place in the duct, is apt to be a high one and of short
duration, but when the stone and infection are in the gallbladder, fever
does not go so high, but is more prolonged. This comparison, of course,
is made with stones in the common duct which do not produce absolute
obstruction. The downward flow of bile tends to overcome the infection,
^ La Sem. MM., Jan. 7, 1903.

DISEASES OF THE LIVER, ETC. 191

and the result is a cessation in the fever and other evidence of infection.
There is no such influence in the gallbladder or cystic duct to aid in over-
coming the infection, and therefore it is apt to be of longer duration.
According to this rule, in those cases accompanied by frequent attacks
of a rapidly rising, high temperature (the type of intermittent hepatic
fever described by Charcot), the seat of stone is likely to be in the common
duct. Jaundice is said usually to depend upon an angiocholitis involving
the smaller ducts, and not upon mechanical obstruction by one or more
gallstones. Generally attacks of jaundice which occur frequently and
are of short duration are the result of stone or stones situated in the bile-
duct. Jaundice, when the stone is confined to the gallbladder, is rare.
Naunyn has shown that when the stone is in the gallbladder pain is intense,
but that when it is in the bile-duct pain is slight. It is therefore stated
that febrile attacks with intermittent jaundice unassociated with severe
pain suggest that the stone is in the common duct. A continuous leu-
kocytosis is of value as a symptom, and it tends to indicate that the
stone is situated in the gallbladder. A leukocytosis which occurs during
the attacks and disappears during the interval is of no diagnostic value.

Delageniere^ describes a successful case of incision of the hepatic
duct for the extraction of calculi. The operation is called hepaticot-
omy. It is stated that only 6 other cases of this operation have been
recorded. The calculi were impacted near the hilum of the liver at some
distance from the common duct. The method of exposing the gall-
bladder and its ducts is carefully described. After exposing the hepatic
duct in the case reported and removing 2 stones, the incision in the duct
was closed by a continuous suture. Suture of the bile-ducts is strongly
recommended, though the author admits that it is seldom perfect and
must be associated with drainage.

Rutherford Morrison^ describes an incision for operations upon,
the gall-passages which is transverse, beginning 1 inch below the tip
of the twelfth rib ending in the middle line at the upper part of the
middle one-third of a line drawn from the ensiform cartilage to the um-
bilicus. All the layers of the abdominal wall including the rectus are
divided. It is maintained that this incision gives a much better exposure
than the vertical one through the rectus muscles, and that if properly
approximated there is less likelihood of hernia. The wound should be
closed in layer sutures. Forty-three gallstone patients have been traced
since operation, and in 41 of these the transverse incision was employed.
Seven of the 43 patients had some complaint to make : in 1 it was known
that a stone had been left at the time of operation ; in 2 cases the trouble
was probably due to a recurrence of stones, as there was no relapse until
4 and 6 years after operation; in 1 case it is not certain that stones were
the cause of the illness, as none were found at a second operation; of the
remaining 3 cases it is certain in 1, and highly probable in 2, that stones
had been overlooked at the time of operation. A careful inquiry was
made regarding an occurrence of hernia in these cases and it was dis-

' Bull, et Mem. de la Soc. de Chir. de Paris, No. 10, 1903.
* Brit. Med. Jour., Nov. 8, 1902.

192 GENERAL SURGERY.

covered in 4 of the 43 patients. In one of the eases it occurred where
a vertical incision had been employed. In the other 3 it was attributed
to defective suture.

Thienhaus^ urges the transduodenal route (duodenal choledo-
chotomy) in cases of impaction of gallstones in the lower portion
of the common duct. He reports a case in which he removed 3 stones
from the common duct by incising the duodenum, and in which he be-
lieves it would have been impossible to have removed them by opening
the common duct alone.

Regarding Maj^o Robson's statement, as to the mortality of this
operation, the author has collected 29 cases with 2 deaths, or about 7 %,
and a little less than that which has accompanied the operation of chole-
dochotomy in Robson's hands. As to the greater chances of sepsis in
the duodenal route, Thienhaus quotes Riedel, who has pointed out that
those cases in which severe infection of the bile-passages has taken place
before operation are the ones giving a high mortality from sepsis after
operation. These people die whether one resorts to transduodenal
choledochotomy, to supraduodenal choledochotomy, or to any other
method. The author also points out that it is often impossible to remove
a stone impacted in the retroduodenal portion of the common duct, near
the opening of the papilla, before the diverticulum of Vater, or before
the pancreatic portion of the common duct, by supraduodenal chole-
dochotomy. It has been pointed out that it would be difficult to clean
out from the duodenum all the stones in the common duct when lying
in the supraduodenal portion or in the hepatic duct, and that when a
stone is impacted in the retroduodenal portion of the common duct, and
more or less complete obstruction has taken place for some time, the
common duct usually becomes dilated ; and if there are other stones lying
higher up, they are generally movable, and can, after removal of the im-
pacted stone, be easily stripped down into the duodenum by putting
two fingers of the left hand into the foramen of Winslow, and the thumb
above the duct. In his own case he found it easy to remove 3 stones
lying behind the incarcerated concretion because he had already, before
incising the duodenum, stripped them down to the impacted stone, and
held them tightly in this position to avoid their slipping back after the
opening and collapse of the duct. From the study of this question Thien-
haus draws the following conclusions: "First, the transduodenal route
has a well-defined place in the surgery of obstruction of the common duct
produced by gallstones ; second, transduodenal lithotomy, first advocated
and practised by McBurney in 1891, either after his methods, that is,
with incision of the papilla, or Collins's method, that is, dilation of the
papilla, is the method par excellence for all cases of gallstones impacted
at or near the opening of the papilla, as soon as experiments of manipula-
tion, to press the stone into the duodenum by bimanual manipulations,
have proved unsuccessful; third, transduodenal choledochotomy is in-
dicated for stones impacted in the retroduodenal portion of the common
duct, or before the diverticulum of Vater, as soon as efforts to dislodge
1 Ann. of Surg., Dec, 1902.

DISEASES OF THE LIVER, ETC. 193

the stone up into the supraduodenal portion have proved futile; fourth,
in all cases in which transduodenal choledochotomy has been performed,
it is advisable to suture the common duct to the duodenum to avoid in-
fection (choledochoduodenostomia interna) ; fifth, transduodenal chole-
dochotomy seems to be more advisable than retroduodenal choledochoV
omy because it can be more easily performed, and the integrity of the
pancreas is not interfered with ; sixth, it has not been proved by statistics
that transduodenal choledochotomy has a greater percentage of fatalities
produced by septic infection than supraduodenal choledochotomy.
Further contributions in this direction are desirable for the purpose of
procuring definite conclusions. Most of the cases where sepsis was the
cause of the death of the patient after an operation on the common duct
were cases of infection of the bile-passages before operation, and the
method of operation was not responsible for the fatal result."

B. B. Davis ^ discusses the indications for cholecystectomy. The
author first calls attention to the unsatisfactory results frequently ob-
tained after the performance of cholecystectomy, and later particularly
refers to Hans Kehr's statistics to show that the relief following chole-
cystostomy is often disappointing. In 17 % of the cases Kehr says that
relief is only partial, whereas less than 1 % of the same operator's chole-
cystectomies continue to present symptoms after these operations. Davis
states that since January 1, 1902, he has done 12 uncomplicated chole-
cystotomies with no deaths; 16 complicated cholecystotomies with 3
deaths; 12 cholecystectomies with 1 death, and in these cases conditions
were badly complicated. After cholecystotomy there are a number of
conditions which may seriously interfere with perfect drainage of the
gallbladder. They are: "(1) Adhesions to neighboring viscera; (2)
crippling of the gallbladder from inelasticity of its walls; (3) partial occlu-
sion of the cystic duct; (4) interference with the perfect contraction of
the walls during the effort to empty itself, due to the fundus being fixed
to the anterior abdominal wall ; (5) the weight of the liver pressing down
on the anchored gallbladder." Of course there are a number of condi-
tions demanding opening of the gallbladder in which the cystic duct is
normal and in which the mucous membrane is intact and the walls
normally elastic. Such cases usually do well after simple drainage, but
when complications exist, such as those above enumerated, the convales-
cence is apt to be prolonged and imperfect. The advantages of cholecys-
tectomy are enumerated: "(1) When the cystic duct is wholly or par-
tially occluded healing is prompt and complete; (2) when the wall of the
gallbladder is thickened, friable, and atrophied, the functionless viscus is
taken out and can no longer torment the patient; (3) when there are
adhesions they will remain as long as a pathologic gallbladder is present
to keep up the irritation ; (4) it is a well-known fact that intraabdominal
adhesions gradually weaken, stretch, and disappear when there is no dis-
turbing element; (5) the value of the gallbladder as a reservoir for the
bile is nil, and functionally it serves no more useful purpose than does
the vermiform appendix ; (6) after a gallbladder has been as profoundly
* Jour. Am. Med. Assoc, June 20, 1903.

194 GENERAL SURGERY.

diseased as it usually is when made the object of surgical attack it never
regains its normal state and is thenceforth not only valueless but, on
account of the defective drainage, is constantly subjected to the risks of
fresh infection; (7) the cholesterin, which is the principal element of
almost all stones/is only elaborated in such a quantity as to do harm by
the epithelium of the gallbladder when infected, being due to degenera-
tion; therefore, when removed, all danger of future stone formation is at
an end; (8) it is estimated that at least 5 % (Mayo) of the cases of
serious disease of the gallbladder are followed eventually by carcinoma;
removal will take away this menace." In gangrene and empyema of the
gallbladder cholecystectomy is also recommended, but it is admitted that
there are conditions of this kind when the simplest and quickest surgical
procedure possible to give temporary relief is all that is indicated. Where
drainage is required after cholecystectomy in the presence of infection,
Davis recommends the method of Mayo, and removes a portion of the
outer coats of the gallbladder near the cystic duct, and attaches to them
a drainage-tube by means of the purse-string suture.

H. M. Richardson^ reaches the following conclusions after dealing
with the indications for extirpation of the gallbladder : " (1) Certain
lesions in themselves demand removal of the gallbladder whenever possi-
ble. Such are new-growths and gangrenes. (2) Certain other lesions of
the gallbladder are better treated by cholecystectomy. These are the
contracted and inflamed gallbladders, with thickened walls. All gall-
bladders which do not permit easy and efficient drainage should be extir-
pated, for in such gallbladders the risks of drainage are quite as great as
the risks of extirpation ; and the one great advantage of retention is im-
possible— retention of the biliary reservoir to fulfil the functions of that
reservoir, and to permit, if necessary, renewed drainage in future years.
(3) Drainage is preferable in the dilated and infected gallbladder, which,
however, is neither gangrenous nor to any great extent changed — the
slightly thickened gallbladder containing gallstones and infected bile.
This gallbladder will, after drainage, become normal, and therefore capa-
ble of fulfilling the functions of a gallbladder. Through it the biliary
passages will become effectually drained, after subsidence of the tem-
porary swelling about the cystic duct. (4) As a rule, drainage rather
than extirpation is demanded in acute cholecystitis with severe constitu-
tional symptpms, when the gallbladder is dilated, or at least not con-
tracted, and when it is not gangrenous. (5) In chronic cholecystitis,
with dilation and thickening of the gallbladder, especially when a stone
is impacted in the cystic duct, extirpation is the preferable operation,
unless the stone can be dislodged backward into the gallbladder, in which
case drainage is, if not preferable, quite as advantageous as extirpation.
(6) In simple gallstones, without visible evidence of infection or chronic
changes incompatible with complete restoration of function, simple drain-
age of the gallbladder is indicated. (7) In chronic pancreatitis, whether
associated with gallstones or not, drainage through the gallbladder is in-
dicated. Cholecystectomy is unjustifiable, for immediate drainage is

' Med. News, May 2, 1903.

DISEASES OF THE LIVER, ETC. 195

essential. Furthermore, reopening of the biliary passages may in the
future be required."

J. F. W. Ross^ calls attention to the great improvement in the
treatment of gallstones by surgical measures, and refers to the dan-
gers incurred by patients suffering from gallstones. These dangers are
considered sufficient warrant for surgical procedure in practically all
cases. Two cases of gangrene of the gallbladder are referred to in which
recovery occurred after simple drainage. Cholecystectomy is discussed
at some length. This operation should be performed in gangrene unless
the local conditions present a contrary indication. In the presence of
obstructive jaundice cholecystectomy is not advisable. In such cases
drainage should be established. Because stones have been found in the
hepatic duct when the cystic duct was obstructed, Ross does not think
that the operation of cholecystectomy can be looked upon as a warrant
of future immunity from gallstones. *In performing cholecystenterostomy
he prefers a small Murphy button, although he has also used the elastic
ligature. The colon is chosen as the most suitable portion of the intestine
for anastomosis with the gallbladder. The operation of cholecj'stenteros-
tomy, however, must be looked upon as a makeshift, to be used only
when the patient is in bad condition, since stones in the common duct
can, in most cases, be removed by incising the duct. The use of the
sandbag underneath the back is a great aid to the exposure of the common
duct. Ross is a strong advocate of posterior as well as anterior drainage
in certain cases in which leakage is apt to occur after operation upon
the gall-passages. He does not believe in opening the intestine for re-
moval of a stone from the common bile-duct.

Six eases of cholecystectomy are recorded by Moynihan.^ The
author does not think that the removal of the gallbladder is necessary
in cases of recent acute or subacute cholecystitis due to the blocking of
the cystic duct by a large stone. The gallbladder should never be re-
moved unless the operator is convinced that the common duct is open.
It is Moynihan's habit to ligate the cystic duct in most instances when
removing the gallbladder. The first case in which the gallbladder was
removed was one of fistula between the gallbladder and duodenum.
The patient recovered. The organ was removed in this case, as the
operator was not sure that the thick pulpy wall of the gallbladder might
not be the seat of new-growth. The second case was that of a woman
60 years of age suffering from primary carcinoma of the gallbladder.
The cavity of the gallbladder was barely as large as a thimble and con-
tained a dirty greenish-black fluid. No stone was present in either the
gallbladder or cystic duct, and none could be felt in either the hepatic
or common duct. Six months after the operation the patient had gained
two stone in weight and was in robust health. The growth was a typical
glandular carcinoma. The third case was one of membranous chole-
cystitis which was at first thought to be a growth of the ascending colon.
When the abdomen was opened, however, the gallbladder was found
adherent to the abdominal wall and ascending colon. This patient also

1 Jour. Am. Med. Assoc, Dec. 20, 1902. ^ Brit. Med. Jour., Jan. 24, 1903.

196 GENEEAL SURGERY.

recovered. In the fourth case, one of chronic cholecystitis, the gall-
bladder and a portion of the liver were removed. The gallbladder con-
tained about an ounce of pure pus and a number of stones. There was
so much thickening about the gallbladder that it was thought it might be
due to a malignant disease, and it was with this idea in mind that a por-
tion of the liver was removed with the gallbladder. This patient also
recovered. The fifth case was one of chronic sclerosing cholecystitis with
multiple perforations and stone in the common duct. The stones had
ulcerated through the walls of the gallbladder and lay in pockets in the
omentum, and one was almost hidden in a cavity in the liver. A stone
was removed from the common duct. This patient recovered. In the
sixth case the gallbladder was removed because of incipient gangrene.
This patient likewise recovered.

W. P. Manton,^ of Detroit, describes a case of extirpation of the
gallbladder through a lumbar imcision. The diagnosis in this case
was nephroptosis with probable cystic metamorphosis of the kidney.
When the kidney was brought out of the lumbar wound, the gallbladder,
containing a number of stones, could be easily palpated, and was so thor-
oughly shut off from the general peritoneal cavity either by adhesions or
because of its anomalous situation that the operator was able without
much difficulty to remove it and also the cystic duct. The cystic duct
and gallbladder contained 19 stones, the size of hazel-nuts. The opera-
tion was peritoneal.

W. W. Seymour^ discusses the present position of gallstone sur-
gery. He states plainly in the beginning that no gallstone can be dis-
solved, and that therefore operation is indicated early, not necessarily
after one attack, but certainly after repeated attacks of gallstone colic.
He refers to a case in which the physician assured the patient that he
was cured of gallstones by medicines and yet the patient died within 6
weeks of the time of the assertion, from perforation of a gallbladder
which contained 150 stones. The patient had been considered cured,
when the stones were only quiescent. Gallstone colic is due rather to
the inflammation caused by the stone than to the presence of the stone
itself. A distended gallbladder accompanied with jaundice indicates
malignancy. Reference is made to the great frequency of the removal
of the gallbladder for the cure of gallstones, and also to the recent improve-
ment in the treatment of stones in the common duct, and the great ad-
vantage to be obtained by drainage of the common and hepatic ducts.
Seymour bases his remarks upon a series of 47 operations on the gall-
bladder.

Fistula between the gallbladder and stomach is discussed by
Snively,^ who reviews the literature on the subject and reports an in-
teresting case. The rarity of the condition is shown by the fact that,
out of a collection of 10,866 autopsies, fistula between the gallbladder
and stomach was found but once. Other biliary fistulas occurred 42
times. The case reported is that of a woman, 53 j^ears of age, who

1 Amer. Med., Oct. 4, 1902. ^ Jour. Am. Med. Assoc, April 18, 1903.

3 Jour. Am. Med. Assoc, April 11, 1903.

DISEASES OF THE LIVER, ETC. 197

suffered from numerous attacks of hepatic colic, during which she passed
large numbers of stones. Symptoms of gallstones had existed for 22
years. In a recent attack the patient passed 97 stones, and in one pre-
vious to that 80 stones. After the last attack she improved in strength,
but the bowels remained constipated, and she complained of a burning
sensation in the stomach. The diagnosis of fistulous opening between
the gallbladder and stomach was made upon the following symptoms,
which later developed : Eructations of bile and gas ; a persistent tender
spot in the region of the pyloric end of the stomach ; continuous obstinate
constipation, and pain when any food was taken into the stomach. At
this time operation was advised, but the patient refused to be operated
upon; later, however, she consented, and Cullen, of Baltimore, operated.
The gallbladder was small and found intimately adherent to the stomach
and surrounding structures. The opening between the stomach and
gallbladder was easily discovered and the two organs were separated.
The opening in the stomach was closed, the gallbladder was attached to
the abdominal wall, and 2 stones were removed from the cystic duct.
On the fourth day after the operation the stools were bile-stained. The
external fistula closed promptly and the patient ultimately recovered.

Sixteen cases of primary cancer of the hepatic duct have been
collected from the literature by Ingelrans.^ The disease appears to be
about as common among women as among men. The ages of the patients
vary from 29 to 73 years. Secondary involvement of other organs, ex-
cepting the liver, is rare. Jaundice precedes cachexia. If one branch
of the duct is free, jaundice is not an early manifestation. There is
marked dilation proximal to the growth. This is sometimes so great
as to produce an angiomatous appearance of the liver. The liver is
usually much enlarged and smooth, but it may even be atrophied. The
invariable symptom is jaundice, which is persistent until death, which
takes place in from 2 to 26 months. The patients complain of itching
of the skin, and especial disgust for fatty foods. The pain varies in de-
gree, but tenderness is almost invariable. The leukocytosis varies. In
Ingelrans's case it was 30,080, but in Jenner's case it was but 9000.

Before entering upon a discussion of malignant disease of the gall-
bladder, William J. Mayo^ states that between 1891 and 1902 he and
Charles H. Mayo in 405 operations upon the gallbladder and biliary
passages encountered malignant disease 20 times, or in about 5 % of the
cases. A careful study of the statistics shows the following facts to be
indisputable : " First, gallstones are almost constantly present in primary
malignant disease of the gallbladder and rarely in secondary; second, the
relative proportion of gallstones and malignant disease of the gallbladder
in women and men is practically identical; third, the pathologic lesions
found are best explainable on this theory; and, fourth, the similarity in
age frequency. Certainly we are warranted in concluding that gall-
stones are the most important etiologic factor in malignant disease of the
gallbladder." The diagnosis of primary cancer of the gallbladder may
be easy, since there is usually a hard tumor in the region of the gallblad-

' Arch. G4n. de M6d., Sept., 1902. ^ Med. News, Dec. 13, 1902.

198 GENERAL SURGERY.

der not very tender to touch, and, unless there is some peritonitis in the
neighborhood, there is Httle abdominal rigidity. Progressive loss of
weight takes place and the tumor becomes nodular. Later jaundice
develops. Usually a previous history of gallstone-disease can be obtained.
Jaundice when it occurs is persistent and unchanging, and if a tumor is
present which is accompanied by loss of flesh and which appeared before
the jaundice, there can be but little doubt as to the malignant nature
of the trouble. It sometimes happens that even on the operating table
it is impossible to say whether a thick-walled gallbladder is malignant or
not. Many surgeons have reported errors of judgment in such cases,
and Mayo reports one of his own. Since cholecystectomy is gradually
replacing drainage in these cases, it is thought that many cases of cancer
of the gallbladder will be discovered early and removed. Mayo reports
a second case of cancer of the gallbladder in a woman 63 years of age in
whom the growi;h returned one year after a cholecystectomy. Another
case is referred to in which he removed a portion of the liver with the
gallbladder. In this case there was also a recurrence. In all the eases
in which the liver is involved or in which the lymphatics are involved,
recurrence takes place early.

Gibbon,^ after calling attention to the extreme rarity of gangrenous
cholecystitis, reports a case in which he successfully removed the gall-
bladder. The patient was a woman 52 years of age who gave a history
of frequent attacks of indigestion accompanied by nausea and vomiting.
The present attack began in the same way and had lasted for 3 days when
she was admitted to the hospital. She presented evidences of a peri-
tonitis, abdominal pain being particularly marked on the right side.
The rigidity was sufficient to prevent palpation of the distended gall-
bladder, and it was not until the patient was anesthetized that the con-
dition was absolutely differentiated from appendicitis. The patient's
leukocyte count was 37,600. Free fluid was found in the abdominal
cavity and the gallbladder was covered by adherent omentum. There
was a quantity of lymph about the liver, omentum, and bowel in the
neighborhood. The general cavity was protected by gauze pads, and the
gallbladder, which was distended and very dark in color, was opened, a
quantity of very foul pus being evacuated. The fundus of the gall-
bladder was gangrenous through all its coats. The line of demarcation
between this and the remaining portion of the organ was very clear and
could be observed months afterward in the specimen. A large stone
was found fixed at the mouth of the cystic duct. The general condition
of the gallbladder walls can be understood from the fact that when a
ligature was placed about the cystic duct, the gallbladder separated and
came away before the ligature was tied. Extensive gauze drainage was
employed and the patient made a complete recovery. It is stated that
gangrenous cholecystitis rests probably on two causal factors, obstruc-
tion of the cystic duct and infectious microorganisms. It is very doubt-
ful whether either of these conditions alone could produce gangrene of
the gallbladder or even phlegmonous cholecystitis. A true gangrene,
1 Am. Jour. Med. Sci., April, 1903.

DISEASES OF THE LIVER, ETC. 199

such as is presented in this case, does not of course develop until inflam-
mation has become sufficient to shut off the circulation. The abun-
dant blood-supply of the gallbladder no doubt saves it frequently from
gangrene, just as the poor blood-supply of the appendix renders it more
liable to this condition. Although the gallbladder separated when very
little traction was made upon it in this case, the cystic artery bled freely,
and because of the infiltration about it afterward, it was found impossible
to control the vessel with forceps, and therefore gauze packing was re-
sorted to for this purpose. The adhesion of the omentum over the whole
fundus of the gallbladder was quite similar to the same condition so fre-
quently found in the appendix. The symptoms in such a condition as
this are those of a violent localized peritonitis, with usually some ele-
vation of temperature, persistent vomiting, obstruction of the bowels,
and a high leukocyte count. Jaundice is not generally present unless
there exists marked cholangitis or unless the inflammation has extended
by contiguity into the liver structure. The condition is likely to be
confused with appendicitis, but when the patient is anesthetized the
two conditions can usually be differentiated, and both of course call for
operation. The author believes that the only treatment for a condition
so dangerous and severe as gangrene of the gallbladder is immediate re-
moval. This view is shared by most American surgeons, although there
are men of large experience who think that drainage alone should be the
operation of choice. It is thought that the same rule should apply to
gangrene of the gallbladder as applies to gangrene of the appendix. The
immediate relief in the author's case, as indicated by the subsidence of
symptoms and the drop in the leukocyte count from 37,600 to 12,600 in
24 hours, is attributed to the complete removal of the offending organ.

A case of primary typhoid perforation of the gallbladder is reported
by Erdmann.^ The patient >vas a woman 46 years old. The perforation
occurred in the sixth week of the fever and during the first week of con-
valescence. During the third and fourth week a left-sided phlebitis
developed. The patient suffered from two attacks of pain in the back
between the shoulder-blades during the third week, but there was no
other symptom to suggest trouble either of the gallbladder or the liver.
At the time the perforation took place the patient's temperature had
been normal for a week. Erdmann saw the patient 12 hours after
the onset of pain. At this time she presented the following symptoms:
anxious countenance; pulse 120; respiration rapid; temperature 102°;
abdomen somewhat distended; exquisitely sensitive, but more marked
on the right side. It was thought that the patient probably had an in-
testinal perforation; therefore, the right iliac fossa was first explored.
When the peritoneum was opened there was a gush of bile-stained colored
fluid with no odor and containing no fecal matter. No perforation was
found in the small intestine, and a further exploration revealed a per-
foration of gallbladder about { of an inch in diameter and situated in
the lower portion and near the cystic duct, and through it clear bile was
flowing. There was no evidence externally whatever to indicate any
1 Ann. of Surg., June, 1903.

200 GENERAL SURGERY.

inflammation of the gallbladder. An immediate cholecystectomy was
decided upon, and easily accomplished. Drainage was established at
former site of gallbladder and another drain placed in the pelvis. The
patient recovered. When the gallbladder was opened two small stones
were removed, but they were so small as not to be considered factors in
the production of the ulceration. The mucous membrane showed numer-
ous small points of ulceration; one about the size of the head of an or-
dinary pin was found to connect with the opening on the peritoneal
coat by an oblique channel. Cultures taken from the fluid found in the
peritoneal cavity showed the colon and typhoidal bacilli. Erdmann
discusses typhoidal perforation of the gallbladder based upon 34 cases
which have been collected from the literature. The diagnosis of the
condition can only be approximately made by obtaining a very thorough
and careful anamnesis, particular stress being laid upon the original
site of the pain. The only treatment is operative. Erdmann strongly
urges the removal of the gallbladder, Wlien this is impossible, the gall-
bladder should be opened and drained; inversion of the perforation by
sutures is unwarranted. Of the 34 cases reported, 4 patients recovered
and 30 died. Of these, 7 were operated upon and 4 recovered, while
of the nonoperated patients, 27 in number, all died.

A. E. Ash^ describes a typhoid perforation of the gallbladder
occurring in an English soldier 27 years old. On the twenty-ninth day
of the disease cholecystitis was diagnosed and an exploring needle intro-
duced at the lower margin of the liver dulness. No fluid was found,
however. The patient grew worse, and died on the thirty-third day of
the disease. At the autopsy the gallbladder was found perforated, and
when examined it showed three points of ulceration, one of which had
perforated. It was discovered that the exploring needle had entered
only the liver-substance. [One lesson which this case would seem to
teach is that the exploring needle is hardly a reliable diagnostic measure
in cases of supposed cholecystitis.]

W. W. Grant^ reports a case of rupture of the gallbladder, believed
by him to be the result of violent vomiting. In this case the appendix
was cystic and was also found ruptured. The patient died of septic
peritonitis. No gallstones were found at the operation, but it was be-
lieved that the gallbladder and ducts were the seat of advanced inflam-
mation. In making a diagnosis it was difficult to decide whether the
case was one of perforated gallbladder or a perforated appendix. No
S3Tiiptoms of an inflammatory or ulcerative condition preceded the illness.

Roswell Park' presents a careful consideration of cysts and other
neoplasms of the pancreas. His introductory remarks have to do with
the anatojnic relations of the pancreas. Cysts are considered under the
classification adopted by Robson and Moynihan, that is, retention,
proliferation, hemorrhagic, hydatid, congenital, and pseudocysts. The
causes of retention cysts are: intrinsic — impaction of calculi and stricture;
extrinsic — pressure from without, abnormalities of shape and position^

1 Brit. Med. Jour., Aug. 30, 1902. ^ Jour. Am. Med. Assoc, April 18, 1903.
3 Am. Med., June 13, 1903.

DISEASES OF THE LIVER, ETC, 201

and closure or obstruction by parasites. Chronic pancreatitis may be
looked upon as the commonest cause of retention cysts, producing, by
inflammatory exudate, occlusion of the duct. In experiments upon
animals it has been shown, however, that simple occlusion of the duct is
insufficient to alone produce retention cysts. Proliferation cysts often
so closely resemble malignant cysts that only their subsequent course
indicates to which variety they belong. Some of them seem to be in-
dependent of the excretory ducts. They are more apt to be found at the
tail of the organ and frequently contain blood-stained fluid. It is thought
by some that they are really hemorrhagic in origin and they have received
the name "apoplectic cysts." Park prefers the name cystic carcinoma
to cystic epithelioma as applied to malignant cysts. These are essentially
cystic formations with cancerous deposits in their walls, and are usually
accompanied by secondary growths in the liver and adjoining tissues.
Most of the hemorrhagic cysts met with are retention cysts into which
blood has escaped in varying quantities. Hydatid cysts of the pancreas
are extremely rare. Tricomi states that there are 7 cases on record.
Congenital cystic degeneration resembles that of other solid viscera, and
Moynihan states that there are but 3 recorded instances. Pseudocysts,
as Korte has proposed to call them, constitute a large proportion of cases
reported as pancreatic cysts. These are fluid collections in the lesser
omental cavity, and it is often impossible to differentiate them from true
pancreatic cysts. They often contain pancreatic elements and are
sometimes spoken of as peripancreatic cysts. They result, as a rule,
from an injury of the organ, allowing the escape of blood and pancreatic
juice. Such swellings present themselves usually in the umbilical, epi-
gastric, or left hypochondriac regions. The fluid is peculiar in that there
is an absence of trypsin. It is thought that injury has more to do with
the production of pseudocysts and morbid processes than with the true
pancreatic cyst. It appears that the greater proportion of the former
are encountered in males, who are more exposed to injury; whereas of
the latter the majority seem to occur in females. The youngest patient
with pancreatic cyst reported was a child 13 months old. Cysts may
be single or multiple and the fluid may be almost any color, but it is
usually brown, tinted according to the amount of blood admixture. It
is alkaline in reaction and of low specific gravity. It always contains
albumin, usually cholesterin, and sometimes epithelial or fatty debris.
It may contain either of the pancreatic ferments, proteolytic, fat-split-
ting, or starch-converting. The latter seems unimportant; the two
former are of interest, or even importance. Their presence is of real im-
port, their absence of negative value. When enzymes are present in
considerable and active amounts, the presumption is strong that this fluid
comes from the pancreas. The cyst may reach such si^e as to even resem-
ble an ovarian cyst. The growth of the cyst is most commonly beneath
the stomach and above the colon, pushing forward the gastrocolic omen-
tum. This is the variety best suited for operation. The next most com-
mon direction is above the stomach, between this and the liver, where
adhesions make enucleation difficult or impossible. These cysts are
14 S

202 GENERAL SURGERY.

usually adherent, sometimes firmly or denselj' adherent, to the adjoining
structures. When a cyst is thus fixed, it will be best not to attempt to
enucleate, but rather drain front and rear. The portal vein has often
been found deeply buried in the cyst- wall; however, adhesions are not
always met and enucleation is sometimes easy. The symptoms are
inainly those caused by pressure. Vomiting is usually proportionate to
the pain. Emaciation is rapid. Fat in the stools and glycosuria are
most suggestive, though less frequent in cystic than in other pancreatic
diseases. The salol test may be of service ; it is based on the fact that the
presence of the pancreatic secretion in the intestine causes decomposition
of salol in the duodenum into carbolic and salicylic acid, which may be
recognized in the urine. The splenic vessels have been found both in
front of and behind the tumor, and the superior mesenteric vessels have
been found to cross the tumor surface. Aortic pulsation is often trans-
mitted. A cyst may suddenly shrink and then gradually refill; or it
may become suddenly enlarged by hemorrhage into it. Sudden collapse
and pain indicate hemorrhage into the cyst. The use of the needle for
diagnostic purposes is of little value and is strongly condemned on ac-
count of its dangers. The treatment is divided into aspiration, drainage,
and removal. Aspiration is condemned. If drainage it done, the cyst
should be securely sutured to the abdominal wall before it is opened,
but it is not necessary to wait until adhesions have formed. If the sutur-
ing has been properly done, immediate drainage can be instituted. Pos-
terior drainage through the left costospinal angle is of the greatest ad-
vantage, but should only be done after the most careful cleansing and
scrubbing of the back. Anomalous conditions are frequently found
which require especial and ingenious treatment; a number of such cases
are referred to. After operation on pancreatic cysts recovery may be
prompt and satisfactory and the pancreatic function be apparently un-
disturbed. Pancreatic fistula may persist for a long time without detri-
ment and may be expected to close with or without treatment after a
somewhat indefinite time. Of the solid tumors of the pancreas, cancer
is the most frequent, and is far more common in the head of the organ,
which, like the biliary passages, is most open to infection, more than half
of the cases appearing here. It may begin in the glandular epithelium
or in the cells of the excretory ducts. Terrier has extirpated one as large
as the patient's head, which weighed 5^ pounds. The symptoms of can-
cer are divided into those pertaining to the pancreas itself and its func-
tions; those pertaining to adjoining and related organs; those indicating
dissemination of cancer; and the tumor itself. The early symptoms are
vague and indicate some form of digestive disturbance. Voluminous
fatty stools, due to incomplete digestion, are occasionally noted. Should
these symptoms be followed by jaundice and then by glycosuria with
epigastric pain and emaciation, pancreatic cancer is probable. Pain is
a very uncertain feature. When characteristic, it radiates around the
sides to the back and may be severe. It may simulate the crises of tabes,
but it lasts longer and is often worse at night. Jaundice usually appears
late, though it may appear early. It is first a pressure-symptom and

DISEASES OF THE LIVER, ETC. 203

later may be due to the extension of the disease to the liver itself. As-
cites may result from pressure on the portal vein or involvement of the
peritoneum. Intestinal obstruction may also occur. Bronzing of the
skin may result from secondary involvement of the adrenals. Late in
the disease a tumor may be felt which resembles a growth of the pylorus,
but is deeper and more fixed and conveys a transmitted pulsation from
the aorta. After the development of pain, jaundice, and tumor, the
disease runs a rapid and fatal course. The outlook of such a condition
is poor. Cholecystenterostomy is thought to be a better operation for
the relief of symptoms than cholecystostomy. Tuberculosis of the pan-
creas is exceedingly rare. Syphilis may occur in the pancreas, but it has
never been diagnosed during life. Pancreatic lithiasis is difficult of
diagnosis. Kinnicutt has been able to collect but 7 cases, including one
of his own, in which a diagnosis was made. In the absence of pancreatic
calculi in the stools, there are absolutely no diagnostic symptoms. The
discovery of pancreatic calculi in the stools being so rare, it will be seen
that the evidences of pancreatic lithiasis are always very scanty; never-
theless attacks of colic in the upper abdomen, with or without jaundice,
with undigested muscle-fibers in the stools, with evidences of diminished
fat-splitting, and with glycosuria, may properly lead to a tentative diag-
nosis of this condition, which may be confirmed if fragile concretions
destitute of biliary pigment and cholesterin are found in the evacuations.

Moynihan* reports a ver>' interesting case of pancreatic calculus
in a woman aged 57, of nervous temperament. After a number of months
the patient lost considerable weight and had persistent attacks of epi-
gastric pain which closely resembled hepatic colic, though less severe, and
unattended, until very late in the history, by jaundice, which was then
but trivial. A peculiar irregular pigmentation of the skin of the color of
cafe au lait had developed slowly. The stools were occasionally "frothy"
and "greasy." An examination under chloroform revealed an indefinite
swelling above the umbilicus extending a little to both sides of the median
line. Moynihan made a diagnosis of chronic pancreatitis, probably due
to a stone in the pancreatic duct. A month later the abdomen was
opened. The gallbladder was found distended, but neither it nor any
of the ducts were adherent. The pancreas was enlarged, particularly
at the head. At the point of entrance into the bowel a small hard tumor
could be felt. The duodenum was incised and a stone removed from the
lower end of the pancreatic duct. The opening into the duodenum was
closed and the gallbladder drained. The patient made a very satis-
factory recovery. The pigmentation of the skin, which was a most
marked symptom before the operation, had undergone a considerable
fading at the end of a month after operation. The stone was about the
size of a French bean, 1^ inches in length, and about f of an inch in
diameter. Moynihan before describing this case deals with the history,
symptoms, diagnosis, and treatment of pancreatic calculi.

A case of typhoid pancreatitis is reported by Moynihan.^ The
patient was a boy 13 years old who was in good health until September,

' Lancet, Aug. 9, 1902. * Lancet, June 6, 1903.

204 GENERAL SURGERY.

1901, when he had an attack of typhoid fever. Since his convalescence
he had complained of attacks of pain in the upper part of the abdomen.
On several occasions the pain lasted for several hours accompanied by
nausea. In November, 1902, for the first time such an attack was fol-
lowed by jaundice, which later cleared up. Between this time and the
date of operation, March 6, 1903, the attacks were numerous and the
patient became more and more jaundiced. Considerable emaciation
had also taken place. A distinct tenderness was present in all the region
above the umbilicus; nothing abnormal could be felt. The diagnosis
of typhoid infection of the gallbladder with possibly a stone in the com-
mon duct was made. When the abdomen was opened, the gallbladder
was found to contain bile but no stone. The head and much of the body
of the pancreas were found to be at least twice as large as the normal
and almost as hard as stone. Moynihan says that he had never felt, even
in old-standing cases of indurating pancreatitis, a gland so intensely hard
as this was. Drainage of the gallbladder was established and kept up
for 4 weeks. The patient made a very satisfactory recovery. The fluid
removed from the gallbladder contained typhoid bacilli and an examina-
tion of the blood for Widal's reaction was positive. Three weeks after
drainage was established the discharge contained large numbers of
typhoid bacilli. The patient was put upon 10-grain doses of urotropin
3 times a day, and on the eleventh day after the commencement of this
treatment there were no typhoid organsims found in the discharge.

An exhaustive article dealing with the various diseases of the pan-
creas is presented by Deaver.^ The first part of the article deals with
the anatomy and the anomalies of the pancreas. The history of pan-
creatic diseases, with numerous references to the literature on the sub-
ject, is also given. Injury of the pancreas is rare, owing to its protected
situation. It is, however, occasionally injured by gunshot and stab-
wounds. As the result of injury inflammatory cysts, especially of the
lesser peritoneal cavity, are apt to develop. Chronic pancreatitis may
result from bruising during operations upon the stomach and biliary
passages. Prolapse of the pancreas through an abdominal wound has
been reported 8 times. Acute pancreatitis is characterized by the sudden
onset of pain in the epigastrium, colicky in nature and accompanied by
prostration and anxiety. Vomiting is an early symptom and is severe.
The diagnosis is difficult because of the obscurity of the symptoms, which
are mainly those of acute peritonitis originating in the upper abdomen.
The condition is most frequently confused with intestinal obstruction,
which, in fact, may result from inflammatory material or a swollen pan-
creas producing strangulation of the duodenum. Many of the milder
cases of acute pancreatitis, recover without operation. In such cases
the patient should be given sufficient morphin to quiet the pain and the
compression should be combated by the use of stimulants, especially salt
solution and whisky by the rectum. Gastric lavage should be employed
for the vomiting. In the more severe cases the abdomen should be opened
and drainage be established. Extreme shock should first be treated and
' Am. Jour. Med. Sci., Feb., 1903.

DISEASES OF THE LIVER, ETC. 205

the patient be operated upon when the condition has improved. Gan-
grenous and suppurating pancreatitis are accompanied, as a rule, by
widely disseminated fat necrosis. The two conditions may be associated.
An abscess may form as a peripancreatic collection and open into the stom-
ach, duodenum, or colon. Thrombosis of the portal vein and infection
of the liver may follow the extension of infection. The symptoms
of the suppurating and gangrenous forms of pancreatitis are those of
sepsis following the acute onset already referred to. In addition to
these, often a tender mass can be felt in the epigastrium. Fat may be
found in the stools and glycosuria may also be present. The treatment
of this form of the disease is drainage. Chronic indurating pancreatitis
is a more common disease than is generally supposed, and it is thought
that many of the cases diagnosticated as malignant disease of the head of
the pancreas are in reality of this character. The gradual and painless
onset of this condition makes its diagnosis difficult, though in a certain
number of cases the onset may be somewhat acute. The beginning of
the condition frequently produces symptoms resembling those of a gall-
stone attack. Pain, however, is more in the epigastrium, and the tender-
ness will be found one inch above and one inch to the right of the um-
bilicus. Asthenia is a constant symptom and dyspeptic symptoms and
frequently diarrhea will be noted. Later a tumor will be palpated.
As sequels of chronic pancreatitis are mentioned such conditions as gas-
trectasis, abscess of the liver, ascites, and intestinal obstruction from
adhesions. Pancreatic lithiasis is difficult of diagnosis. The condition
frequently accompanies chronic interstitial pancreatitis. The symp-
toms resemble those of biliary colic. Cysts of the pancreas are not infre-
quent. The situation of the cyst is variable, as is the direction of the
growth. As a rule, it is adherent to the surrounding structures, especially
the stomach, colon, duodenum, omentum, and anterior abdominal wall.
In a few cases there are no adhesions and excision is easy. The symp-
tomis depend upon the degree of pressure exerted upon neighboring organs.
Deaver reports 2 cases in which there was neither pain nor vomiting,
symptoms which are usually present. The presence of sugar in the urine
and of fat and undigested proteids in the stools is inconstantly noted.
Carcinoma is the most frequent new-growth occurring in the pancreas,
and the head of the organ is the most common seat of the disease. The
early symptoms are very vague and are often entirely lacking. The
treatment of malignant disease offers little hope. Deaver closes with
some remarks on the technic of pancreatic operations and with a brief
report on a:-ray findings in pathologic conditions of the pancreas by Wil-
bert.

An interesting case of pancreatitis associated with cholelithiasis
and glycosuria is reported by Nash.^ Cholecystotomy was performed
with a good result. The patient was a man 60 years old who had attacks
of epigastric pain extending over a period of 7 years. The onset of the
present attack was sudden, and the pain was located in the epigastrium,
accompanied with nausea, vomiting, hiccough, and collapse. In the be-

1 Lancet, Nov. 1, 1902.

206 GENERAL SURGERY.

ginning the temperature was subnormal, but in the course of 2 days it
rose 2° or 3° above normal. The pulse was very rapid (abovit 160). The
whole abdomen became enormously distended, suggesting intestinal ob-
struction. This distention was relieved by enemas and aperients, but it
quickly reappeared. With the subsidence of the distention there was
increased resistance over the pancreas, giving impression of effusion into
the lesser peritoneal cavity. The urine showed a large quantity of sugar
w^hen examined several days after the onset of the attack. The abdomen
was opened, and fat necrosis was apparent over the mesentery and omen-
tum in the neighborhood of the pancreas. The pancreas was enlarged,
but there was no effusion into the lesser peritoneal cavity. The gallblad-
der contained a large calculus which was removed. The gallbladder was
attached to the abdominal wall and drainage was established. The
patient made a satisfactory recovery and 4 months after operation his
urine was free from sugar. Nash believes that the stone in the gallbladder
was accompanied by a sudden inflammation of the bile-passages and that
some infection spread along the ducts to the pancreas.

The relation of cholelithiasis to acute pancreatitis is set forth by
Joseph Wiener,^ who describes an illustrative case. The patient was a
woman 41 years of age who was suffering from symptoms which seemed
to indicate an acute inflammatory condition of the appendix, although
the gallbladder also was considered a possible seat of disease. The abdo-
men was opened along the outer border of the right rectus at the level
of the umbilicus. The appendix was long and tightly bound down by
adhesions; it was removed. The omentum was found to be thickly
studded with small, irregular, opaque, yellowish-white patches, firm to
the touch and slightly raised. A portion of the omentum was removed
for examination. The gallbladder was found distended and there was a
large stone in the cystic duct. The stone was milked back into the gall-
bladder and cholecystectomy was performed. The hepatic and common
ducts were found free from stones. The head of the pancreas was hard
but not enlarged. The cystic duct was ligated. The gallbladder-wall
was somewhat thickened, the mucosa dark and congested with yellowish
punctate areas. The stone was half an inch in length and not faceted.
The portion of omentum which was removed was found to be the seat
of typical fat necrosis. The patient developed pneumonia at the base of
both lungs, but recovered, and left the hospital with the wound entirely
healed on the tw^enty-second day. Wiener discusses his own case with
the 32 which have been collected by Opie, and believes that in many,
if not in all the cases, there is a causal relationship between the two
conditions. In many of the cases there was positive proof that the duct
of Wirsung was occluded by a stone. The 32 cases collected by Opie all
ended fatally because of delayed operation.

In discussing acute pancreatitis, George Woolsey^ reports 3 cases
in which he has operated, with recovery in each case. In 2 of the cases
there was a marked history of alcoholism, which is looked upon as causing
the condition indirectly through the establishment of gastroduodenal

1 N. Y. Med. Jour., May 16, 1903. ^ ^ed. News, Dec. 20, 1902.

DISEASES OF THE LIVER, ETC. 207

catarrh. The usual channel of infection is through the pancreatic duct.
Injury is also considered a cause, but there was no historv' of traumatism
in any of these cases. The symptoms were much alike in all of the cases,
the onset being sudden with more or less collapse, indicated by pallor,
feeble and rapid pulse, and general prostration, together with severe
cramp-like epigastric pain not relieved by vomiting, distention of the
abdomen, and irregular temperature. Abdominal rigidity develops early,
accompanied by tenderness. No mass can be felt. In but one of the
three cases was there obstinate constipation simulating intestinal ob-
struction. This is a symptom which is frequently observed in acute pan-
creatitis. Glucose was present in the urine in but one case, and the
finding materially aided the diagnosis. Fat in the stools was not ob-
served in any of the cases, although Robson regards it as more common
than glycosuria. The diagnosis is always difficult and uncertain. The
first case in this series was not diagnosed; in the second a probable diag-
nosis was made; the third case was diagnosed because of the typical
symptoms combined with the alcoholic history- and the glycosuria.
Operation should be avoided in the acute early stages when the symptoms
are indefinite and the patient is in a state of collapse. The operation is
frequently undertaken for some of the conditions which simulate the
disease, and from which it may be difficult to differentiate it, such as
intestinal obstruction, septic peritonitis of unknown origin, biliary colic,
etc. The prognosis is grave in all of the forms of acute pancreatitis,
and is especially grave in the hemorrhagic fonn. In each case gauze
drainage was employed which extended down to the foramen of Winslow,
and in two of the cases drainage of the pelvis was also employed because
of the septic fluid found in this location.

Tropical abscess of the spleen is discussed by Fontoynant and Jour-
drau,^ who report a case occurring in a man 47 years old. In this
case the abscess jwas drained, but the patient died 2 weeks later from
pernicious malaria. The abscess developed during the course of a mala-
rial attack and followed promptly upon violent exertion. The marked
symptoms were intense pain in the splenic region, dry tongue, and dysp-
nea, which were later followed by fluctuation. The latter symptom is
very rare in splenic abscess, being present but once in 21 cases collected
by Grand-Moursel. In the authors' case there was no elevation of tem-
perature and the pus evacuated was sterile. The diagnosis in the absence
of fluctuation is nearly impossible. It is suggested, however, that in
malarial patients with hypertrophied spleen and who develop intense pain
in the splenic region, together with dyspnea, coated tongue, etc., it would
be wise to make an exploratory puncture. The treatment consists in
drainage, or in splenectomy if the latter operation can be performed
without infecting the peritoneal cavity.

Giuliano^ discusses the question of hemorrhagic cysts of the spleen
and reports an interesting case of this condition coming under his own
care. He also briefly abstracts 15 others which he has collected from
the Uterature of this subject. The author's patient was a man 33 years

• Arch. Prov. de Chir., No. 11. 1902.. ' Riforma Med., Nov. 21, 22, 23, 1902.

208 GENERAL SURGERY.

of age. The spleen had been enlarged for several years, during which
time the patient was subject every spring and fall to the quotidian type
of malarial fever. The tumor was ovoid in shape, extending from the
sternum and median line to the posterior axillary line and well below
the ihac crest. At the upper portion the growth fluctuated. Pressure on
its lower portion produced pain. An exploring needle was introduced
and 160 cc. of bloody, chocolate-colored fluid was removed. This fluid
contained red and white blood-cells and a few unclassified cells showing
fatty degeneration. After the removal of the fluid the tumor diminished
gradually in size, but later the patient developed a rather extensive
peritonitis. This attack, however, was not severe, and he recovered.
'When he left the hospital he was not suffering pain and was only slightly
annoyed by the weight of the tumor. Giuliano considers exploratory
puncture necessary in order to make a definite diagnosis of this condition,
and states that the treatment should be surgical, namely, puncture, or,
in some cases when this fails to relieve the condition, the abdomen may
be opened and the cyst-walls sutured to the abdominal wound. Splenec-
tomy is not warranted.

A case of multiple lacerations of the spleen due to the kick of
a horse is reported by Le Dentu and ]\Iouchet. ^ Mouchet performed a
successful splenectomy 8 hours after the receipt of the injury. The
patient was a teamster 34 years of age who was kicked first by one horse
and then by another while grooming them. He was admitted to the
hospital in great shock at 6.15 a. m. The authors saw the patient at
9 A. M., when he was a little better, and they found the abdomen flat
and exquisitely tender in the neighborhood of the spleen, in which region
there was great pain. There was some tenderness over the rest of the
belly. The thighs were flexed upon the abdomen. There had been no
vomiting or hiccoughing and the patient passed flatus. There was slight
dulness in the right but much more marked dulness in the left flank.
It was thought that the patient had a rupture of some abdominal organ,
and because of the site of the greatest pain and tenderness it was thought
likely that the spleen was the viscus involved. Immediate operation was
advised, but the patient would not consent. Three hours later, however,
when his condition became worse, he consented, and operation was per-
formed at 2.30 p. M., 8 hours after receipt of the injury. The patient
was anesthetized with ethyl chlorid and ether and the abdomen was
opened in the median line. It was found to contain a large quantity of
free blood and there was no injury of the stomach or intestine. The
blood seemed to come from the left side of the abdomen and there were
practically no clots. In order to expose the splenic area thoroughly a
transverse incision was made. The spleen was found to be the seat of
numerous lacerations, many of which were subscapsular. The organ was
removed, the general cavity cleansed with gauze sponges and closed
without drainage. The duration of the operation was 40 minutes. An
immediate subcutaneous injection of artificial serum was employed and
it was repeated once a day for 6 days, during which time the patient
1 Bull, de I'Acad. de Med., June 16, 1903.

DISEASES OF THE LIVER, ETC. 209

remained in a more or less precarious condition and developed bronchitis.
Two days after the operation the leukocytes numbered 27,000 ; 2 months
later they had fallen gradually to 11,000. The patient's recovery was
gradual but satisfactory. After the operation there was no enlargement
of the thyroid gland or lymph-glands. The authors think that in cases
of multiple lacerations of the character here described the spleen should
be removed whenever possible. Although it was not employed in this
case, drainage is usually advised. The operation of splenectomy for
traumatism is somewhat rare in France, this being but the seventh
successful case. The statistics of Mauclaire (1901) comprise 61 cases, 31
of which terminated in recovery. Berger, of Halberstadt, reports 67
cases of splenectomy, for subcutaneous lacerations only, with 38 re-
coveries.

A case of laceration of the spleen with recovery after packing the
wound with iodoform gauze is reported by Stirling,^ of Melbourne. The
patient was a boy who was kicked in the abdomen by a horse. He was
admitted to the hospital at 4 p. m., having received his injury early in
the morning. He was operated upon at 8 p. m. The incision was made
below the umbilicus and revealed an abdominal cavity filled with blood,
which blood was found to come from the splenic region. The incision
was prolonged upward and a rent was found on the posterior border and
diaphragmatic surface of the spleen. At this stage of the operation the
patient's radial pulse could not be felt. The wound was firmly plugged
with iodoform gauze and saline infusion was given. The patient re-
covered.

A case of splenectomy for rupture of the spleen is reported by
Marmaduke Sheild.^ Rupture in this case was at the hilum and the
patient had lost an enormous amount of blood. The recover}^ from the
operation was very satisfactor}\

Beaumont and Houseman^ report an interesting case of traumatic
rupture of the spleen with recovery after splenectomy in spite of
subsequent empyema. The patient was a boy 17 years old who had been
run over by a wagon. There was no immediate collapse and the develop-
ment of the abdominal symptoms was gradual. When the abdomen was
opened, the spleen was found divided into two portions. The hemorrhage
was controlled by digital compression of the pedicle and the two portions
of the organ were removed. The patient was in a grave condition on the
operating table, but improved after thorough stimulation. On the third
day his temperature suddenly rose to 105° and he became violently
delirious. On the sixth day, while the patient was still in this condition,
there were evidences of effusion at the base of the left lung, and aspiration
withdrew about 6 ounces of decomposed blood with almost a fecal odor.
The patient's condition not improving, the abdomen was opened and the
splenic stump and subphrenic regions were thoroughly explored, but no
pus was found. An examination of the patient's blood at this time
showed streptococci in large numbers. Within 4 days 330 cc. of anti-

» Intercol. Med. Jour, of Australasia, Feb. 20, 1903. ^ Lancet, Oct. 25, 1902.
3 Lancet, Sept. 13, 1902.

210 GENERAL SURGERY.

streptococcic serum were employed. There was a fall in the temperature
and return to consciousness. There was evidence of pus in the left chest
15 days after the original operation. The pus was drained away and the
patient recovered. The operation was done on May 20, 1902, and on
September 8 the patient was in perfect health and was following his
occupation. His pulse-rate still remained between 112 and 120. After
the operation there developed a general enlargement of the lymphatic
glands, with anemia, but this entirely disappeared.

Eisendrath^ discusses traumatic rupture of the spleen, reporting a
case in which he performed splenectomy. Pathologic spleens are more
prone to rupture than normal ones. Of 131 cases of splenic rupture col-
lected by Lewerenz, 82 occurred in pathologic organs. In 292 cases of
injuries of varjdng degree of severity of the abdominal viscera, Makins
found 89 cases of rupture of the viscera. The largest number were those
of the kidney (39 %); next were those of the liver (23.59 %), and third
those of the spleen. Eisendrath has found the following to be the most
constant symptoms in the cases which he has collected : First, severe pain,
most frequently referred to the left hypochondriac region. Second, sooner
or later signs of internal hemorrhage or of collapse. It is true that there
are exceptional cases in which there is but little change at first, the signs
of hemorrhage coming on rather late (in one case on the fourth day).
Such hemorrhage may come on late as the result of dislodgment of the
clot. Third, one of the most characteristic symptoms is dulness in the
flanks, especially on the left side, changing with change of position.
Fourth, some French surgeons and Trendelenburg have laid great
stress upon rigidity of the abdominal muscles upon the side of
the injur}^ as a valuable sign of rupture of one of the abdominal
viscera. It is almost impossible to differentiate between hemorrhage
from a rupture of the spleen and liver, or those intraperitoneal hem-
orrhages due to the free communication between the seat of rupture in
a lacerated kidney and the general peritoneal cavity. It may be said,
in general, that the earlier the diagnosis is made, the better the prognosis.
It is not denied that there are cases in which recovery is spontaneous,
but they are rare; and, although the patient may recover from the imme-
diate effects of the hemorrhage, there is great danger of the sepsis later.
In order to demonstrate how operative measures have improved the
mortality, it is interesting to study the cases which have been reported
up to the present time. Up to 1890, 3 patients were operated upon, all
of whom died. From 1890 to 1900, 34 patients were operated upon; of
these, 20 recovered (58 %) and 14 died (41.2 %). From 1890 to 1902, 53
patients were operated upon, of whom 28 recovered (52.8 %) and 21
died. Treatment is operative, and consists in splenectomy, suture, or
tamponage. Except for an occasional slight glandular swelling and a
moderate anemia, the removal of the normal spleen causes but slight, if
any, changes in the organism. "It is advisable to tampon if the tear
is located on the convex surface or one of the borders and does not extend
very deeply into the parenchyma, but is contraindicated if the tear is
1 Ann. of Surg., Dec, 1902.

DISEASES OF THE LIVER, ETC. 211

either deep at this place, or there is extensive pulpification of the spleen,
or, lastly, if the tear involves the hilus of the organ. Under these con-
ditions, it is far safer to perform splenectomy." While examining the
seat of injury and deciding upon a mode of procedure the hemorrhage
can be controlled by digital compression of the splenic vessels. The
patient operated upon by Eisendrath died on the third day with
peritonitis.

J. Basil HalP discusses the operation of splenopexy for wandering
spleen, taking as a text for his remarks a case in which he operated.
Examining the literature on the subject, he was able to find records of
only 8 cases in which splenopexy had been performed for floating spleen.
The considerable enlargement of the organ, the free hemorrhage which
results from sutures which penetrate the parenchyma, and the low mor-
tality following splenectomy have caused surgeons to choose extirpation
rather than to attempt fixation of a wandering spleen. Before removing
the spleen, however, Hall thinks it should be demonstrated that fixation
of the organ is impracticable. The case reported is that of a woman,
aged 30, who presented the symptoms of a floating and enlarged spleen.
When the patient stood erect, the organ could be carried nearly as far
as the right iliac fossa. Hall made an incision 4 inches long at the outer
border to the left rectus muscle, and was able without much difficulty
to bring the spleen entirely out of the abdominal cavity. The organ meas-
ured 7^ inches in length and 3^ inches across its center. The pedicle was
so long and the arrangement of the vessels such that the organ could
have been easily removed and the separate ligations applied to the vessels.
"While considering the advisability of removal, however, it was noticed
that the notch on the anterior border was only 2 to 3 inches from the
lower extremity of the spleen, and the depth of the notch was such that
the lower pole of the spleen was only connected to the rest of the organ
by a comparatively narrow isthmus. This arrangement at once sug-
gested an easy means of fixing the organ. The main body of the spleen
was therefore replaced in the abdomen after rendering the parietal
peritoneum raw in the splenic fossa in order to excite adhesions. Then,
while the lower pole was held in the wound, the edges of the peritoneum
were drawn tight by a purse-string suture until they closely gripped the
narrow isthmus in the notch. The abdominal aponeurosis was next
sutured in a similar manner until it grasped the isthmus in the notch
sufficiently tightly to produce marked congestion of the now isolated
lower pole. The left rectus muscle was next drawn outward somewhat,
so as to overlap the projecting pole of the spleen as much as possible, and
the skin incision sutured. After closing the skin incision, a prominent
lump the size of half an orange remained." The patient suffered a great
deal of pain for the first 24 hours. Two days after the operation fluid
had collected beneath the rectus muscles and around the projecting
spleen; this was evacuated and a tube inserted. After this recovery was
uneventful. Three months after the operation there was a hard flattened
swelling to be felt in the abdominal wall; it was painless and the spleen
' Ann. of Surg., April, 1903.

212 GENERAL SURGERY.

within the abdomen was firmly attached to it. The patient was entirely
relieved of the symptoms and was able to undertake her household duties
even if requiring active exertion. She was perfectly well 12 months after
the operation. Hall does not think that the method here practised is
capable of universal application, but if feasible it will certainly anchor
the spleen. To Kouwer, instead of Rydygier, is given the credit of first
performing splenopexy. Brief notes are presented of the other 8 cases of
splenopexy.

Ten cases of splenectomy for malarial hypertrophy of the spleen
associated with movability of the organ are reported by Rodolfo
Schwarz.^ The average age of the patients operated upon was 43 years,
and all were women. The frequency of movable spleen in women is
referred to. In one case there was a thrombosis of the vessels and a
necrotic area of the spleen with adhesions about the organ. In 6 cases
the pedicle was twisted. The spleen was delivered in each case out of
the abdominal cavity and the pedicle was then tied, silk being employed.
There were no accidents in any of the operations. In but one case was
it necessary to include the tail of the pancreas in the ligation of the
pedicle, and this gave rise to no subsequent trouble. The spleens varied
in weight from 800 to 3500 grams. There was no death as the immediate
result of operation, but one patient died on the fourteenth day from
peritonitis. In some of the cases there was no return of the malarial
fever, but in others the fever was not affected by the removal of the
spleen. Schwarz doe^ not recommend splenectomy for simple malarial
hypertrophy, but when the organ is movable the operation should be
performed. In the district of Adria nearly one-half the population suffer
from enlarged spleens. In a large number the condition gives rise to
no symptoms. Schwarz has found that the use of quinin or the hypo-
dermatic injections of arsenic or iodin, especially the latter remedy, will
do much toward reducing very large malarial spleens. It should not be
thought that the removal of the spleen will cure the malaria. Splenic
enlargement is but one of the manifestations of the disease, and the
treatment should be directed to the malarial infection. In many cases
the operation of splenopexy cannot be successfully performed because of
adhesions or because of a twisted pedicle. ' Because of the size of the
spleen, also, splenopexy is not productive of much good.

Webster^ reports an interesting case of enlarged spleen with
twisted pedicle. The spleen extended down to and was adherent to
the right side of the pelvis and was successfully removed. An unusual
complication of the condition was multiple nodulation and pigmentation
of the skin. The medical aspects of the case are discussed by Tieken.
The diagnosis of this condition was not made prior to operation because
of the peculiar situation of the tumor. The kidney was suspected as the
seat of disease. Webster states that this is the only case on record, so
far as he has been able to ascertain, in which an enlarged spleen has
become fixed in the right side of the pelvis. The history of the condition
extended over a period of 17 years.

» Gaz. degli Osped., Aug. 24, 1902. ^ Jour. Am. Med. Assoc, April 4, 1903.

DISEASES OF THE RESPIRATORY ORGANS. 213

DISEASES OF THE RESPIRATORY ORGANS.

Freer^ discusses at length the diagnosis of carcinoma of the larynx.
Early diagnosis of this condition is frequently not made, because, at
first, of the shght regard usually paid by the patient to the persistent
hoarseness that may precede the graver manifestations for years as the
only symptom,- and, secondly, the widespread indifference to the acquire-
ment of even moderate skill in laryngoscopy shown by a number of
the profession. The great importance of careful inspection of the larynx
is shown, and a strong plea made for an early diagnosis. At present the
cases usually come late to the operator. Chronic hoarseness in a man
past 40 makes laryngoscopic examination an imperative duty to all
practitioners. None of the symptoms of carcinoma is of much value in
proving its absence, but they are of great use in arousing suspicion of
its existence. Positive diagnosis rests upon the use of the laryngoscope
and microscopic examination of sections of the growth. The author's
article is numerously illustrated with cuts representing carcinoma in
various stages. The differential diagnosis between tuberculous and
syphilitic tumors and ulcers and carcinoma is carefully detailed. Freer
urges the removal of portions of a suspected growth for microscopic
examinations. The piece removed must be taken from the center of the
growth and the instrument should be crowded in deeply. The author
prefers Schiemann's forceps for this purpose. Although strongly urging
the use of the microscope as one of the means for making a diagnosis,
it is stated that it would be a mistake to follow its results blindly and
without a corroboration from clinical appearances. [We believe that it is
not from the center of the growth the piece should be taken for examina-
tion but from the edge. Further, the piece should contain some of the
apparently sound tissue. Atypic epithelium from the center of a growth
suggests but does not prove the existence of cancer. Proof is afforded
by epithelial infiltration of tissue at and beyond the edge.]

Ingals^ has reported a case of laryngectomy for carcinoma. The
operation was performed by the late Christian Fenger. The patient was
a man aged 47. The symptom of hoarseness began 18 months before he
applied for treatment. The growth began as two small smooth nodules
involving the middle third of the left vocal cord. Ingals performed pre-
liminary tracheotomy, and Fenger later removed the entire larynx, as
the growth had at this time perforated the walls of the larynx. Fenger's
remarks made at the time of the operation are quoted in full. He called
attention to the fact that laryngoscopic appearances gave no idea of the
extent of the disease. The patient recovered from the operation, but a
pharyngeal sinus persisted.

Ricketts''' (Cincinnati) presents an exhaustive communication on lung
surgery. The subject is considered from the historical, experimental,
and statistical standpoint. His conclusions regarding the various opera-

• Jour. Am. Med. Assoc, Feb. 14, 1902.

^ Jour Am. Med. Assoc, March 7, 1903.

" N. Y. Med. Jour., March 21, April 18 and 25, May 9, 1903.

214 GENERAL SURGERY.

tive procedures are as follows: " Pneumonotomy: (1) Emergency surgery
precedes elective surgery, and surgery of the lung is not an exception to
the rule. (2) One can hardly imagine a pathologic condition in the lung
that has not been dealt with surgically, with more or less success in
emergency cases. (3) This being true, the same methods may be applied
in selected cases, with even better results, if the more modern surgical
principles be employed. (4) Severing one or more of the larger pul-
monary bloodvessels results in instant death. (5) If death does not
result within a few minutes, bleeding will be slow and gradual. (6) If
bleeding is slow and gradual, it may require hours or days to cause fatal
exhaustion. (7) If death does not occur until after the end of the
second day following severe bleeding, infection is its cause. (8) All or
part of the escaped blood may pass through the opening in the chest
into the bronchus or alimentary tract. (9) The blood may escape into
the pleural cavity or cavities, pericardial or peritoneal cavity, or all of
them, and thereby become concealed. (10) More definite knowledge of
conditions and symptomatology is necessary that surgery of the lung may
be perfected and made more aggressive and general. (11) Abnormalities,
congenital or acquired, must always be considered in dealing surgically
with the lungs. (12) Atelectasis and apneumatosis should be cared for
by relieving the compression by removing the cause. (13) The same
surgical principles can be applied to the lung as to other organs of the
living body. (14) The bony chest may be opened for exploration of the
lung with as little danger as opening the abdomen, cranium, articulating
capsules, kidney, liver, pancreas, spleen, stomach, gut, or hepatic ducts.
(15) Hermetically closing the chest is irrational, unscientific, and dan-
gerous. (16) Closing the chest wound by any means does not prevent the
escape of blood from injured pulmonary vessels into the pleural cavity.
(17) All wounds of the chest-wall, whether penetrating or nonpenetrating,
should be treated antiseptically, and with reference to drainage. (18)
No instrument or needle should be made to enter the lung tissue for
exploration or the removal of fluid unless the bony chest has previously
been opened. (19) Foreign bodies in the bronchi or parenchyma of the
lung may be detected with a fine exploratory needle through an open
chest with the lung contracted. (20) Foreign bodies in the lung and
bronchi when causing serious symptoms should be removed. (21) Some
small foreign bodies become encysted and remain harmless. (22) The
position of a foreign body in the lung changes with expansion and con-
traction of the lung. (23) Hemorrhage, when due to pulmonary tubercu-
losis, should not be allowed to become fatal without opening the bony
chest, and the application of pressure by forceps, gauze, or otherwise.
(24) Bleeding of the lung from any cause will in many cases cease when
the lung is allowed to contract upon itself with an open chest. -{25)
Blood-clots within the pleural cavity should be removed at the time they
are discovered, whether infected or not infected. (26) Blood-clots in the
pleural cavity may become organized with or without adhesions of the
parietal and visceral pleura, or they may become infected and cause most
serious consequences. (27) Hemoptysis may be absent in the most

DISEASES OF THE RESPIRATORY ORGANS. 215

severe lacerations of the lung. (28) If bleeding from larger pulmonary
vessels results, forceps should be applied. If not, gauze should be securely
packed in the cavity. (29) Drainage of pulmonary cysts of any character
can be done with the same success as in any other organ. (30) Incision
for drainage should be done with or without the presence of adhesions.
If without adhesions, the opening in the chest should be at the lowest
point of the pleural cavity for gravity drainage. (31) Many incisions of
the lung may, and should, be made with or without even local anesthesia.
(32) It is probable that but few will necessitate the use of general anes-
thesia. (33) Abscess of any character and of any location in the lung
should be found and opened. (34) Gangrene of the lung demands most
radical surgical measures, such as opening the chest, drainige, and the
removal of all necrotic tissue. (35) Polypi of the bronchi seldom necessi-
tate removal, but they may cause conditions which may require surgical
intervention.

" Pneumonorrhaphy: (1) Silk, silkworm-gut, and animal tendons are
the most desirable materials for lung surgery. (2) Absorbable sutures
and ligatures are, as a rule, not to be relied on as to strength and dura-
bility. (3) Silk and silkworm-gut may become encysted in the lung and
remain harmless. (4) The tug and a combination of the tug and tobacco-
pouch sutures constitute the most desirable ones to use in the lung. (5)
Ligatures and sutures may be dislodged by sudden expansion of the lung
due to sudden closing of the opening in the chest-wall. (6) The blood-
vessels, bronchi, and lung tissue should be ligated separately, great care
being taken not to include too much tissue of any kind in one ligature.

(7) Needles to be employed in lung tissue should be round, with a
rounded point. They should never have a sharp point, or sharp edges.

(8) Not all ruptures, punctures, or lacerations of the lung require suture,
or any surgical intervention whatever. (9) Many lacerations of the lung
without fracture of the bony chest can, and should, be treated by suture,
compression with gauze or forceps. (10) Puncture of the lung from any
cause (such as stab and gunshot) resulting in hemorrhage should be
treated by opening the chest, and the application of ligature or com-
pression. (11) Rupture of the lung should be treated as laceration.

"Pneumonectomy: (1) A portion of all of one lobe, or the entire right
or left lung, may be removed without causing death. (2) For complete
or partial lacerated portions of the lung when severe, pneumonectomy is
necessary and should be done. (3) Gangrene of the lung requires in
many cases removal of all necrotic tissue. (4) Hernia of the lung, when
sudden and of but few hours' duration, should as a rule be amputated,
and the stump fixed in the chest-wall, as there is no sac. (5) Hernia of
the lung coming on gradually has a sac, and should be returned to the
pleural cavity, if possible without amputation.

'^ Pneumonopexy: (1) This is the safest and most rapid way of dealing
with the stump of lung tissue in the majority of cases necessitating
excision for any cause. (2) Adhesions of the parietal and visceral pleura
have without exception taken place, where either has been lacerated or
incised, with or without suture. (3) The degree of adhesion corresponds

216 GENERAL SURGERY.

with the degree of injury. (4) Cysts of the lung of any character can
best be drained through visceroparietal adhesions. In the absence of
adhesions the wall of the cyst may be sutured to the edges of the opening
in the chest-wall, drainage to be at once accomplished or at some subse-
quent time."

DeForest Willard^ presents a paper on the surgery of tuberculous
cavities of the apex of the lung, including extensive references to the
literature, a table of cases operated upon, and a report of a number of
experiments upon lower animals. His conclusions as to operation in the
human being are as follows : " (1) With improvement in technic pneumo-
notomy will become a practicable operation, even in cavities at the apex.
The operation would be especially helpful in the early period of cavity
formation, but it is exceedingly difficult at this stage to obtain the consent
of the patient, since hygienic and dietetic methods of treatment often
result in cure. (2) In advanced cases both tubercular and streptococcic
infection are often present; the cavities are usually multiple and the
operation cannot cure. It may be employed, however, as a palliative
to cough, hemoptysis, and sepsis. (3) In abscess of the lower lobes, fol-
lowing pneumonia or pleurisy, whether tubercular or not, incision and
drainage are to be recommended in any stage. (4) Pneumonectomy in
our present stage of surgical and diagnostic skill is not advisable in tuber-
culosis. (5) With improved technic tubercular foci will in the future be
eradicated, as we now eradicate tuberculosis in joints and other tissues.
An efficient and certain method of producing strong adhesions between
the two laj'^ers of the pleura at the site of the disease is the most important
step in this technic. (6) The careful and methodic application of aus-
cultation, percussion, and the aj-ray for the accurate locating of the dis-
eased focus is also an important factor in securing a safe operation. (7)
Pneumothorax is so serious a menace to life that in all operations on
the lung, an artificial respiration apparatus, like the Fell-0'Dwyer or
Matas instrument, should be at hand, together with a full jar of oxygen."
The following is a condensed summary of the tables presented. "The pro-
duction of adhesions is a most important part of the operative procedure.
If these can be secured, either artificially or if they are present from the
disease itself, the operation is not more serious than many major opera-
tions. In the human being the position of the abscess can be much more
definitely fixed than in the dog by auscultation, percussion, and the x-ray.
Operation, therefore, becomes one of greater certainty. If slight adhe-
sions only are found, immediate stitching of the lung to the walls around
the margin of the opening, while not avoiding pneumothorax, may escape
pyothorax. If pneumothorax occurs, the most speedy method of relief
is that of dragging the lung into the opening and fixing it, thus giving
greater action to the opposite lung. Excision of the diseased area would
be the best operation, provided the entire tuberculous portion could be
definitely removed, a condition which at present does not seem possible.
In dogs even a collapsed lung becomes functionally active in a few days
after excision of a portion."

iJour. Am. Med Assoc, Sept. 20, 1902.

DISEASES OF THE RESPIRATORY ORGANS. 217

Whitacre^ (Cincinnati) discusses the surgery of pulmonary tuber-
culous lesions and reaches the following conclusions: " (1) The excision
of the pulmonary lesion is, in the vast majority of cases, both impossible
and irrational. (2) The incision and drainage of tuberculous cavities in
the lung does not seem to be a justifiable operation. (3) The nitrogen
compression-method of Murphy is a rational procedure in a limited num-
ber of selected cases, its application is safe, the effect on the tubercular
lung seems favorable, and the reported results are encouraging. (4)
Thoracoplasty, while based on the same sound principles that give value
to the nitrogen method, is an extensive operative procedure involving
great risk to life, and furnishes slight promise of improving the percent-
age of cures obtained by climatic treatment."

After a discussion of empyema in children, based upon an experience
in the Children's Hospital of Boston, F. J. Cotton^ reaches the following
conclusions: " (1) Empyema in children usually follows lobar pneumonia
— after a varying interval. (2) The infection is usually with the pneu-
mococcus. (3) Spontaneous cure, even when aided by tapping, is rare.
(4) Operation should not be delayed, as time lost is strength lost, and
the issue is largely one of nutrition. (5) The best form of operation is
in general the subperiosteal resection of an inch of the eighth or ninth
rib in the posterior axillary line, the evacuation of pus and fibrin masses,
and tube drainage. (6) Irrigation at or after operation is not usually
advisable. (7) The routine after-treatment in fresh cases should be tube-
drainage, the tube being progressively shortened, and removed when thb
cavity is nearly healed. (8) When failure to heal seems to depend on
failure of the lung to re-expand, treatment by valve or suction apparatus
is indicated. This is especially of value in the more chronic cases. (9)
The mortality is about 1 in 7 ; in small children it is much greater than
in those over 5 years. The causes of mortality are, in the main, beyond
our control. (10) The great majority of cases heal even when the healing
is delayed for many months. Chronic empyema, in the strict sense, is
rare in children. (11) The closure of the cavity depends mainly on
nutrition and on adequate drainage. (12) Recurrences may occur from
faulty drainage at any time, and they may occur years after apparently
sound healing, without obvious cause.. (13) Deformity of the chest is
usually temporary and yields to treatment. (14) Long-continued dis-
charge from the cavity is not infrequently followed by chest deformity
and scoliosis of a severer type, permanent and sometimes extremely
severe." The accompanying illustration (Fig. 45) shows the apparatus
employed.

The following is a summary of a communication by C. N. Dowd^
on the surgical treatment of empyema based upon 75 cases occurring
in St. Mary's Hospital for Children, in New York: " (1) For simple cases
of empyema the following treatment is used: Excision of about H inches
of the seventh or eighth rib in the posterior axillary line; light ether
anesthesia is usually employed; the purulent coagula are removed; short

* Jour. Am. Med. Assoc, Sept. 27, 1902.

» Boston M. and S. Jour., July 17, 1902. 'Med. News, Sept. 13, 1902.

218

GENERAL SURGERY.

rubber tubing, cut partly across, doubled and held by large safety-pins,
is used for drainage; abundant gauze dressing is applied and changed
when saturated. (2) If the patient's condition contraindicates general
anesthesia, an incision into the chest may be made between two ribs
under cocain anesthesia. (3) Aspiration is only used to give temporary
relief in patients who are in great distress from the pressure of the fluid,
or temporarily to relieve the second side of a double empyema after the
first side has been opened. (4) The patients are allowed out of bed as
soon as practicable, and the expansion of the lung is encouraged by
forced expiration. (5) Irrigation is used only when there is a foul-
smelling discharge from necrotic lung tissue. (6) Secondary operations

are not done until good oppor-
tunity has been given for heal-
ing; usually 3 or 4 months
should have elapsed after the
primary operation, and there
should have been no noticeable
improvement for about a month.
(7) In the secondary operation
the expansion of the lurig should
be encouraged by incising, strip-
ping back, and, if necessary, re-
moving portions of the thick-
ened pulmonary pleura. (8) The
examination of 44 of the patients
at long periods after operation
indicates that recovery is usually
complete in the simple cases,
and that there is surprisingly
little deformity in most of the
severe cases."

Rolleston and Trevor^ report
a case of primary sarcoma of
the lung simulating empyema.
The condition occurred in a girl
13 years of age. The clinical
interest in this case is the close imitation of an empyema as shown in
the physical signs on the right side of the chest; edema of the chest-
wall in the right axilla, the displacement of the heart, and the raised
temperature. The condition ran a very acute course, the whole dura-
tion of the illness being 12 weeks. At the necropsy it was found that
the entire right lung, except the apex of the upper lobe, was replaced
by a soft growth of the consistence of gruel. The growth was firmly
adherent to the ninth and tenth ribs in the axillary region. The authors
present a table of pulmonary malignant disease containing 58 cases of
primary carcinoma of the lung, 8 cases of primary sarcoma of the lung,
1 Brit. Med. Jour., Feb. 14, 1903.

Fig. 45.— Suction apparatus, a, Cliest cavity; b,
tube iu opening; c, slieet-rul)ber and gutta-perclia
gummed down with cliloroform to make air-tight
joint; d, tube connecting chest with; e, the catcli-
bottle into which the dii<cliarge is drawn; it is con-
nected by the tube/ with g, the air-reservoir bottle;
h, suction syringe used to exhaust air from bottle {i ;
i, tube connecting the water in (/ with that in basin
k. The column sustained is represented hy the differ-
ence in height of the water-levels i and /. It can he
increased at will by pumping the bulb h (Cotton, in
Boston M. and S. Jour., July 17, 1902).

DISEASES OF THE RESPIRATORY ORGANS. 219

16 cases of primary carcinoma of the bronchi, and 2 cases of primary
sarcoma of the bronchi.

Karewski and Unger^ have conducted a series of experiments upon
animals with the object of discovering a more rapid and satisfactory
method of producing pleuritic adhesions. The ultimate object of
course was to avoid complications, particularly pneumothorax, in the
performance of transpleural operations. After trying a number of
materials, the authors finally found that the employment of silk sutures
soaked in turpentine resulted in the production of adhesions which after
4 or 5 days were sufficiently dense to form a thorough protection to
the remaining portion of the pleural cavity. The experiments of the
authors were confined to animals.

John O'Conor^ (Buenos Ayres) discusses the treatment of pul-
monary hydatids, and reports 3 cases upon which he has operated. It
is stated that the prevalence of hydatid disease in the Argentine 'is not
generally knowm. During the past 8 years O'Conor has operated upon
84 cases of hydatid disease. In 56 the liver was involved ; in only 3, the
lung. The diagnosis of pulmonary hydatid disease may be attended
with much difficulty, especially in cases in which the cyst has not rup-
tured into a bronchus. In such cases the family and personal history
of the patient and the locality in which he has resided are of much value.
The unilateral situation of the affection, with probably a sharply defined
outline, not corresponding to the usual site of a pleural effusion or hepatic
enlargement, taken in connection with diminished breath-sounds, vocal
and tactile fremitus, with an antecedent hacking, irritating cough asso-
ciated with bronchitic sputum, should lead one to suspect hydatid dis-
ease. When rupture has taken place, there is a history of a sudden
evacuation of a quantity of fluid followed by frequent and at times con-
siderable hemoptysis. Later an intrapulmonary pus sac may develop,
in which case general toxemic symptoms promptly arise. Microscopic
examination of the sputum is the only positive means of making a diag-
nosis. The absence of the usual symptoms does not negative the pres-
ence of a cyst, since symptoms may be absent because of the deep situa-
tion of the cyst. Great stress is laid upon the value of the personal
history, particularly the existence of a hacking cough with or without
pain in the chest. The use of the exploring needle is advocated, not only
as a diagnostic aid, but for localizing purposes. While advocating the
use of the needle, O'Conor mentions that in two hepatic cases rather
alarming transitory toxemia followed the exploratory puncture. He
therefore makes it a practice to perfonn such exploration under anes-
thesia on the operating table. On discovering and localizing the cyst,
he immediately operates. If fluid is found, the syringe is detached and
the needle remains in position and is utilized as a guide to locate the cyst.
As soon as the pleura is incised the lung is caught by two bullet-forceps
and is rapidly drawn into the wound. By this manoeuvre the confusing
storm consequent on a collapsed lung is obviated and the pleural cavity
is kept free from blood and hydatid fluid. The lung is held firmly in

1 Deut. med. Woch., May 7, 1903. ^ Lancet, May 23, 1903

220 GENERAL SURGERY.

position until the cyst is opened, and its cut edges are then sutured
together with the cyst-wall to the external wound. The endocyst is
removed by the gentle application of a long forceps. Free drainage is
established. The after-treatment is tedious, as there is a tendency to
closure of the external wound before the cavity in the lung is obliterated.
Of the 3 cases here reported, 2 were very serious, but all the patients
recovered after operation.

An unsuccessful attempt to remove a foreign body from one of the
main divisions of the left bronchus by posterior bronchotomy is re-
ported by Andrews.^ The patient was a boy of 15 years, and the foreign
body was the squeaker of a doll. There was absolutely no doubt about
the position of the body in the bronchus. Two unsuccessful attempts
were made to remove it through a tracheotomy wound, and, failing in
these, Andrews resected the third, fourth, fifth, and sixth ribs between
the scapula and the vertebral column and explored the lung and bronchi
from behind, but could not locate the body. The discharge from the
posterior wound later became purulent and required drainage with a
tube. The patient continued for some time to expectorate purulent
matter; he ultimately recovered, though the foreign body was never seen.
A skiagraph taken after recovery showed no foreign body present,
although a picture made the night before the operation showed the
squeaker plainly. Every possible avenue of escape for the foreign body
was carefully watched. Andrews cannot in any way account for its
disappearance. He refers to the literature relating to the operation of
posterior bronchotomy.

James F. Baldwin^ reports an operation by which a knife-blade was
removed from the lung. [This case closely resembles a case reported
by Korteweg, of Leyden (see Year-Book, 1903), in which a piece of
lyddite-shell was removed from the lung. Baldwin's case antedated
Korteweg's by two years.] The patient was a young man, about 28
years of age, who was stabbed with an ordinary pocket-knife, the blade
of which broke off in the lung. • The knife entered just below the axilla.
The wound healed promptly, but the patient later developed consolida-
tion of the lung with accompanying purulent expectoration, and the
ordinary manifestations of infection. Two radiographs were taken.
They showed definitely the situation of the foreign body, which measured
I^ inches in length and ^ inch in width. About an inch of the rib over- ■
lying the foreign body was resected and the latter was easily removed.
There were adhesions between the lung and the thoracic wall. The knife-
blade was encountered at a depth of about a finger's length. There was
an offensive purulent discharge for some days. The patient recovered.

Brokaw'' reports a case of removal of an upholsterer's tack from
the right bronchus. The patient was a child, 8 years of age. When
the patient was seen by Brokaw, the tack had remained in the bronchus
nearly a month. At this time it was easily located with the Rontgen
rays. A reproduction of the radiograph accompanies the report. A low

» Lancet, May 9, 1903. ^ Ann. of Surg., March, 1903.

3 Ann. of Surg., Dec, 1902.

DISEASES OF THE VASCULAR SYSTEM. 221

tracheotomy opening was made; the tracheal mucous membrane was
cocainized and a large endoscopic tube introduced, but owing to the
accumulation of blood and mucus the tack could not be seen. A futile
attempt was made to remove the tack with a pair of laryngeal forceps.
The child's condition became grave, and the operation was stopped.
Ten days later the patient was again anesthetized and a powerful electro-
magnet was introduced through the tracheal wound. Although the tack
could be felt with the magnet, it was too firmly embedded to be withdrawn
by this means. The endoscopic tube was again introduced, in to the right
bronchus; the tack, however, could not be seen because of the blood and
mucus. It was finally caught with the laryngeal forceps passed through
the tube, but the head of the tack was so large that it could not be made
to enter the tube. Removal was finally accomplished by withdrawing
the tube and forceps together. The child made an uneventful recovery.
Kellock^ reporte a case of foreign body impacted in the left bron-
chus which was removed through a tracheotomy wound. The patient
was 2 years of age. On the day previous to admission she had swallowed
some dry uncooked haricot beans, and immediately afterward was seized
with an attack of dyspnea and cyanosis. A second attack followed some
hours later and the child was sent to the hospital. With the exception
that the entire left lung was functionless the child appeared well and
comfortable. After her admission, however, it was noticed that her
face became dusky in color when she cried. In view of the history, and
the physical signs presented, it was thought wise to perform tracheotomy.
When the trachea was opened, a probe passed into the left bronchus
came in contact with the foreign body. Numerous futile attempts to
remove it were made with forceps. It was finally extracted by the use
of a silver wire loop, which method is strongly recommended by the
author. The tracheal wound was closed completely in layers, healed
primarily, and the child recovered. The bean was f of an inch in length
and f of an inch in width.

DISEASES OF THE VASCULAR SYSTEM.

Peyrot^ reports a most interesting case of gunshot wound of the
heart operated upon successfully by Launay. Reference is made to
the literature and statistics in cases of stab-wounds and gunshot-wounds
of the heart. In cases of single stab-wounds there have been 6 recoveries
out of 20 cases. Gunshot- wounds are much more serious and difficult
to treat, since 17 % of them are double, whereas in stab-wounds but
1.2 % are double. Marion and Bougie have both sutured double wounds,
but each of the patients died. The cause of death, however, in Bougie's
case was pulmonary hemorrhage subsequent to the suture of the heart-
wound. The case here reported, which was operated upon by Launay,
is the first to recover after a double gunshot-wound of the heart. The
patient was a man 26 years of age who had been shot about midnight;
he was seen by Launay at 3.30 a. m. At this time the patient was very

' Lancet, Nov. 15, 1902. ^ Bull, de I'Acad. de M^d., July 29, 1902.

222 GENERAL SURGERY.

weak, the pulse being uncountable, but he was able to speak enough
to give an account of the injury. The external wound was at the nipple,
and from it there was a small amount of bleeding which was intermittent.
The heart-sounds were indistinct, but a splashing sound could be heard.
There was also evidence of blood in the pleura. A diagnosis of probable
wound of the heart was made. Chloroform was administered and an
osteoplastic flap turned back containing a portion of the fourth, fifth,
and sixth ribs. When the flap was turned back, there was a complete
pneumothorax with a large amount of blood also in the pleural cavity.
There was a perforation of the thin edge of the lung by the bullet. There
was a small wound of the pericardium from which the blood flowed slowly
but persistently. This was enlarged and a wound of the left ventricle
found 2 cm. from the apex. The bleeding was not in jets, but occurred
only during diastole. . This wound was easily closed with a catgut suture.
Examination of the posterior surface of the heart was somewhat difficult,
but the wound of exit was found when the finger was placed under the
apex and the heart tilted up. It was situated near the base of the left
ventricle. A traction suture was placed in the heart-muscle in order to
give access to the wound, which was closed with two sutures of catgut.
The pericardium was cleared of clots and partially closed. The pleura
was treated in the same way, both cavities being drained. During the
operation 2 liters of salt solution was injected into the subcutaneous
tissue. The operation lasted about 35 minutes. The pulse remained
uncountable throughout, although the heart had never ceased to beat.
The next day the patient was remarkably comfortable and in good con-
dition. His pulse was of good volume, from 100 to 120 per minute.
There was a slight rise of temperature for two days, but it then sub-
sided. The drains were removed 48 hours after the operation. The
patient was out of bed on the tenth day and made an excellent recovery.
Milesi^ reports a case of suture of the heart for penetrating wound.
The patient was a man aged 25, who was admitted to the hospital a
half-hour after receiving a stab-wound in the left chest. He was in a
state of collapse and unconscious. The radial pulse was imperceptible;
respirations were rapid and superficial. The wound of entrance was at
the upper border of the sixth rib 1.5 cm. from the edge of the sternum.
It measured 2.5 cm. in length. The area of cardiac dulness did not
seem to be increased, and the heart-sounds, though very faint, could
be heard. There was no effusion of blood into the pleural cavity. The
fourth and fifth ribs were divided and turned back. The pericardial
wound was enlarged and an enormous quantity of blood escaped. A
wound of the right ventricle about 1.5 cm. in length was seen. Bleeding
from this point was controlled by a pressure of the thumb and forefinger,
and a silk suture was introduced which stopped the bleeding almost
entirely. Three other more superficial sutures were then inserted. The
pleural and pericardial cavities were each drained by a piece of iodoform
gauze. After the operation the patient ralhed and was able to give
testimony regarding his injury with perfect clearness of mind. He later
' n Policlinico Sezione Practica, Feb. 14, 1903.

DISEASES OF THE VASCULAR SYSTEM. 223

grew weak and died 15 hours after the operation. At the necropsy the
suture of the heart was found to be perfect, but in addition to the wound
of the right ventricular wall, one of the musculi papillares was found to
be divided, and there was also a penetrating wound of the intraventricular
septum.

Two cases of penetrating wound of the left ventricle are reported
by Giordano.^ The first patient was a man aged 23, and the wound was
in the sixth intercostal space, 1 cm. external to the nipple. There was
a marked hemothorax at the time of admission. The wound in this
instance was at the outer margin of the left ventricle, near the apex.
It was closed with two silk sutures. Drainage was introduced and the
wound closed. The patient rallied somewhat, but died in 1^ hours
after operation. The second patient was a suicide 26 years of age who
presented two wounds, one in the fourth and one in the sixth intercostal
space. A wound 2 cm. long was found in the left ventricle. This was
closed with two silk sutures and drainage introduced. After a long
illness, due to the development of suppuration under the third costal
cartilage near the sternum, and causing necrosis of the sternal end of
the fourth and fifth ribs, which were later resected, the patient recovered.

Hill^ (Montgomery, Ala.) adds another to the successful operations
for suturing stab-wounds of the heart. The patient was a negro 13
years of age. The external wound was situated in the fifth intercostal
space a little to the right of the left nipple. The wound was in the left ven-
tricle and measured | inch in length. It was closed with one suture of cat-
gut. The operation was performed 8 hours after the receipt of the injury
under chloroform anesthesia. The patient made a good recovery. The
author presents a list of 39 reported cases of operation for penetrating
wounds of the heart, and draws the following conclusions: "(1) That any
operation which reduces the mortality of a given injury from 90 % to about
63 % is entitled to a permanent place in surgery, and that every wound of
the heart should be operated upon immediately. (2) Whenever the loca-
tion of the external wound and the attending symptoms cause suspicion
of a wound of the heart, it is the duty of the surgeon to determine the
nature of the injury by an exploratory operation, as is recommended by
Professor Vaughan. (3) Unless the patient is unconscious, and corneal
reflex abolished, as in Pagenstecher's case, an anesthetic should be given,
and preferably chloroform. Struggling is liable to produce a detachment
of a clot, and renew the hemorrhage, as occurred in Parlavecchio's patient.
(4) Never probe the wound, as serious injury may be inflicted upon the
myocardium. (5) Rotter's operation renders access to the heart ex-
tremely easy, and. should be generally adopted. (6) Steady the heart
before attempting to suture it, either by carrying the hand under the
organ and lifting it up, or, if the hole is large enough, introduce the little
finger, as Parrozzani did, which will serve the double purpose of stopping
the bleeding and facilitating the passage of the stitches. (7) Catgut
sutures should be used, as wounds of the heart heal in a remarkably
short time. The sutures should be interrupted, introduced and tied

1 Gaz. degli Osped., Jan. 11, 1903. ^ Med. Rec, Nov. 29, 1902.

224 GENERAL SURGERY.

during diastole, not involve the endocardium, and as few as possible
should be passed commensurate with safety against leakage, as they
cause a degeneration of the muscular fiber with its tendency to dilation
and rupture. (8) In cleansing the pericardium it should be sponged out,
and no fluid poured into the sac. (9) It hardly seems necessary to
accentuate the fact of the necessity of perfect /cleanliness in these opera-
tions whenever the urgency of the case does not require instant inter-
vention, as in the patients of Longo and Ninni. (10) The wound in the
pericardium should be closed, and should symptoms of compression arise,
reopen the wound and drain as Rehn did."

Gibbon^ reports a case of penetrating wound of the heart in which
he made an unsuccessful attempt at suturing. The patient was a
negro 25 years old, admitted to the Pennsylvania Hospital a few minutes
after receiving a stab- wound of the chest. When Gibbon saw him, a
half-hour after the injury, the radial pulse could not be counted, and
the patient was in a state of semi-unconsciousness, although any manipu-
lation produced a great deal of restlessness. He was immediately re-
moved to the operating room, the heart was rapidly exposed, and a
large amount of blood-clot was evacuated from the pericardium. A
wound of the right ventricle which measured 1.5 cm. in length was dis-
covered. As soon as this opening was found the finger was introduced
into the wound. This controlled the bleeding, and one catgut suture
was introduced. At this time the heart, which had been making des-
perate efforts to perform its function, ceased to beat, and in spite of
manipulation did not resume its action. The pleural cavity was not
opened by the stab, but was opened unintentionally during the resection
of the third costal cartilage. An interesting point in this case is the
fact that respiration continued for about two minutes after the heart
ceased to beat. Reference to the literature of this subject is made,
and the reported cases are discussed.

An exhaustive study of the surgery of the heart is presented by
Ricketts.^ The following are the conclusions reached by the author:
" (1) The heart may have only one auricle and one ventricle, or it may
have five cavities. (2) The heart may be in the right thoracic cavity .
or in the abdominal cavity. (3) Removal of the pericardium does not
of itself cause death. (4) It may, however, cause death subsequently,
as the result of extensive cardiopneumonic adhesions. (5) Exploration
of the walls and chambers of the heart with a knife or needle for foreign
bodies or pathologic conditions should be done, but only after the peri-
cardium has been opened for ample space. It is rational, justifiable, and
safe. (6) Not all wounds of the myocardium wall require suture, but
the pericardium should be opened to remove clots and make drainage
available. (7) A myocardial abscess or cysts of any character can be
incised by knife or needle and drained through an open pericardium.
(8) Gangrene of the heart demands incision of the pericardium and
drainage of the pericardial cavity. (9) Malignant disease of the heart at

» Phila. Med. Jour., Nov. 1, 1902.

2 N. Y. Med. Jour., May 16-23, and June 20-27, 1903.

DISEASES OF THE VASCULAR SYSTEM. 225

this time resists treatment of any kind. (10) Aneurysm, mitral stenosis,
hypertrophy and dilation of the heart may be more or less successfully
dealt with by surgical methods yet to be determined. (11) The injection
of hot water or gelatin into angiomas of the heart may add to the solution
of their treatment. (12) Aneurysm of the coronary artery should be
treated by proximal ligation. (13) Ligation of one coronary artery at
its origin or elsewhere will not of itself produce death. (14) Rupture of
the heart, spontaneous or otherwise, demands suturing (immediate death
does not always occur). (15) Pedunculated tumors upon the external
surface of the heart can be successfully removed. (16) Pedunculated
tumors within the cardiac chambers may also be removed. (17) Lacer-
ated, incised, and punctured wounds (penetrating or nonpenetrating) of
the heart can be successfully sutured. (18) Suture of wounds in the
aortic arch can be successfully done (19) Interrupted sutures of fine
silk and the smallest practicable needle are preferable for suturing the
heart and ligating the coronary artery. Continuous sutures should
not be used; if one breaks all are lost. (20) Suturing or any other
surgical procedure should not be discontinued because of the heart
ceasing to pulsate. The work can and should be completed in a much
shorter time on a quiescent heart. (21) Divulsion of the sphincter
ani and all methods of resuscitation should be persistently followed
while operation is being conducted. (22) The removal of cardioliths
(intramyocardial or within the chambers) is possible, and should be
attempted when they cause serious trouble. (23) The a;-ray will
greatly aid in determining their presence. (24) They are usually in the
apex of one of the ventricles of bipeds. (25) When found in the myo-
cardium, they are usually in the ventricular wall (most frequently that
of the left, which is thicker), and, as a rule, are contained within a cyst.
(26) There have been about 53 operations upon the heart for injury,
with 18 recoveries."

A detailed account of a case of pyopericarditis, pyopneumoperi-
carditis, and pneumococcus pyemia is reported by Sibley, Lane, and
Rowell.^ The patient was a boy 16 years of age, and the conditions
mentioned developed subsequent to pneumonia of the left base. After
an apparent crisis on the eighth day there was a return of febrile tem-
perature for 5 days and then a subnormal temperature for 8 days, during
which time there existed the pulsus parodoxus. At no time was there
an endocardial or exocardial murmur heard. At this time a localized
empyema was evacuated. The pus was found to contain pneumococci in
considerable numbers. The relief to symptoms was not marked, however,
although the pulse became of better volume and more regular. Ten days
later the patient was anesthetized, and when Lane inserted the finger into
the opening in the anterior chest-wall which had been made for the
drainage of the pleural cavity, he discovered a distended pericardium.
He forced his finger through the wall of the pericardium and a large
quantity (about 10 ounces) of pus escaped into the pleural cavity and
externally. A slight elevation of temperature with general improvement
1 Brit. Med. Jour., May 23, 1903.

226 GENERAL SURGERY.

followed this procedure, but the patient died 13 days later. ( Jreat num-
bers of pneumococci were found in the blood of the patient and death
was due to a general pyemia of pneumococcal origin.

Latham and Pendlebury^ report a case of extensive pericardial
effusion occurring in a man 53 j-ears of age in which Pendlebury success-
fully drained the pericardium. Some weeks before performing the opera-
tion, however, he tapped the pericardium and withdrew 95 ounces of
fluid. When drainage was instituted, the sac contained but 20 ounces.
After drainage was established the patient's general condition, which had
been ver}^- bad, rapidly improved. The sinus remained open for 3 weeks.
The sac Avas drained after the method of Allingham and Ogle, which
consists in the establishment of drainage at the lowest point of the sac.
[By the method of Ogle and Allingham the surgeon opens the pericardium
from below through the diaphragm. An incision is begun at the costo-
xiphoid angle and is carried down along the seventh left costal cartilage.
The cartilage is retracted upward and outward and discloses the fibers
of the diaphragm and the cellular interval between the diaphragmatic
attachments to the xiphoid and to the cartilage of the seventh rib. This
cellular interval is enlarged by tearing or cutting and a fatty mass is
reached. This mass of fat is just above the diaphragm, in front of the
pericardium and back of the sternum. By pulling down the fat and
the diaphragm the pericardium is exposed and can be incised at its
lowest point.]

Ricketts^ gives the careful study of his experiments upon a number
of dogs with reference to cardiotomy and cardiorrhaphy. The author
explains carefully the technic which he practised. The heart can be
handled to a remarkable degree without any appreciable change in the
beats. Exposure of the heart, however, results in its dilation, since the
support afforded by the pericardium is removed. Before suturing a
wound in the heart, the flow of blood can be controlled by light pressure;
it is not necessary to press hard enough to prevent the action of the
organ or to bring its walls in contact. If during manipulation the heart
ceases to beat, the wound in the heart should be kept closed with the
finger and the wound in the chest-wall should be closed as nearly as
possible. This maneuver helps to restore the support of the heart. The
Glover continuous suture is preferable to all others. The weight of
opinion is in favor of interrupted sutures of twisted silk. The smallest
possible silk and needle should be employed; the objection to kangaroo
tendon and catgut sutures is that a large needle is required to pass
them. Some wounds which enter the heart-muscle do not require sutur-
ing, as they will close and heal spontaneously. In speaking of his results
Ricketts says that we can ligate either of the coronary arteries at any
point of their distribution without producing death.

Sir Isambard Owen^ reports a case of perforation of the aorta by
a pin which was lodged in the esophagus. The patient was a man 53
years of age who was admitted to the hospital suffering from pain in

' Lancet, March 21, 1903. ^ Jour. Am. Med. Assoc, Nov. 15, 1902.

3 Brit. Med. Jour., June 27, 1903.

DISEASES OF THE VASCULAR SYSTEM. 227

the chest and giving a histor}^ of repeated attacks of hematemesis. It
was for the latter condition that he was admitted. He gave no history
of having swallowed a pin and it was thought that possibly the patient
had an intrathoracic aneurysm which was oozing into the esophagus.
He was treated for this condition, but died after repeated attacks of
hematemesis. At the necropsy it was found that an ordinary pin,
slightly bent, had lodged head-first in a small diverticulum above the
right bronchus, and that its point had, bj^ continual scratching, pene-
trated the esophagus and the thoracic aorta. The aorta and esophagus
were adherent and the tissues between were infiltrated with blood nearly
as far down as the diaphragm. The stomach contained a pint of blood
and the whole intestinal canal was filled with blood.

Rudolph Matas^ details a new and original operation for the radical
cure of aneurysm based upon arteriorrhaphy. In this operation the
sac, as a rule, is not extirpated or disturbed, except to the extent requisite
to permit of evacuation of its contents and free exposure of its interior.
The operation is applicable to all aneurysms in which there is a distinct
sac, and in which the cardiac end of the main artery can be provisionally
controlled. It is especially applicable to all forms of peripheral aneurysm
of the larger arterial trunks. It is particularly indicated in the treat-
ment of traumatic aneurysms in which the wounded artery communi-
cates with a well-developed and circumscribed sac, and in all fusiform
and sacculated aneurysms, whether traumatic or idiopathic, in which the
conditions for securing provisional hemostasis can be obtained. The
method is not applicable to the treatment of arteriovenous aneurysms,
or to recent circumscribed or diffuse pulsating hematomas. The main
principle which underlies the operation devised by the author is the fact
that the lining membrane of the aneurysm is the same as that of the
artery, namely, a serous membrane possessing the adhesive qualities
pertaining to this tissue in other parts of the body. In the fusiform or
saccular aneurysm caused by direct injury to the artery the sac is in its
major part an adventitous product of new-formation, in which, however,
the newly formed elements resulting from the connective-tissue prolifera-
tion have assumed the fibrous and endothelial characteristics of the
adventitia and intima of the parent artery. It therefore follows that,
whether the sac be of purely traumatic or of pathologic origin, it can be
regarded for surgical purposes as a prolongation or expansion of the
affected vessel, and, as such, it is amenable to the same pathologic reac-
tions which characterize the normal bloodvessels when subjected to irri-
tation. In the larger and older aneurysms this sac loses in places its
serous surface, but these areas are usually in the distant and peripheral
parts which are not in contact with the blood-current, and which are
covered and altered by fibrinous deposit. The lining membrane of an
artery manifests the reactionary tendencies displayed by serosa when
subjected to irritation.

This conception of the sac is the basis of the method here described
and successfully utilized by the author in securing the obliteration of the
aneurysmal pouch and its orifices by suture.

1 Ann. of Surg., Feb., 1903.

228 GENERAL SURGERY.

The first step of the operation as applied to peripheral aneurysms of
the larger arteries is prophylactic hemostases. This is accompHshed by
elevation of the limb and application of the Esmarch constrictor or the
exposure of the main trunk and its compression with a traction loop held
by an assistant. After the absolute control of the circulation, the sac is
exposed by a free incision, but it is not disturbed from its position. A
longitudinal incision is then made from one pole of the tumor to the other.
The edges are retracted, the clot is removed, and the interior of the cavity
thoroughly exposed. If it is a fusiform aneurysm, two large openings
will be seen, usually at the bottom of the sac, separated by an intervening
space of variable length, frequently marked by a shallow groove which
represents the continuation of the floor of the parent artery. If the
aneurysm is of the sacciform type, there will be a single opening of vari-
able size, circular or ovoidal in shape, which connects the sac with the
main artery. Differentiation of the sac into these two fundamental
varieties is most important in its bearing upon the further aims of the
technic. In spontaneous aneurysm of the fusiform type the artery
blends so completely with the sac walls that its continuity cannot usually
be restored, at least in the present state of our experience. In these cases
the object of the suture is simply to close the openings leading to the
artery for the purpose of hemostasis and obliteration of the sac. In the
sacciform aneurysms, with a single opening leading to the main vessel,
it is often quite possible to close the opening without encroaching upon
the lumen of the parent vessel, thus maintaining the functional as well
as anatomic continuity of the artery. After identifying the main open-
ings into the sac a careful search should be made to discover the opening
of any collaterals which if not carefully sutured would give rise to most
troublesome hemorrhage. When the hemostasis is complete, the interior
of the sac should be gently but thoroughly scrubbed with gauze soaked
in sterile saline solution, with the view to clearing it of adherent laminated
blood-clots, which interfere with the healing of the sutured surfaces.
This toilet of the sac also improves the circulation of the intima and pre-
pares it for more prompt plastic reaction when the surfaces of the sac are
brought in apposition. Comparatively few sutures are required to
approximate the margins of the parent vessel, as they are usually com-
paratively thick. The suture material may be silk, chromicized catgut,
or finest kangaroo tendon. The full curved round intestinal needles are
well adapted for this work. Suturing wounds of arteries differs from this
work in that the margins of the aneurysmal sac are much thicker and
more easily approximated. The method of applying the sutures is well
shown in the accompanying illustrations (Plate 2). This technic also
applies to the obliteration of a sacciform aneurysm in which the suture
is reconstructive, preserving the lumen of the parent artery. This type
of sac is most favorable for the display of the conservative value of
arteriorrhaphy from every point of view. The intrasaccular suture of
the orifice not only permits of the radical cure of the aneurysm by closing
its nutrient orifice, but also favors the restoration of the affected artery
to its functional and anatomic integrity. The suture is here not only

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EXPLANATION OF PLATE 2.

A, The orifices in the aneurysmal sac in process of obliteration by suture. The first plane
of sutures may be made with Aae silk, but chromicized catgut is preferred. The sutures are
applied very much like Lembert's sutures in intestinal work ; the first plana of sutures should be
sufficient to secure complete hemostasis. The orifice of the collateral vessel on the left upper side
of the sac is shown closed b}' three continuous sutures.

B, A second row of sutures, — a technical detail of the operation which is advantageous,
but ilot necessary in every case. The first row of sutures has been completed and the arterial
orifices have been obliterated. As the walls of the sac are usually relaxed, it is easy to insert
a second series of sutures which add security to the first row, and, in addition, reduce the size
of the cavity which is to be obliterated by inversion of the skin and surplus sac walls at a
later stage in the operation. This second row of sutures is applied as in the first series, by
either the continuous or interrupted method, with a curved needle, and Nos. 1, 2, or 3 chromic
catgut. A large surface of the sac is thus brought in apposition, and the best opportunity given
for adhesion by plastic or exudative endarteritis. If the floor of the sac is rigid or too adherent
to the underlying parts, this second row may be omitted, and the operation can be advanced to
the last step, — i. e., obliteration of the sac after suture of the orifices.

0, The deep supporting sutures in position and the details of transfixion of the flaps. The
Reverdin needle is used to carry the free ends of the threads through the flaps formed by the
skin and aneurysmal walls.

D, The sac opened-. The dotted lines indicate the position and relations of the main artery
to the sac and to the orifice of communication. The object of the operation in this case is to
close the orifice of communication without obliterating the main artery.

E, The obliteration of the orifice of communication completed. The appearance following
the application of interrupted suture is shown. If the suture has been properly applied, the
hemostasis will be complete, and the circulation of the main artery restored. After this has been
done, the second protective row of sutures shown in R and other details of the technic of the
obliteration of the sac should be carried out precisely as in dealing with aneurysms of the fusi-
form type. Anomalous orifices or collaterals opening into the sac, in addition to the main orifices,
are less liable to exist in the sacciform aneurysms than in the fusiform aneurysms, in whicii a
large area of the arterial wall is involved. In any event, however, should such additional ori-
fices exist, they should be individually closed by a few continued sutures, as shown in A.

F, Sectional view of the obliterated aneurysmal sac when the lumen of the parent artery is
preserved and the vessel originally communicates with the aneurysm by a single orifice: a, First
line of sutures which close the orifice of communication and restore the lumen of the parent ves-
sel; h, second row of protecting sutures which also reduce the size of the sac; c, supporting
through-and-through sutures, which bring the roof and floor of the aneurysm in contact; d,
sutures which hold the skin flap and sac in contact with the bottom of the cavity.

0, Method of obliterating the aneurysmal sac in the fusiform type of aneurysms with two
openings. In this class of cases the tunics of the parent artery blend with the sac and the arte-
rial channel cannot usually be restored. The diagram shows the first row of suture (a), which
obliterates the orifice of the artery at the bottom of the sac. The second row of sutures is shown
higher up (J), and also the effect of this row in reducing the capacity of the sac. The oblitera-
tion of the remaining part of the cavity by the folding in or inversion of the sac walls, with the
attached overlying skin is shown in c. The function of the deep sutures {d ) tied over gauze pads,
and of the more superficial skin sutures (e) in obtaining firm contact of the opposed surfaces, is
also shown. This drawing is purely schematic ; it gives an exaggerated idea of the size of the
sac walls, and is chiefly intended to give an idea of the position of the sutures and other parts.

H, The sutures are nearly all tied, and the new channel is completed except in the center.
The two irftddle sutures are hooked and pulled out of the way while still in position, and the
catheter is withdrawn. The obliteration of the sac and final steps of the operation are carried
out precisely as previously described.

Plate 2.

The radical cure of aneurysm based upon arteriorrliaphy (Rudolph Matas, in Ann. of

Surg., Feb., 1903).

DISEASES OF THE VASCULAR SYSTEM. 229

occlusive but reconstructive. The main point to bear in mind is that in
introducing the sutures, these should be inserted at a sufficient distance
from the usually thick and smooth margins of the opening in order to
secure a firm and deep hold of the fibrous basal membrane. The needle
should be made to appear just within the lower edge of the margin, care
being taken that when the sutures are tightened the caliber of the artery
will not be encroached upon so as to obstruct its lumen, and that the
threads will not be brought in contact with the blood in the lumen of the
artery. Greater care must be exercised in securing accurate coaptation
in this class of cases than in the fusiform type previously described.
The larger the cahber of the parent vessel, the more favorable will the
conditions be for the restoration of the lumen of the artery and for the
functional success of the operation. After obUterating the openings or
reconstructing the vessels, as the case may be, the constriction of the main
artery should be removed in order to test the suturing. Any capillary
oozing wiU be usually stopped by pressure or by the means subsequently
adopted to obhterate the cavity. Obliteration of the aneurysmal sac is
accompHshed by reinforcing the closure of the vessels with a continuous
or interrupted suture extending longitudinally in the floor of the sac and
by infolding the skin-flaps as shown in the accompanying illustrations
(Plate 2). When the operation is completed, the aneurysmal cavity
has been obliterated without in the least disturbing the sac or interfer-
ing with its vascular relations. The collateral circulation, which is
usually important in the vicinity of the aneurysm, is also respected, and
in this way the best conditions for the maintenance of the healthy nutri-
tion in the sac and in the parts beyond the aneurysm are assured. No
drainage is employed and the parts should be dressed upon a splint.
This method of treating aneurysms is also apphcable to the intraperi-
toneal varieties. The peritoneum is not to be separated by dissection,
but is allowed to remain adherent to the sac, and is utilized in place
of the skin-flap with even greater ease and certainty of successful union
than when the skin is used. Matas also suggests a method of recon-
structing the main vessel in fusiform aneurysms by utilizing a portion of
the aneurysmal sac and suturing it over a catheter, which is withdrawn
before the last sutures are tied.

Matas has employed the method here described in 4 cases; two of
direct traumatic aneurysm of the brachial, caused by gunshot-wounds;
one femoral and one popliteal, both of the so-called spontaneous variety.
(For detailed accounts of these four operations, see "Transactions of the
American Surgical Association," volume xx, 1902.) [This method of
curing aneurysms certainly deserves a trial at the hands of surgeons, as
it is based on good surgical principles and has been most carefully and
thoughtfully prepared. The success wiU depend greatly on a close ad-
herence to the author's technic]

An interesting case of aneurysm involving the innominate, the
right subclavian, and the right common carotid arteries is reported
by Ballance.^ The patient was a marine, 35 years old. The aneurysm

' Lancet, Nov. 1, 1902.

230 GENERAL SURGERY.

was a large one. The symptoms began 18 months before admission to
the hospital; there was no clear history of syphilis. A modified Val-
salvan treatment, consisting in absolute rest, reduction of food and
drink, and large dose of potassium iodid, was instituted. Under this
treatment, however, the aneurj^sm slowly increased in size. Proximal
ligation of the innominate close to the aorta was then determined upon.
When the aneurysm was exposed it w^as found to extend to within a half-
inch of the aorta. This proximal portion of the artery seemed healthy
and was not dilated. In order to have free access to the vessel, the manu-
brium was split and retracted. This step in the operation, however,
Ballance believes was unnecessary, and he does not recommend it. The
vessel was ligated with 4 ligatures of gold-beaters' skin, size No. 4. Pul-
sation in the aneurysm immediately ceased. The common carotid was
then exposed above the aneurysm, and 2 strands of the same ligature
material were passed around it and tied. It was obvious, however, at
this time that the carotid was distended with a clot and that its ligation
was really needless. When the patient left the operating room there
was no right radial pulse ; the right half of the face was colder than the
left, and the left half was sweating. On the afternoon of the following
day left hemiplegia developed, and the patient died in the evening. At
the necropsy the right common carotid, the right internal carotid, and
the right middle cerebral arteries were found distended with clot. The
other vessels at the base of the brain were collapsed and contained no
clot. The entire innominate artery, except the lower half-inch, was found
involved in the aneur\'sm. The first and second parts of the right sub-
clavian and the lower portion of the common carotid were also involved in
the aneurysmal tumor. The ligatures were found holding the vessel- walls
in contact, but the coats had not been ruptured. In Ballance's article a
number of cuts representing the aneurysm and also 2 cross-sections of the
anatomy of the parts are shown. Reference is made to the published
cases of ligation of the innominate, and the various authorities are quoted.
Before attempting ligation of this vessel the surgeon should have well
fixed in his mind the anatomy of the parts. The gold-beaters' skin liga-
ture made from the peritoneum of the ox is strongly recommended.
Three pounds of pressure are required to occlude the innominate arter}'-
and 10 pounds to rupture it. The " stay-knot" is the one of choice in the
ligation of large vessels. Two ligatures should be placed about the
vessel and a single knot made in each; these knots are tightened at the
same time by pulling on the ligatures. The two ends of each side are
then tied in a second knot as one ligature. Regarding the cause of death
in the case reported, Ballance does not think it directly due to the opera-
tion, but believes that the preceding Valsalvan treatment, which reduced
the patient's resisting power, had much to do with it. The adoption of
the plan of Valsalva in an operable case of aneurysm is regarded as an
error.

JacobsthaP presents a critical review of the treatment of aneurysm
of the innominate artery and reports a case in which Braum ligated the
1 Zent. f. Chir., Aug. 23, 1902.

DISEASES OF THE VASCULAR SYSTEM. 231

right subclavian and carotid arteries. No improvement followed the
operation; the patient died 51 days later. After investigating the results
obtained by distal ligation and comparing them with those secured by
other forms of treatment, it is shown that this operation is not productive
of results which warrant its performance. The immediate mortality is
55.7 %. In Poivet's collection of 94 cases the cures were put down at
7.4 %. Jacobsthal has collected 28 more recent cases in which there
were no cures, though improvement was found 13 times. [Two years
ago one of us (DaCosta) showed a man to the Philadelphia Academy of
Surgery who had suffered from an aneurv'sm of the innominate and also
an aneurysm of the right common carotid near its origin. A ligature was
placed upon the carotid between the innominate vessel and the carotid
aneurysm, and another ligature was placed about the third part of the
right subclavian. This man was apparently cured. In spite of advice
he returned to his work (he was a blacksmith). One year later he re-
turned to the Jefferson Hospital. The innominate region was apparently
sound, but an aneurysm had developed upon the common carotid at the
seat of ligation. No further operation was" performed and the patient
has been lost sight of,]

Stonham^ reports a verj^ interesting case of aneurysm of the second
and third portions of the subclavian artery which was first treated
by ligation of the first part of the subclavian. This, however, was fol-
lowed in a short time by a recurrence of pulsation in the tumor, and a
second operation was performed which consisted in the ligation of the
inferior thyroid, vertebral, and third portion of the axillary arteries.
The patient was a syphilitic 43 years old. At the primary operation the
subclavian was ligated after a subperiosteal resection of the clavicle.
After the second operation the patient recovered without any permanent
interference with the circulation of the arm. Stonham examined this
man about two years after the operation and found him perfectly well,
with a complete disappearance of the aneur}'smal sac. [Nassau, of St.
Joseph's Hospital, Philadelphia, recently successfully ligated the first
portion of the right subclavian for traumatic aneur^-sm.]

Martin^ reports the interesting case of a British soldier who received
a gunshot injury in the left groin and as a result developed a large trau-
matic aneurysm involving the external iliac artery so high up as to
render the ligation of the common iliac the only available treatment.
This was done and the patient recovered and retained perfect use of the
leg. For some time after the operation he complained of anesthesia in
the leg and inabiUty to move it, but these annoyances gradually disap-
peared.

Rankin' reported before the Royal Medical and Chirurgical Society
4 cases of aneurysm treated by the subcutaneous injection of gelatin.
The solution employed consisted of 1 ounce of gelatin, 131 grains of
sodium chlorid, and 50 ounces of sterile water. The inner aspect of the
thigh was the point chosen for the injection. Each of the four cases

* Lancet, Aug. 2, 1902. ' Brit. Med. Jour., Jan. 10, 1903.

' Lancet, June 27, 1903.

232 GENERAL SURGERY.

showed marked improvement. Three were thoracic and one was an
abdominal aneurysm. The following conclusions are reached regarding
the treatment: "(1) That gelatin injections, given with proper precau-
tions, are safe. (2) That they produce alleviation of all the subjective
and many of the objective symptoms. (3) That the relief of symptoms
is probably to be explained by shrinkage of the aneurysmal sac and con-
sequent diminution of pressure on surrounding parts. (4) That such
diminution can be demonstrated in 3 out of the 4 cases treated. (5)
That the after-histories afford evidence of the permanent nature of the
beneficial results of the treatment." [We have never obtained benefit
in aneurysm by injections of gelatin. The commercial material is diffi-
cult to sterilize, and sometimes contains the spores of tetanus bacilli, and
we regard its injection as hazardous. It should only be given when there
seems to be no other plan of treatment which offers any reasonable chance
of success.]

A. H. Ferguson^ reports a case of end-to-end anastomosis of the
popliteal artery for gunshot injury. The patient was a man, 38 years
of age, who received a gunshot wound of both thighs. On the right side
there were all the evidences of a ruptured popliteal artery. Among these
evidences were a diffuse pulsation in the popliteal space which could be
seen and felt, and a systolic bruit which could be heard behind the knee.
A tourniquet was applied to the thigh, and the popliteal space was ex-
posed by a free incision. The artery was completely severed except for
a few shreds of the outer coat at the conjunction of its middle and upper
thirds. The bullet was found immediately behind the injured artery.
Strips of gauze were tied around the vessel, one being placed above and
one below the injury. The tourniquet was then removed. About one
inch of the lacerated ends were resected, and an anastomosis by invagi-
nation was performed. When the suturing was completied and the gauze
strips were removed from the vessels, the blood flowed readily into the
limb, pulsation at the ankle was at once restored, and the extreme pallor
of the foot disappeared. A flap about an inch wide was taken from the
semimembranosus muscle and lapped around the artery at the side of
/the union. A day after the operation sensation had returned to the toes
and foot and the skin was nearly normal in color and felt warm. The
patient did well until 41 hours after the operation, when he complained
of a sudden severe shooting pain in the calf. The foot became rapidly
engorged with venous blood, and sensation in it was lost. Pulsation of
the anterior tibial artery had also suddenly ceased. Following this
sudden onset of symptoms there developed dry gangrene of the toes and
a portion of the foot, which later necessitated two partial amputations
of the foot. The patient ultimately recovered. Four months after the
operation the patient complained of inability to straighten his leg owing
to the tension produced by the cord-like scar in the popliteal space.
Ferguson excised this, and in doing so examined thoroughly the artery.
He could see and feel free pulsation above and below as well as at the seat
of the anastomosis.

1 Ann. of Surg., May, 1903.

DISEASES OF THE VASCULAR SYSTEM. 233

Alexander Lambert and W. B. Coley^ detail a case of embolism of
the mesenteric artery occurring in a young man 34 years of age of
decided alcoholic habit. The patient was very fat. The symptoms came
on suddenly during the night, the patient being awakened by severe pain
in the abdomen. There was no vomiting or nausea at this time. The
following evening the abdomen was markedly distended, generally tym-
panitic, and moderately tender throughout. He gave a history of having
had recurring attacks of appendicitis five years previous. During his
present attack there was no tenderness in the right iliac fossa. Attempts
to move the bowels were unsatisfactory. The next day the patient
began to vomit. In the evening the vomiting became stercoraceous, and
it was evident that there was absolute obstruction of the bowels. When
the abdomen was opened, some dark fluid escaped and considerable
matting together of the omentum by recent adhesions was noted. The
omentum also presented numerous small embolic infarctions. S'everal
feet of the small intestine were greatly thickened and dark. In the ab-
sence of other cause it was determined that the obstruction was produced
by a thrombosis of the mesenteric vessels. The general distention of
the bowels was so great that the exact point of embolism could not be
determined. The abdomen was drained and closed. The patient died
7 hours after the operation. At the postmortem examination the mesen-
teric vessels were found thrombosed and there were also multiple pul-
monary infarctions. There was general atheroma of the vessels and
extreme fatty degeneration of all visceral parenchyma, notably of tlie
heart-muscle. These changes were probably due to alcoholic toxemia.
Embolism of the mesenteric artery occurs in the majority of instances in
patients beyond middle life, and many of 'the victims suffer from coexist-
ing diseases, most often cardiac or renal, with atheromatous arteries; a
minority, however, are younger than 40 years with no serious disease in
other organs, and in such case the cause of the embolism is not discov-
erable. While the variability in individual symptoms is noticeable,
there seem to be two main types of the cHnical picture. The less common
is sudden, violent, colicky pain, not localized, with obstipation and vom-
iting which later become fecal. The more connnon type is sudden, in-
tense colicky pain, not localized, with or without distended abdomen and
a diarrhea often bloody, wi^h blood often in the vomitus, a subnormal
temperature, and great prostration. A few cases of recovery from occlu-
sion of the mesenteric arteries have been reported, as branches of these
arteries have been found occluded with long-standing fibrous plugs.

Eugene Fuller^ describes the control of hemophilia by the admin-
istration of thyroid extract. He also points out the effect of thyroid
in another form of hemorrhage. The use of this drug in hemophilia was
the result of an experiment after other means had failed. The first
patient in whom it was employed was a Hebrew boy 15 years of age. He
presented the following interesting family history: Four of his maternal
uncles had bled to death following circumcision performed as a religious
rite. Two of the patient's elder brothers had bled to death from the same

1 Med. News, Sept. 6, 1902. ^ Med. News, Feb. 28, 1903.

IG S

234 GENEllAL SURGERY.

cause. The patient was never circumcised, but since early life had had
copious nose-bleeds and severe hemorrhage following the shedding of his
first teeth. His joints had swollen repeatedly, and as the result of the
slightest bruising extensive subcutaneous hemoi:rhages developed. For
a year the patient had been in a very weakened condition through spon-
taneous attacks of hematuria. His pulse was 130 and very weak when
Fuller first saw him and he was extremely cachectic and short of breath.
The usual remedies had no effect, and after they had failed he was put
upon 5 grains of thyroid extract 3 times a day. After the second dose
had been administered the bleeding ceased, and at the time of the report
it was 9 months since the treatment was begun and the boy had given not
the slightest evidence of hemophilia. In these 9 months the patient had
grown a great deal and was markedly better in every respect. In a case
of hematuria due to congestion of the prostate Fuller has also used thyroid
extract with wonderful result. The remedy was not employed here until
after perineal drainage had been unsuccessfully employed.

Crile^ presents a research into the means of controlling the blood-
pressure, illustrated by numerous charts. The following is a summary
of the article: "In many instances the control of the blood-pressure is
synonymous with the control of life itself. Surgical shock is an exhaus-
tion of the vasomotor center. Neither the heart-muscle, nor the cardio-
inhibitory center, nor the cardioaccelerator center, nor the respiratory
center, are other than secondarily involved. Collapse is due to a sus-
pension of the function of the cardiac or of the vasomotor mechanism.
In shock therapeutic doses of strj'^chnin are inert, physiologic doses are
dangerous or fatal. If not fatal, increased exhaustion follows. There is
no practical distinction to be made between external stimulation of this
center, as in injuries and operation, and internal stimulation by vaso-
motor stimulants, as by strychnin. Each in sufficient amount produces
shock, and each, with equal logic, might be used to treat the shock pro-
duced by the other. Stimulants of the vasomotor center are contra-
indicated. In shock cardiac stimulants have but a limited range of
possible usefulness, and may be injurious. In collapse stimulants may be
useful because the centers are not exhausted. Saline infusion in shock
has a limited range of usefulness. In collapse it may be effective. The
blood tolerates but a limited dilution with saline solution. Elimination
takes place through the channels of absorption. Its accumulation in the
splanchnic area may be sufhcient to fix the diaphragm and the movable
ribs, causing death by respiratory failure. Saline infusion in shock raises
but cannot sustain the blood-pressure. Adrenalin acts upon the heart
and bloodvessels. It raises the blood-pressure in the normal animal; in
every degree of shock; when the medulla is cocainized, and in the de-
capitated animal. It is rapidly oxidized by the solid tissue and by the
blood. Its effects are fleeting ; it should be given continuously. By this
means the circulation of the decapitated dog was maintained 10^ hours.
In excessive dosage there is a marked stimulation of the vagal mechanism.
Due caution must be exercised. The pneumatic rubber suit provides an
1 Boston M. and S. Jour., March 5, 19021.

DISEASES OF THE VASCULAR SYSTEM. 235

artificial peripheral resistance without injurious side effects, and gives
a control over the blood-pressure within a range of from 25 to 60 mm.
mercury. By the combined use of artificial respiration, rhythmic pres-
sure upon the thorax and adrenalin injected into the jugular vein, animals
which were apparently dead as long as 15 minutes were resuscitated."
Sir William H. Bennett,^ in an instructive address, deals with varicose
veins of the lower limbs. Varicose veins are divided into 3 classes:
congenital, acquired, and intermediate. The latter is congenital in
origin, but influenced in its increase by the same causes which give rise
to the acquired variety. The large majority of cases belong to the first
class. Such veins are usually discovered accidentally about puberty.
True cystic, that is circumscribed, dilations of considerable size are not
common in the congenital varix unless a rapid increase has been caused
by injury or strain. True cystic dilation should not be confused with
the appearance of a cyst caused by the bends and twistings in the course
of a varicose vein. In some of the most exaggerated cases of congenital
varix the increase in size affects the main arteries as well as the veins,
and it is this which explains the fact that some of the most severe and
dangerous cases give rise to no discomfort of any kind under ordinary
circumstances. As to the second variety, that of acquired varix, Bennett
states that it is doubtful whether a really normal vein can be made
varicose by any ordinary strain which may be thro\vn upon it after
adult life has been fully reached. The intermediate varix results from
injury or strain of the congenital variety, and it is this type which is
the most productive of symptoms. Aside from the isolated areas of
varix in the different parts of the limbs, the distribution of varix may
be primarily arranged over three main areas ; along the line of the internal
saphena vein, along the line of the external saphena vein, and along the
outer side and back of the thigh. The external varicose vessels which
may or may not be associated with varix in the corresponding labium
may invariably be taken to be due to pelvic causes, and are seldom
seen in women who have not borne children. It is this variety which is
likely to give rise to great trouble during pregnancy and labor. Varix
of the saphenal area is of comparatively small moment in pregnancy and
labor. Among the troubles arising from uncomplicated varix and their
causes are pain, fulness without edema with a feeling of weight and
tension in the limbs, and edema. Any one of these may exist alone, or
be associated with the others. It must be realized, however, that the
mere existence of a varix itself does not necessarily entail discomfort
or any other disability. Congenital varix, which is also generally heredi-
tary, rarely gives rise to any symptoms at all in the absence of direct
injury, great strain, or other conditions which may produce trouble in
any ordinary vein. If the main arteries of the limb participate in the
exaggeration in size, the liability of trouble arising from a congenital
varix is less than when the alteration affects the veins alone. On the
other hand, the acquired varix nearly always in due time produces
symptoms of varying degrees of importance. The primary change in

' Lancet, Nov. 22, 1902.

236 GENERAL SURGERY.

acquired varix is the partial or complete giving way of one or more of
the vein valves; the more complete the inadequacy of the valves, the
more rapid is the change toward varicosity. Pain is of two kinds — a
sharp pain along the line of the veins which comes on soon after rising
in the morning and becomes gradually worse during the day; and the
pain which is felt generally throughout the limb, dull, heavy in character
rather than sharp and acute. It commences in the foot usually and
travels up; there is no edema. Tension and weight are generally asso-
ciated with the steady growth of the congenital cases. There is no actual
pain here, but a feeling of weariness. Edema is met in two forms, that
in which it commences in the foot and by degrees involves the whole
limb, and the other, in which it commences in the thigh along the inner,
posterior or outer aspects, and may remain almost entirely limited to
the area above the knee. In any case in adults the occurrence of edema
indicates derangement of the vascular apparatus to a serious degree, but
in growing subjects this is not generally so, unless there is a reckless
neglect of all precautions. In growing young people the tendency to
edema is usually temporary. Bennett calls especial attention to the fact
that although edema and varicosities may be limited to the thigh, the
pain is often felt in the leg, and this fact frequently leads to a mistake
in diagnosis. Varix rarely becomes obvious before puberty. In con-
genital cases the appearance of the varix is invariably prior to the occur-
rence of symptoms arising from it; in the acquired kind, on the other
hand, feelings of discomfort, such as pain, weight, and leg weariness,
generally precede the manifestation of the altered veins and call attention
to them. " Spontaneous increase" is the descriptive term applied to
changes which take place in varicose veins without obvious cause. It is
likely to show itself at, or soon after, puberty. In beginning the dis-
cussion of treatment attention is again directed to the fact that the
mere existence of varicose veins does not necessarily call for any treat-
ment. With few exceptions varicose veins which cause no inconvenience
or discomfort should be let absolutely alone, treatment often producing
symptoms which did not exist before. Exceptions to this rule are the
requirements of the public service, the existence of well-defined cysts, or
other conditions in localities liable to injury, and the occurrence of isolated
and limited masses of congenital varix. The minority of cases of varix
can be cured, but the majority cannot. Acquired varix in the early
stages in growing subjects is susceptible to cure; so also is the circum-
scribed congenital variety. All other varieties of varicosity are incurable
in the true sense, although the symptoms arising from them can be
alleviated or entirely removed. It is a mistake to advise complete rest
in cases of increasing uncomplicated varix. The treatment of varicose
veins is divided into nonoperative, consisting in hygienic, manual, and
mechanical treatment; and operative or radical treatment. Intensely
cold baths are not advisable in cases of marked varicosity, Bennett stating
that they tend to the production of thrombosis. The treatment described
as manual consists in massage. Massage properly applied in early in-
creasing varix in growing patients can do much to check the process.

DISEASES OF THE VASCULAR SYSTEM. 237

It requires patience and time. The amount of improvement following
this treatment will depend upon the degree of valvular insufficiency
which has been reached. The simple rubbing of the varicosed areas
with alcohol night and morning is highly recommended, but should never
be used if eczema exists. The irrational use of mechanical supports is
productive, of much harm. The accidental discovery of varicose veins in
the limbs is no justification for the employment of a support of any
kind. In many such cases the elastic stocking is the sole cause of increase
of the pathologic condition and the symptoms accompanying it. A
properly applied support at the onset of pain, discomfort, or edema in
varix is most useful, and gives relief and comfort in many cases. Such
support should only be used, however, when it relieves symptoms and
when its application is unaccompanied by coldness of the feet. If relief
is not obtained and the feet are cold, it is a sure indication that the
support either does not fit, has been improperly applied, or that the
method of treatment is not suitable for the case. Great pains should be
taken to see that the elastic stockings fit snugly but not too tightly.
The unperf orated rubber bandage should never be used, and the per-
forated rubber bandage should always be worn over a thin stocking. In
speaking of the operative treatment Bennett says that a most important
feature is the keeping of the patient in bed for at least 3 weeks after
operation, and that 6 weeks to 2 months should elapse before the patient
resumes anything like ordinary active exercise. Localized masses of
congenital varicose, cystic dilations and aberrant varicose veins in dan-
gerous places should be dissected out. In all operations for varicose
veins a portion of the long saphena vein should be removed. This opera-
tion alone, provided there is sufficient rest after it, will result in a general
shrinking of all the affected veins below the seat of operation. This can
be supplemented also by a removal of 3 inches of the vein below the
knee. It is the author's custom always to combine the two operations.
When there are well-defined cystic dilations above the inner side of the
knee, it is Bennett's practice to remove the whole of the saphena from
the thigh. When this is done, the resection of the vein below the knee
is unnecessary. Because of the complications liable to result from the
varicosities in the external femoral region during pregnancy it is strongly
recommended that such veins should be removed."

The operative treatment of varicose veins is dealt with by J. B.
Blake. ^ He first sets forth the history of the treatment of this condition.
It is shown that before a cure is claimed for any method of treatment
one year should elapse from the time of operation, and recurrences have
even taken place at a much later period. There are three forms of
operative treatment: Ligation in one or more places; excision in short
portions, chiefly high up; removal in extenso by continuous dissection;
or a combination of the last two methods. Multiple ligation is distinctly
less effective than the other methods. Trendelenburg's operation, which
has been so extensively employed, consists simply in the ligation of the
internal saphenous vein in two places 5 cm. or 6 cm. apart in the upper
' Boston M. and S. Jour., Sept. 25, 1902.

238 GENERAL SURGERY.

third of the thigh, and the removal of the short intervening portion.
It is indicated only in those cases where, the limb being raised and made
free from blood, the saphenous vein being compressed, and the leg lowered,
the blood is seen to rush in a wave down into the empty vein the moment
the pressure is removed. This test, which is Trendelenburg's own, is
supposed to demonstrate the fact that in such a vein there is a column
of blood extending from the right heart to the foot which is unsupported
by vein valves, and which is the essential feature in the production, or
at least in the continuation, of the symptoms. There has been a great
difference of opinion regarding the condition of the deep veins when
the superficial ones are varicosed. Gay, Verneuil, and others state that
the deep veins and frequently the arteries are also varicosed. Callendar,
however, failed to discover evidence in his dissections of the constancy
of the intermuscular varix. In the Trendelenburg operation of course
the entire circulation is thrown upon the deep veins. This latter is an
argument in favor of their not being varicosed, else permanent results
could hardly be obtained. Blake points out that the following two
points require settlement in the future regarding the operative treatment
of varix: " (1) To determine how often the deep veins are actually and
clinically affected, in connection with superficial varicosity, and how it is
possible to determine the condition of these deep veins before operation.
(2) To subject a large number of cases of all degrees of varicosity and
its complications to the same method of treatment, and trace the results
carefully for one or two years. This method of treatment might be the
unmodified Trendelenburg operation, or this operation combined with
local dissection."

W. F. CampbelP has made a careful study of the anatomy of the
internal saphenous vein with the idea of determining some satisfactory
guide for the ligation of the ve'in. He recommends the following pro-
cedure : " Find the spine of the pubes. From this point project a line 3^
inches long at right angles to Poupart's ligament. The end of this line
marks the point for the center of the incision, which should be about
one inch long and parallel with the fold of the groin. In retracting the
edges of the incision, retract the upper edge so as to ligate as near the
saphenous opening as possible."

John G. Clark^ discusses postoperative femoral thrombophlebitis
and presents a careful consideration of a large table of cases. Regarding
the theory that femoral thrombosis is secondary to a propagating throm-
bus of the deep epigastric veins, the following substantiating points are
drawn from the cases collected: '"' (1) It occurs in cases where trauma-
tism due to heavy retraction — as in the delivery and operation upon
fibroid tumors, adherent cysts, and cancer of the uterus — may directly
injure the epigastric vessels, especially by digging the end of the retractor
into the under surface of the abdominal wall at a position where the
deep epigastric vessels may directly be injured. (2) A relatively large
proportion of cases occurs in the operation for suspension of the uterus
where the peritoneum is drawn out and the ligatures passed out laterally

1 Med. News, Feb. 21, 1903. ^ Univ. of Penna. Med. Bull., July, 1902.

DISEASES OF LYMPHATIC SYSTEM AND OF THYROID GLAND. 239

in about the position to catch the epigastric vessels or make sufficient
traction upon them to induce the formation of a thrombus. (3) The
entrance of the epigastric vessels just above Poupart's ligament at right
or obtuse angles to the main venous currents, along with the superficial
epigastrics immediately below in the femoral, and the circumflex iliac,
set up an extensive eddying or whirlpool movement essential to the
propagation or formation of a thrombus. (4) The interval of from 8
to 15 days between the time of the operation and the appearance of
symptoms of femoral thrombosis is accounted for by the slow growth
of the thrombus in the deep epigastric, thus gradually extending until
the advancing plug is thrust out into the venous whirlpool beneath
Poupart's ligament. (5) The greater frequency of the occurrence of a
left rather than a right-sided thrombus is doubtless due to the presence
of the mechanical conditions on the left side, which still further slow
and derange the femoral and iliac circulation, thus favoring the propaga-
tion of the thrombus downward into the femoral vessel. (6) Thrombi
quite likely form in the epigastric vein after many abdominal operations,
but only in the rare exceptions are they propagated beyond these vessels,
hence the infrequency of femoral thrombi as a postoperative sequel. (7)
The fact that there are on each side two deep epigastric veins which
freely anastomose with one another also explains why the femoral vein
is seldom reached b}^ the propagating thrombus, for in the event of a
segmental occlusion of one vein, the other, b}' compensation, may carry a
freer blood-current into the iliac vein. (8) Femoral thrombi are slow in
formation, and likewise slow in disappearance, for when once formed
they tend to perpetuate themselves, and only finally give way by slow
liquefaction."

DISEASES OF THE LYMPHATIC SYSTEM AND OF THE THYROID

GLAND.

DanieP gives a very interesting report of 4 cases of sarcoma of the
thyroid. Extirpation was possible in only one of these cases. The
ages of the patients varied from 57 to 69 years. In 3 cases the sarcoma
was of round or mixed cells; in the fourth the growth was giant-celled.
The cases terminated fatally in from 8 to 17 months from the time of
the earliest observation of the growth. In each of these cases it is
thought that the growth was primarily malignant. The right lobe was
the one involved in all. In 3 cases the cervical glands were involved
and were palpable; in the fourth case no glands were found. Secondary
growths were present in 3; in one the secondary growth involved the
dorsal and lumbar vertebras, both kidneys, both suprarenals, the celiac
and cervical lymphatic glands, and the stomach; in another the kidneys,
the cervical and thoracic glands were involved; in the third case, in
which there was a coexisting. myxedema, there were present malignant
ulcers of the stomach and intestine, malignant infiltration of the pan-
creas and involvement of the cervical glands. In but one case was there

' Lancet, July 19, 1902.

240 GENERAL SURGERY.

marked deviation of the trachea. Pain was not a permanent symptom in
any of the cases. Dysphagia and dyspnea were present in 3 cases. In
2 there was extensive infiltration into the trachea. Complete fixation of
the tumor to the deep structures was found in 3. In 2 of the cases the
carotids were embedded in the growth.

An editoriaP in the Journal of the American Medical Association
says: "Albert Kocher^ has reported the cases of Basedow's disease
which have come under the observation of his father, Professor Kocher,
in his hospital and private practice between the years 1883 and 1899.
The series comprises 93 cases, of which 74 were cases of true exophthalmic
goiter. Kocher insists that the operation should not be done when the
patient is in the stage of marked cardiac and psychic irritability. Means
must be used to reduce these as much as possible first. All the operations
were performed under the local use of a 1 % solution of cocain. Alto-
gether, 59 of the 74 cases of true Basedow's disease were operated on.
Four of the 59 patients died wdth symptoms of tetany within 10 days
of the operation. Of the remaining 55 cases, 39, or about three-fourths,
had unpleasant postoperative symptoms. These consisted of transitory
psychic disturbances, irritability, oppression, palpitation, sensation of
heat, congestion of the face, general tremor, sweating, vomiting, fever
and irregular, frequent pulse; in fact, temporary increase in the symp-
toms present before the operation. The fever and tachycardia persisted
in all the 39 cases. The other symptoms mentioned occurred in the
majority of the patients. The possibility that these symptoms were due
to an acute toxemia resulting from absorption of certain substances
pressed from the gland during the operation is discussed, but a satis-
factory explanation for the aggravation of the symptoms is not arrived
at. The other 16 patients operated on had no disagreeable after-effects.
The results of the operative treatment are satisfactory. Of the 59 cases
operated on, 45, or 76 %, were cured; 8, or 14 %, were decidedly im-
proved; 2, or 3.5 %, were only slightly improved; 4, or 6.7 %, died
with symptoms of tetany after the operation. In 15 of the 74 true
Basedow cases medicinal treatment of various kinds was used. The
results, notwithstanding the fact that several of them were mild cases,
are in striking contrast to those obtained from operative procedures. In
only one case could a cure be said to have occurred, and this was really
brought about by the patient developing an intercurrent disease. Necrop-
sies were obtained in 3 of the 4 fatal operative cases. Several factors
may have played a part in causing the fatal termination in the first
case. There was a persistent thymus; the heart was dilated and there
was a fluid exudate in the serous cavities, and the superior cervical
ganglion was very much enlarged. In the second case death was found
to be due to double-sided pneumonia and pleurisy. The fatal result in
the third case was beheved to be due to the extreme severity of the
intoxication. At autopsy the dilated heart, spleen tumor, jaundice and
fatty degeneration of the liver and spleen confirmed this view."

1 May 23, 1903.

^ Mitteilungen aus den Grenzgebieten der Med. u. Chir., 1902, Bd. ix, 1 u. 2
Heft.

DISEASES OF LYMPHATIC SYSTEM AND OF THYROID GLAXD. 241

F. C. Madden^ reports 2 fatal cases of partial thyroidectomy for

goiter. The first patient died 24 days after operation during an attack
of tetany. At the necropsy no trace of thyroid tissue could be found
in the neck, although a small portion had been left at the time of opera-
tion. The second patient died 28 hours after operation from thyroid
intoxication.

In a clinical lecture on goiter, J. Chalmers DaCosta,^ in discussing
the operative treatment of exophthalmic goiter, states that operations,
whatever their nature, frequently fail to cure Graves's disease. Often
an operation will cure the goiter and not the other symptoms. In the
average case operation is indicated only when some particular necessity
arises. ''Further, in reaching a conclusion as to the advisability of
operation we should remember that exophthalmic goiter is, in some cases,
cured by rest or by the administration of drugs ; and that in rare instances
it disappears spontaneously after a shock to the nervous system or after
an operation upon a distant part of the body performed for some other
trouble. Again, operation is more dangerous than in common goiter,
and sudden death may occur during its performance or after its com-
pletion. For these reasons it is wise, in the majority of cases, to employ
medical treatment; but if that fails to cure or to ameliorate, and if the
symptoms are urgent, then the advisabilit}^ of an operation must be con-
sidered. Partial thyroidectomy is the operation to be preferred unless the
goiter is very small, the nervous symptoms being the predominant factors ;
or, unless the goiter is very large, in which case the operation is exceed-
ingly dangerous. If the patient is in an extremely hysteric condition,
such a severe procedure is inexpedient. As a matter of fact, it has been
found that when an exophthalmic goiter is very large, thyroidectomy
relieves the patient of the thyroid enlargement, but does not cure the
symptoms. If it is quite small, it is evident that thyroidectomy is
unnecessary; and if the hysteric element is well marked, the operation is
generally perfectly useless. Thyroidectomy is not to be performed simply
because a person has an exophthalmic goiter. Bilateral resection of the
sympathetic ganglion is a purely experimental operation. Rest in bed,
an ice-bag over the thyroid, and suprarenal extract internally is probably
the best medical treatment. In cases of parenchymatous goiter, thyroid
extract should always be tried. "We are justified in operating if the
goiter is rapidly or steadily increasing in size, or if it is producing dyspnea,
marked discomfort, or annoying deformity. If it is producing marked
pressure, operation is imperatively necessary." Tapping is uncertain
and imsafe. Injections are more dangerous and less satisfactory than
radical operation. Ligation of the thyroid arteries is practically re-
stricted to the treatment of exophthalmic goiter. "Occasionally, when
the patient is in a desperate condition, when the goiter is very large,
when we are certain that a radical operation would be productive of
death, and when a tracheotomy is impossible, the operation known as
exothyropexy may be performed. In order to perform this operation
make a large incision, exposing the capsule of the gland, pull the goiter

* Lancet, June 20, 1903. "^ Am. Jour. Med. Sci., July, 1902.

242 GENERAL SURGERY.

itself— or, at least, a part of it — out of the wound, and leave it exposed
to the air. This dislocation of the goiter relieves the dyspnea, and may
be followed by atrophy of the gland. Some surgeons have advised a
simple division of the thyroid isthmus — an operation which may relieve
the dyspnea and may produce glandular atrophy; but it is uncertain and
often of no avail. The two operations most in vogue are enucleation and
extirpation. Enucleation is an operation frequently practised in cystic
goiter and in adenomatous goiter."

H. S. Barwell^ reports a case of goiter in an abnormal thyroid
gland. The tumor was on the left side of the heck. On its inner side
it was completely separated from the thyroid gland by two layers of
fascia which formed the capsules of the gland and the tumor respectively,
and between the two ran the sternothyroid muscle. Attached to the back
of the right lobe of the thyroid gland was a process which passed vertically
downward into the thorax for more than an inch. The case was a dis-
secting-room subject. The tumor was developed, not from an accessory
thyroid, but from the left lobe of the gland congenitally ununited with
the rest of the thyroid. "The thyroid gland is developed from a median
process of the pharj-ngeal hypoblast, which bifurcates below and forms
the pyramidal lobe, isthmus, and part of each lateral lobe; the main part
of each lateral lobe is formed by a lateral outgrowth from the pharynx.
In man they are found to be fused together in an embryo of 13.8 mm. in
length, or about the seventh week. In most vertebrates they remain
distinct; only in mammals do they become united into one organ. In
rare cases in man the isthmus is entirely absent and the two lateral lobes
quite separate. In many vertebrates, however, the median thyroid rudi-
ment divides to form two distinct lateral glands, but in this case the
median lobe appears to be well developed and undivided."

J. T. Hewetson^ reports a case of congenital goiter which ended
fatally 5 minutes after birth.

Leonard Freeman^ summarizes a paper on the treatment of tuber-
culous glands of the neck as follows: " (1) The gravity of tuberculosis
of the cervical lymphatics, both as regards local deformity and remote
secondary manifestations, is generally underestimated. (2) General
treatment, especially hygiene, is of the utmost importance, both in the
cure of incipient trouble and in the prevention of relapses following opera-
tions on more advanced cases, most recurrences being due to neglect of
such measures. (3) Residence at the seashore has long been recognized
as of great benefit; but there is reason to believe that a high and dry
climate, such as that of Colorado, with its rarefied, stimulating atmos-
phere and abundant sunshine, possesses superior advantages. (4) A
point of extreme importance in local treatment is to abolish sources of
infection, in the teeth, tonsils, nose, ear, scalp, etc., and neglect of this is
apt to result in failure. (5) Nonoperative treatment is often of doubtful
utility, except in the beginning of the disease. (6) Pulmonary involve-
ment does not contraindicate operation, at least in Colorado, except in

' Lancet, April 11, 1903. ^ b^^ lyigj Jquj.^ March 21, 1903.

3 Jour. Am. Med. Assoc, Dec. 6, 1902.

DISEASES AND FRACTURES OP BONES. 243

advanced cases, (7) Curetment is applicable to sinuses, tubercular
ulcers of the skin, and where complete removal would be attended by too
much risk. In all other instances a thorough operation should be done.

(8) The size and shape of the incision should be adapted to the particular
case. It should be free enough to permit of thoroughness and safety.

(9) The chance of permanent cure following operation is probably better
in Colorado than in lower and less favorable altitudes."

James F. MitchelP draws the following conclusions from a study of
the treatment of tuberculous cervical adenitis : " (1) Tuberculous
cervical adenitis is primarily a local disease of very frequent occurrence,
more often in young persons; in itself not extremely serious and rarely
if ever proving fatal. (2) It bears, however, a certain definite relation to
tuberculosis of the lungs and serves as the starting-point from which
tuberculosis may spread. (3) The tuberculin test as an aid to diagnosis
is positive and harmless. (4) While recovery may often take place
under good hygienic conditions, surgical interference is clearly demanded
in most cases. (5) When surgical treatment is resorted to, the operation
should be radical in all cases. (6) Recovery may be predicted in 70 % to
80 % of cases so treated. Tuberculosis of the lungs after complete
removal of the glands is comparatively rare. (7) Tuberculosis of the
lungs unless far advanced is not a contraindication to operation, the
removal of the glands apparently exerting a beneficial influence on the
condition of the lungs."

DISEASES AND FRACTURES OF BONES.

David Officier^ reports 2 cases of fragilitas ossium, occurring in one
family. The first patient, a female aged 12 j-ears, had suffered from
more than 40 fractures of the extremities. The second patient, a male
aged 7 years, had had more than 20 fractures. These fractures were all
produced by very slight violence, were sometimes very painful, and at
other times almost painless. The fractures usually united well in a short
time, probably because of the very slight violence which would in such
a very brittle bone almost necessarily produce transverse lesions. There
are 5 other children in the family who are healthy, and no trace of the
disease can be found in the ancestors. In neither of the cases did a frac-
ture of the ribs take place.

A. W. Morton^ reports a case in which he used a new method of
bone-grafting. The patient, a male aged 45, sustained a compound
fracture of the leg which resulted in the loss of the lower 5 inches of the
tibia from necrosis. After the removal of the sequestrum a dog was
etherized and its foreleg amputated just above the tarsus, the ulna being
left one inch longer than the radius. The skin and muscles of the dog's
leg were divided by a longitudinal incision for 4 inches and left attached
except the lower 3 inches, which were separated from the periosteum.

1 Johns Hopkins Hosp. Bull., July, 1902.

^ Intercol. Med. Jour, of Australasia, Oct. 20, 1902.

3 4mer. Med., July 12, 1902.

244 GENERAL SURGERY. .,j

The end of the ulna was implanted in the medullary cavity of the tibia
and there fastened by silver wire ; the radius was wired to the end of the
tibia. Both the man's leg and the dog were encased in plaster-of-paris.
Five weeks later the skin and muscles were separated from the dog's
leg and the two bones divided near the joint and placed in contact with
the astragalus.

A. H. Andrews^ describes a new method for diagnosing fractures.
"The test is made by placing the stethoscope in close proximity to
the bone near one end, and the handle of a vibrating tuning-fork as
close to the bone as possible beyond the supposed seat of fracture. The
sound will be transmitted through the shaft of the bone to the stetho-
scope and through the stethoscope to the ears of the examiner. When
the bone is intact, if the test is properly made, the sound of the fork
will be heard with great distinctness, but if there is a solution of con-
tinuity the sound will either not be heard at all or will be heard very
faintly. By comparing the intensity of the sound on the suspected
side with the sound heard under similar conditions on the normal side,
the question of continuity of bone can be determined."

Hugh Grouse^ describes his method of windowing plaster casts
in compound fractures. The method is aseptic, permits of frequent
inspection, and allows copious flushing. "Dental rubber, known as
No. 2, is dissolved in commercial chloroform, sufficient of the latter being
used to form a semi-gelatinous paste ; absorbent wool is worked into this
until a meshed mass results. Taking strands of the rubber-laden wool
— the plaster cast having been windowed sufficiently to give an inch of
healthy uninjured tissue around the entire circumference of the wound,
the skin having been previously shaved, sterilized, and well dried — layer
after layer is rapidly packed by the aid of a dural elevator between the
cast and skin until at every point a snug filling exists. Then, by using
a plain chloroform solution of the rubber, the entire area is rapidly
veneered until a smooth rubber mass, extending from near the wound
margin well out on to the cast, exists. The cast is then shellacked."

Joseph C. Bloodgood^ reports a case of medullary giant-cell sar-
coma of the upper end of the tibia, in which the tumor was apparently
removed by chiseling without destroying the continuity of the bone,
and details 6 other similar cases occurring in the Johns Hopkins Hospital.
He thinks that if it be impossible to remove the growth by chiseling or
curetting, the tumor should be dealt with by resection provided the
amount retained is sufficient to permit of good function in spite of a limp.
Amputation is indicated only when the disease has destroyed so much
bone, or infiltrated the soft parts to such an extent, that resection is
either impossible, or, if possible, the extent of the necessary operation
would leave a practically useless extremity. If the attempt at removal
of the disease is followed by local recurrence, the possibility of internal
metastases is apparently not increased.

* Chicago Med. Recorder, March 15, 1903.
^ Virginia Med. Semi-monthly, Jmie 12, 1903.
3 Johns Hopkins Bull., Mav, 1903.

DISEASES AND FRACTURES OF BONES. 245

Lindsay Peters^ reports a case of fracture of the ischiopubic ramus
and rupture of the bladder in which recovery followed suture of the
bladder and drainage.

J. E. Power^ reports a case of arsenical necrosis of the lower jaw
resulting from the use of colored yarn as a tooth-cleanser.

F. C. Larkin^ points out that cerebrospinal rhinorrhea may exist
some time after a fracture of the skull. He relates the ease of a man,
aged 21 years, who fell a distance of 15 feet, lost consciousness, bled
from the nose, and vomited. He regained consciousness after a few
days. He first noticed a clear watery discharge from the nose on the
twentieth day, when he sat up for the first time. Death occurred on
the twenty-seventh day from meningitis. The necropsy showed several
fine cracks in the frontal bone and a slit in the basisphenoid through
which a fine probe could be passed into the nose. He refers to another
case previously recorded by him in which fracture of the frontal bone
extending into the frontoethmoid region resulted from a bicycle accident.
The patient recovered and resumed work, but was troubled by a watery
discharge from the nose. Nine months after the accident he died from
meningitis. Only one other case of cerebrospinal rhinorrhea after frac-
ture of the skull in which the diagnosis was verified by necropsy has
been recorded.

Henry S. Warren* reports a case of acute osteomyelitis of the
cervical spine following trauma. "As regards frequency of occurrence
Hahn, employing the statistics of Frohner and Haaga, found that in
661 cases of infectious osteomyelitis the long bones were affected in 610
instances, the short and flat bones in 51, or 7.7 %. Among the short
and flat bones only one vertebra was found affected. In 41 fatal cases
of acute infectious osteomyelitis occurring in 17 years at St. Thomas's
Hospital only one instance of an affected vertebra is recorded. Otto
Hahn, in a recent study of a series of 41 recorded cases, gives the following
data and general conclusions: (1) Sex: Males 23, females 12, and un-
known 5. (2) Age: The great majority occur in the first two decades
of life, being distinctly a disease of youth. (3) Location: Cervical, 7
times; dorsal, 12 times; lumbar, 17 times; sacral, 5 times. (4) Etiology:
Evidence of undoubted trauma occurred 6 times. In 15 cases there was
a history of trauma, in 10 instances the patient was perfectly well up
to the onset, 3 cases were secondary to the disease elsewhere, and in
one case a purulent paronychia was present; in the remaining cases no
definite etiologic factor was determined." He reports a mortality of 60 %,
and gives the following causes of death: Pachymeningitis, 2 cases; ex-
tensive pneumonia, 2 cases; retropharyngeal abscess, 1 case; empyema,
2 cases; gravitation abscess, 6 cases; amyloid disease, 1 case; invasion
of the cord, 8 cases.

H. M. Chase^ reports 5 cases of fracture of the hip in children.

1 Amer. Med., May 23, 1903. ^ Amer. Med., Oct. 4, 1902.

3 Liverpool Med.-Chir. Jour., Oct., 1902.
* Bo.ston M. and S. Jour., May 7, 1903.
5 Boston M. and S. Jour., May 21, 1903.

246 GENERAL SURGERY.

"These cases emphasize the early age at which the fracture occurs, the
possibihty of fracture following rapid increase in weight, the occurrence
of fracture from slight trauma, and the possibility of relatively slight
disability following fracture of the femoral neck. They emphasize the
fact that the bone may be fractured, giving rise to slight symptoms,
the pain developing a number of weeks or months afterward without
known cause; and that depression of the femoral neck from fracture
predisposes to further depression and a consequent gradual increase of
disability. In contrast to the effects of fracture of the femoral neck
in later life, we see in childhood less marked immediate effects, while
the remote effects are more disabling; and if recent cases of fracture
pass unrecognized, danger lies in confounding their late results with hip
disease."

Fifteen additional cases of fracture of the neck of the femur
treated with a Maxwell dressing are reported by Ruth.^ These, added
to others reported by the author, make 40 cases treated in this way.
The results obtained have been most satisfactory and far superior to
those obtained by any other method. In order to reduce a fracture of
the neck, the thigh is flexed upon the abdomen in order to relax the
psoas and iliacus muscles; then, as the limb is again extended, an as-
sistant makes traction outward and raises the trochanter to the same
level as its fellow. Buck's extension apparatus is then applied to keep
up extension. Binder's board is applied to the thigh high up and an
extension apparatus applied which produces outward and upward trac-
tion of the upper third of the femur. Most excellent results are claimed
from the use of this apparatus.

Thompson^ discusses the treatment of fracture of the neck of the
femur and reaches the following conclusions: "(1) I believe that the
teachings and writings of surgical authors have been rather discouraging
to the general practitioner on this subject. (2) That, in all cases of
fractured femoral neck, firm bony union and useful limbs may be anti-
cipated. (3) That age is not a contraindication to treatment nor to
obtaining bony union. (4) That the patient is best treated by reducing
the fracture and immobihzing it. (5) That this is best accomplished
under anesthesia and by the use of the plaster-of-paris spica. (6) That
the immobilization should be continued for a long time, and 3 months
should elapse before allowing weight on the limb. (7) That Buck's
extension with weight and pulley is not sufficient immobilization to
obtain bony union. (8) That the use of apparatus in these cases is
expensive, hard to obtain when needed, not so efficient in immobifiza-
tion and less convenient for the patient and nurse than plaster-of-paris
spica. (9) That the operative treatment in old and neglected cases
has succeeded beyond all expectations and deserves a place in surgery
among the radical cures for troublesome conditions. (10) That the
patients who usually suffer from the accident are old and enfeebled is a
good reason why the physician should make their declining years as
peaceful and pleasant as possible."

» Jour. Am. Med. Assoc, Nov. 29, 1902. ^ j^^,. Am Med. Assoc, Jan. 3, 1903.

DISEASES AND FRACTURES OF BOXES.

247

J. P. L. Mummery^ describes a new method of treating fracture
of the shaft of the femur. "An extension stirrup is applied with
strapping from the ankle to the knee in the usual way and the stirrup is
fixed round the foot-piece of a Macintyre's splint, the thigh-piece of which
should be made long enough to reach well up to the fold of the buttock.
On the under side of the thigh-piece and close to its upper margin a
metal hook is fixed (see Fig. 46). The best splint for the purpose is
a Macintyre made so that the length of the thigh-piece can be adjusted
by means of a thumb-screw and with a flat metal hook attached to the
under side. An anterior splint for the thigh is then made of Gooch's
splinting, or, better, of guttapercha, padded with a double layer of lint,
and fixed to the thigh with webbings passed round the Macintyre splint.
The fracture having been set the splint is now adjusted with the knee
bent nearly to a right angle and the limb is fixed with bandages or web-
bings, as the case may be. A leather strap, which should be about an
inch in breadth, is now passed through the lugs on the carriage of a
Salter's cradle, then
round the thigh-piece
of the splint and
caught in the hook on
the under side. The
buckle is then brought
to one side and the
strap is tightened un-
til the buttock and
the thigh on that side
are lifted off the bed;
when the strap is suf-
ficiently tight it ought

to be possible to pass Fig. 46.— Mummery's method of treating fracture of the shaft of

., , , , ., thefeintir. c, Hoolc on splint round which strap a passes (Lancet,

the open hand beneath Feb.:28, i903).
the buttock on the in-
jured side. Another strap is then passed round the lower end of the splint
and fixed to the cradle to support the leg; this strap must not be too
tight or it will depress the upper end of the splint. The upper strap will
need tightening from time to time to make up for stretching, etc. All
that is necessary in order to examine the site of fracture is to remove
the anterior thigh splint. The advantages of this method are: (1) The
nursing is very easy, as there are no weights, etc., and the cradle is the
only thing that rests on the bed. (2) There is less tendency to move-
ment at the site of fracture than with most other methods, as if the
patient moves his body, or it should become necessary to move him for
the purposes of nursing, the distal portion of the limb and the splint will
tend to move with him rather than for the movement to take place at
the site of fracture. (3) The splint is comfortable and the limb is in the
natural resting position of semiflexion. (4) The apparatus is simple
and easily applied. Movement of the knee-joint can be carried out from

1 Lancet, Feb. 28, 190.3.

248 GENERAL SURGERY,

time to time by screwing the splint straight with the key while the thigh
is supported by an assistant."

John B. Roberts^ describes his method of treating transverse frac-
ture of the patella by subcutaneous purse-string suture. The only
instrument used is a stout needle 5 or 6 inches long and a strong ligature
of silk, wire, kangaroo tendon, or chromicized catgut. The ligature is
carried around the fragments in the coronal plane and does not enter the
knee-joint or the prepatellar bursa. It is necessary to perforate the skin
with the needle at the four corners of the patella.

Mikulicz-Radecki^ discusses the treatment of fractured patella.
The operative and nonoperative methods give equally good results with
a right interpretation of indications and a correct technic. Cases of
fracture of the patella due to indirect violence in which the accessory
ligaments are torn and in which the fragments are widely separated are
suitable for operation. Fractures due to direct violence in which the
ligaments remain attached to both sides of the patella, thus preventing
wide separation, are treated by medicomechanical means. Those cases
in which the fracture is produced by direct violence and in which
the patients are unable to straighten the knees, the effort causing a
perceptible increase in the separation, are suitable for operation. In
the same way an increase in the gap occurs if the knee-joint is passively
flexed. The decision as to operation must be made, at the latest, by the
end of the first week; for the later one operates, the more difficult does the
operation become and the more uncertain the result. The medico-
mechanical treatment is as follows: Immobilization of the joint for a
short time with elastic compression to hasten reabsorption of the effused
blood, massage of the knee-joint, especially the quadriceps, starting from
the second to the fourth day; the patient gets up at the end of the first
week with a removable plaster-of-paris splint, which he lays aside at the
end of the third week. At this period careful active and passive move-
ments begin, and later exercises with medicomechanical apparatus are
employed. Mikulicz operates without exsanguinating the limb, makes
a transverse incision, uses 3 or 4 brass wire sutures for uniting the frag-
ments, always sutures the ligaments, practises asepsis only, does not
drain, and conducts the after-treatment the same as if the patella were
not sutured except for immobilization of the limb during the healing of
the cutaneous wound. Of 45 cases, 16 were treated without operation.
In 9 instances in which operation was not employed, the result was good
in 8 and only moderate in one; in 2 of these cases the line of fracture
could no longer be recognized with the a;-rays. Suture of the bones was
done 30 times for 29 patients. Of 17 cases of primary suture of the
patella, of which the final result was known, only one showed a bad
result. In 8 cases of late suture only one gave an unsatisfactory result."

H. P. H. Galloway^ reports a case of fracture through the site of
an excision of the knee-joint 9 months after the excision. Serrations
as deep as f of an inch extended up into the femur and down into the

1 Jour. Am. Med. Assoc, Jan. 3, 1903. ^ Brit. Med. Jour., Dec. 13, 1902.

^ Canad. Jour, of Med. and Surg., Jan., 1903.

DISEASES AND FRACTURES OF BOXES. 249

tibia, showing that the union between these 2 bones had been exceedingly
firm.

Albert Carless and Stepen Mayou^ state that fractures of the posterior
' segment of the os calcis are by no means common and that radiography
has demonstrated the frequency of fractures through the greater pro-
cess of the calcaneum. When a person falls from a height on the heels
the force is mainly directed to the astragalus. Should, however, the
violence be applied from above not quite vertically, a greater portion of
the force will be directed either through the anterior or posterior segment
of the arch formed by the astragalus. In the majority of falls there is
some slight plantar flexion of the foot, so that the force is conveyed chiefly
to the anterior section of the bone. "The head of the astragalus rests
inferiorly upon the sustentaculum tali, and to a lesser extent upon the
greater process of the calcaneum. Violence apphed vertically would
force these two surfaces together, but in addition to this the anterior edge
of the posterior articular facet on the under surface of the astragalus
would be driven downward into the outer end of the groove into which is
inserted the interosseous ligament, particularly if there be any tendency
for the anterior part of the foot to be twisted inward; the violence may
be so great as to lead to an impaction of this edge into the upper surface
of the greater process; these two forces acting concurrently, viz., the
downward pressure of the astragalus on the inner side and the impacting
blow of its sharp lower edge on the outer, are likely to break the greater
process of the calcaneum across rather than to lead to rupture of the
powerful and semicartilaginous inferior calcaneoscaphoid ligament. The
one of fracture seems to vary, being sometimes from above downward
and backward, sometimes downward and forward. This anterior frag-
ment is sometimes comminuted, while impaction sometimes occurs.
Flattening of the arch of the foot will be the necessary consequence of this
lesion." Secondary lesions follow this forced flattening of the arch if
the violence still continues to act, but the injury to the os calcis is almost
invariably the primary fracture. The clinical signs in these cases are
not very characteristic, and it would be difficult to distinguish them
without the aid of radiography from fractures of the astragalus without
displacement. The ecchymosis is usually a little above the fracture,
since the tissues immediately below the malleoli are more prone to swell
than are the plantar structures. "The heel is usually somewhat drayvn
up, and the foot is in a position of slight talipes equinus. The loss of
the arch of the foot is not very evident owing to the swelling of the parts,
but it looks longer than usual, and its vertical dimensions may be dimin-
ished. The movements of the subastragaloid and mid-tarsal joints are
more hkely to be impaired than those of the ankle itself, unless the astrag-
alus is involved in the lesion. It is all-important in these cases to take
radiographs not only from" the side, but also from the front." Left to
themselves, these fractures are liable to eventuate in a painful variety
of flatfoot owing to the depression of the "head of the astragalus, and the
formation of a large mass of callus on the under surface of the calcaneum,

1 Practitioner, Dec, 1902.
17 S

250 GENERAL SURGERY.

occupying the cleft between the displaced under surface of the anterior
fragment and the front end of the body of the bone. Another cause of
the pain is a projection on the same lower surface due to the deposit of
new bone from the torn periosteum beneath the insertion of the plantar
ligaments. Unfortunately in this form of flatfoot the use of plantar pads
is of very little use, as the constant pressure increases the pain." In the
treatment an effort should be made to reduce swelling; then, while the
patient is under the influence of an anesthetic, if the displacement be great
the foot may be forced into a position of inversion, and be put up in
plaster-of-paris. In old-standing cases with much pain and deformity
it may be advisable to remove a wedge of bone irrespective of joints or
to take out either the head of the astragalus or even the whole bone.

Robert B. Osgood^ says that the tibial tubercle of an adolescent,
because of its situation and mode of development, is susceptible to in-
juries, especially in athletic subjects. These lesions are usually caused
by a violent contraction of the quadriceps extensor. Fracture and com-
plete avulsions of the tubercle are rare, cause loss of function, and are
easily diagnosed, usually clinically and always by means of the x-ray.
Avulsions of a small portion and partial separation of the tubercle are
more common. They do not cause complete loss of function, but without
treatment, long-continued serious annoyance. The diagnosis should be
made by a combination of the clinical and a;-ray pictures, and before the
latter are accepted as evidence both knees should be skiagraphed and
accurate technic observed.

Murray^ makes a study of 76 cases of simple fracture of the tibia
and fibula in order to discover the ultimate results of this injury.
The patients were all treated in a Liverpool hospital (an institution in
which about 250 fractures of the leg are received yearly). A tabulated
list of the 76 cases is presented and the ultimate result in each case is
stated. Murray does not approve of the ordinary straight posterior
splint with the vertical foot-piece. He shows that the natural position
of the leg when the patient is recumbent is one of slight eversion, and
therefore he employs a splint the foot-piece of which is inclined outward
at an angle of 70° and which has the same inclination forward. To place
the foot at right angles to the leg tends to produce tension of the calf
muscles and a consequent displacement of the fragments, hence the for-
ward obliquity of the foot-piece. At the end of 4 weeks, when the
fractured bones are united, movement of the ankle-joint and knee-
joint, together with massage, is indicated. The usual mistake made in
treating these cases is that the injured limb is kept in a state of im-
movability too long a time. In a case of oblique fracture of the tibia
the patient should not be allowed to put the body-weight upon the limb
until the end of the third month. It is practically impossible in certain
cases of oblique and spiral fracture to produce a proper restoration of the
parts. Although many of these patients recover with bad position, the
function of the part is usually surprisingly good. Hemorrhage and
inflammation of the soft parts together with piercing of the adjacent

1 Boston M. and S. Jour., Jan. 29, 1903. ^ Lancet, Sept. 13, 1902.

DISEASES AND FRACTURES OF BONES. 251

muscles and fascia by the sharp ends of the broken bone are the most
frequent compHcations which interfere with the perfect reduction of the
fragments. In deciding for or against an operation in an obhque- frac-
ture the character of the fracture together with the patient's avocation
must be the deciding points. The author is a strong advocate of the
use of the a;-ray for diagnostic purposes in all doubtful cases of fracture.
In a case of Pott's fracture in which restoration of the fragments is
difficult, tenotomy can frequently be avoided by placing the foot in the
position described.

W. Arbuthnot Lane^ contributes a paper on the mode of production
of fractures of the lower extremity by indirect violence. The ankle-
joint may be regarded as a fairly perfect hinge-joint, in which any slight
rotation of the astragalus outward around a vertical axis in abduction
of the foot is associated with a torsion of the lower end of the fibula on
its long axis by force acting at a great mechanical advantage; while in
adduction, what torsion there is, is trivial in range and in the reverse
direction, and is exerted with very much less force. If the foot is ad-
ducted by a force greater than it is able to bear, the head of the astragalus
tends to become dislocated outward. If, on the contrary, the foot is
excessively abducted, the tendency to rotation of the fibula upon its
own axis may be sufficient to break that bone; while if abduction be
carried still further, the astragalus and the rest of the foot are displaced
backward upon the tibia, when the internal lateral ligament or the in-
ternal malleolus may also yield. In consequence of excessive forcible
abduction a vertical or spiral fracture of the fibula, with displacement
of the whole foot outward and backward upon the tibia with or without
damage to the internal malleolus or internal lateral ligament, may ensue.
The surgeon has no possible excuse to justify noninterference in these
cases, as the disability resulting from any treatment other than the
operative is generally marked. Careful consideration of the anatomy
of the part, and of the mode of causation of such fractures, and experi-
mental manipulations made at the operations, when the seat of fracture
has been freely exposed, show how impossible it is to exert force upon
the lower fragment of the fibula in a direction exactly the reverse of
that by which the fracture was produced; in other words, how impossible
it is to effect accurate apposition of the fragments by manipulation.
"Spiral fracture of the femur is brought about by the transmission of an
excessive vertical force through the lower extremity, which is fixed in a
position of extreme external rotation at the hip-joint by means of the
enormously powerful anterior portion of the capsule, upon an abducted
foot. Here we have two forces acting in opposite directions upon the
axis of the femur; one extends from the front of the great toe to the axis
of the tibia, and the other from the axis of the shaft of the femur through
the neck of the femur and pelvis. Both form levers, the extremities of
which move along arcs in opposite directions. Skiagraphs show the
hopelessness of any surgery other than operative, and they cast very
natural doubts on the truth of the statements that are frequently made
* Practitioner, March, 1903.

252 GENERAL SURGERY.

as to the results obtained by treatment of these conditions by mean&
other than operation."

JOINT DISEASES AND DISLOCATIONS.

F. C. Wallis^ discusses the treatment of the various forms of septic
synovitis. The author thinks that the septic origin of synovitis is
frequently overlooked and that it does not receive sufficient attention at
the hands of writers. The common mistake that is made is in attrib-
uting the condition to rheumatism. It will be noticed, however, that in
the septic cases there is not the sweating which takes place in rheumatism.
Two conditions which are nearly always present in septic cases and which
are thought to be of diagnostic value are the dry, harsh, unpleasant state
of the skin, and the restless, distressed, and unhappy mental condition of
the patient. Cases of septic synovitis cannot be satisfactorily classified
until a sufficient number have been carefully studied from a bacterio-
logic point of view. Such a study is rendered difficult by the fact that
the condition frequently clears up without the necessity of opening the
joint, provided the part is put absolutely at rest and the original focus
of infection is properly treated. In gonorrheal synovitis which does not
promptly yield to rest and the usual treatment Wallis recommends that
the joint should be freely opened and washed out with warm salt solu-
tion. The wound is closed without drainage and the limb is kept at
rest for 10 days or 2 weeks, and the joint is then massaged. It is not
advisable to use an antiseptic solution in such joints. Whenever a
single joint becomes acutely inflamed and distended with fluid in a young
person and does not yield to treatment, no time should be lost in opening
and irrigating the joint. This same treatment is recommended in cases
of synovitis after influenza, those associated with osteomyelitis, and
especially in those cases in which the condition is due to a streptococcic
infection. Pyemic joints if operated upon early give surprisingly good
results. Drainage in these pyemic cases is necessary. In cases of injury,
also, followed by increasing temperature with great distention, local pain,
and general distress, the joint should be opened and irrigated. [That in
the past we have been too conservative in our treatment is certain. More
cases suffer from conservatism than from refusal to operate.]

O'Conor^ strongly urges incision and drainage of joints in acute
rheumatic fever. He reports 20 cases of this condition in which he
has opened and drained the joints with excellent results. In all of these
cases medicinal treatment, both local and general, had proved ineffectual.
The surgical treatment recommended not only causes the immediate dis-
appearance of arthritis and the early cessation of general toxemia, but
it also effectually protects the heart from involvement. O'Conor lays
stress upon the fact that no operation should be undertaken unless the
operator is able to carry it out with perfectly aseptic technic. The joint
should be freely opened, thoroughly drained, and frequently irrigated.

In a paper on hypertrophy of the synovial fringes of the knee-

' Brit. Med. Jour., Jan. 3, 1903. ^ Lancet, Jan. 24, 1903.

JOINT DISEASES AND DISLOCATIONS. 253

joint Edville G. Abbott^ discusses the etiology, pathology, symptoms,
and treatment, and reports 12 cases. His conclusions are as follows:
Such cases should be considered independently, and should not be in-
cluded among the other diseases of the knee-joint. A thorough micro-
■scopic examination of the tissue removed shows it is a simple inflammatory
tissue, and is not the result of the action of microorganisms. Although
the etiology is obscure, the disease is evidently due to some fault in the
weight-bearing structures of the lower extremity, causing the ligaments
of the joint to become lax. Since the matter was brought to Abbott's
notice he has found that in all the cases examined by him a flattened arch
has preceded the knee-joint trouble, and the use of a flatfoot plate has
been of great service in treating the disease. The diagnosis is not diffi-
cult, although a torn cartilage somewhat resembles this condition. In
all the cases operated upon an examination was made of the cartilages,
and in every instance they were found to be intact. It is impossible to
account for the paralysis of the quadriceps extensor muscle, which Abbott
found in 3 instances ; but in several of the cases operated upon, in which
it did not exist before the operation, a similar condition was found after-
ward and was the last symptom to disappear. This shows that some-
times muscular paralysis occurs from trivial, cause. Whether a patient
should be treated by mechanical methods or whether he should be oper-
ated on, is a question which must be left to the judgment of the surgeon.
Some apparently severe cases ^ield easily to treatment; others which are
apparently slight will not improve until the fringes are removed.

Barnard^ reports 9 cases in which he drained the knee-joint both
anteriorly and posteriorly for acute suppurative arthritid. He
states that acute pyogenic infection of the knee-joint is one of the most
dangerous of suppurative diseases and one of the most unsatisfactory
that a surgeon can be called upon to treat. Many of these cases occur
in hospitals and follow wiring of the patella or the removal of the semi-
lunar cartilages or foreign bodies, and terminate in death or amputation,
ankylosed joints, and long-standing open sinuses. After referring to the
failures from repeated or continuous irrigation of the joint and from
extensive transverse incision dividing the patella or its tendon, Barnard
advocates posterior as well as anterior drainage. Drawings are pre-
sented showing two posterior pockets of the synovial membrane where
pus invariably accumulates and which cannot be drained through a lateral
incision. These pockets can be found by making an incision directly
over the posterior aspect of the condyles. Care must be taken not to
injure the long saphenous vein and the external perineal nerves. These
pouches terminate above and behind the condyles in the sacs which are
beneath the corresponding heads of the gastrocnemius. Excellent results
have followed this treatment in several of the reported cases, and all of
them have been greatly benefited. Barnard advises that all really acute
cases of suppuration of the knee-joint with high temperature should be
treated by both anterior and posterior incisions, and particularly if the
suppuration arises from punctured wounds. In cases due to autoinfec-

' Jour. Am. Med. .\ssoc., April 25, 1903. ^ Lancet, April 25, 1903.

254 GENERAL SURGERY.

tion and in subacute cases in which the temperature is not above 102° he
feels inclined first to employ the lateral incisions.

A method of resecting the knee without opening the joint is de-
scribed by Marion/ who does not claim that the idea is original, since
Wolkowitch practised the operation as early as 1896, The method of
Marion, however, which is minutely described, is original. The classic
curved incision is made beginning high up lateralty and passes well down
below the tubercle of the tibia. The skin-flap is then dissected up well
above the limit of the subcrural pouch. The patella ligament is divided
1 cm. above the tubercle, and then the lateral expansion of the ligament.
The periosteum of the tibia just above the tubercle is divided horizontally.
This line indicates the point at which separation of the soft parts in the
popliteal space should be begun. The quadriceps tendon is divided above
the patella by a curved incision until the synovial pouch is reached. The
separation of the tendon and muscle from the pouch is then accom-
plished. The pouch is easily separated from the anterior surface of the
femur by means of a finger or a blunt instrument. A flat retractor is
passed behind the femur and this bone is divided with a narrow saw so
as to form a V-shaped end. The anterior division of the bone is made
from the upper level of the synovial pouch and is carried bilaterally
downward and backward. The posterior division is begun at a corre-
sponding point and brought forward and downward. The tibia is divided
so that the upper part is shaped like an inverted V, into which fits the
V-shaped end of the femur. The soft parts are carefully divided in order
to avoid opening the joint. All bleeding points are controlled after the
removal of the tourniquet. A drainage-tube is inserted between the
bones and the contents of the popliteal space. The dressings are allowed
to remain in place for 25 or 30 days, when the drainage-tube is removed.
The parts should be immobilized for a number of months. The great
advantage of this method of operating is that the field of operation is not
infected by the contents of the diseased joint. Marion reports 9 cases.
In one of these subsequent amputation became necessary because of
suppuration. Another died shortly after the operation from general
tuberculosis. The other 7 cases were completely cured. Union of the
bone occurred in from 2 to 6 months except in one case, and in this in-
stance the patient removed the immobilizing apparatus. The cases
reported were observed for from 2 to 3 years after operation. Because
of the way in which the bone is divided sutures are unnecessary in order
to produce fixation. It is claimed that the results are at least as favor-
able as those following the ordinary method ; in no case has the immediate
reproduction of tuberculous foci occurred; the only objection to the
method is the removal of a considerable portion of bone. It should
therefore be reserved for cases in which the bones themselves are diseased.

J. G. Sheldon^ reports 3 cases, two of his own and one of John B.
Murphy's, of posterior dislocation of the head of the tibia. In each
of these cases reduction was easily accomplished under anesthesia and
there was no evidence of injury to the vessels. Forty-eight hours after

' Arch. Gen. de M6d., Feb. 17, 1903. ^ Ann. of Surg., Jan., 1903.

VENEREAL DISEASES. 255

the injury in one case, 36 hours afterward in another, and two days after-
ward in the third there began to develop gangrene requiring amputation
above the knee. Sheldon is able to find reports of only 52 other cases of
posterior dislocation of the head of the tibia. The following is a synopsis
of them: Total number of cases, 52; complete dislocations, 40; complete
compound dislocations, 7; complete dislocations, with gangrene, 9; in-
complete dislocations, 15; incomplete simple dislocations, 14; incomplete
compound dislocations, 1; incomplete dislocations, with gangrene, 1;
total number of compound dislocations, 8; and total number of disloca-
tions with gangrene, 10. The occurrence of gangrene does not seem to
bear any direct relation to the external evidences of injury. A reliable
prognosis cannot be given on making an examination shortly after the
occurrence of the accident. Another misleading feature in these cases —
from a prognostic standpoint — is the fact that the first evidence of gan-
grene, or of impaired circulation in the injured member, may not be
manifest for some hours or days after the injury. The impairment of
the circulation may be indicated, at the time of the injury, by a very
feeble posterior tibial pulse (Vast's and Wagner's cases). Usually there
is no indication of impaired circulation until the third day; then the leg
becomes cold and gangrene rapidly supervenes. These changes may
come on as early as the second day or as late as the fourteenth.

Captain Hudleston^ reports a case of compound dislocation at the
calcaneoastragaloid and scaphoastragaloid joints occurring in a
soldier. The injury was caused by the man slipping and his foot turn-
ing under him. It was found impossible to reduce the dislocation even
under an anesthetic until the wound was sufficiently enlarged to allow
of thorough inspection and manipulation of the joints. Reduction when
this was done was easy and the patient made a satisfactory recovery with-
out suppuration and obtained a useful joint.

Finley R. Cook^ reports a number of cases in which he has employed
the Gibney adhesive plaster dressing for sprains with excellent re-
sults. It is urged in sprains of the ankle that an attempt be made to
diagnose the ligaments which are torn in order that the ankle may be
strapped in the position indicated by the injury.

VENEREAL DISEASES.

At the closing session' of the Second International Conference on the
Prophylaxis of Venereal Diseases and Syphilis held at Brussels,
September 1 to 6, 1902, the following resolutions were adopted: '^Reso-
lution of Trois-Fontaines: To give to conscripts arriving from their
regiment very condensed, printed instructions on the dangers of gonor-
rhea and S3rphilis. To add to this a paragraph pointing out the neces-
sity of always remembering any attack of venereal disease, in order to
describe it later to the physician. Also to add, perhaps, some brief notes
concerning the dangers of alcoholism and the prophylaxis of tubercu-

1 Brit. Med. Jour., Feb. 21, 1903. = Med. Rec, Jan. 10, 1903.

3 Med. Rec, Sept. 27, 1902.

256 GENERAL SURGERY.

losis. To be assured that the man leaving the service carried these in-
structions away with him as he did his mihtary certificate. Resolution
of Neisser, Gauchcr-Judassohn: It was desirable that a guarantee be
made, to each patient suffering from venereal diseases, of gratuitous treat-
ment, to the largest possible extent. It was necessary to see that all
factors unfavorable to venereal patients should be abolished from hos-
pitals and consultations. It was necessary to see that in public institu-
tions the treatment respected the medical secret and the shame of the
patients. Resolution of Minod: The most important and the most effi-
cacious means to employ to combat the diffusion of venereal diseases con-
sisted in the dissemination to as great extent as possible of the knowl-
edge relative to the very grave dangers, and to the importance of these
diseases. It was necessary especially to teach young men that not only
were chastity and continence not harmful, but that these virtues were
the most valuable from the medical standpoint. Resolution of San-
tiliquido : Whereas, the different statistics ought to be in a condition to be
compared: (1) It was necessary to establish statistics on a uniform
basis. (2) It was necessary to submit the task of their compilation to an
international bureau. (3) The President of the International Bureau
ought to transmit these propositions that had been submitted to it to the
various governments and should take their advice on the formation of
this bureau and on the subsidies. Resolution of Franck: The Conference
should issue the resolution that the problem of rational and progressive
education of the questions of intersexual order, from the hygienic and
moral point of view, should be brought before the institutions for the
education of the young in all degrees. A committee was appointed to
determine the preliminaries for the compilation of a treatise, based upon
already existing monographs and larger works, which might serve as a
tract for the instruction of the general public regarding the dangers of
venereal disease, the means of prevention of the same, and the necessity
of immediate and persistent treatment. The committee was also in-
structed to devise means for the popularization of such a work, for its
translation into the principal languages, and for its general distribution
in all countries of the civilized world."

Llidwig Weiss^ concludes a paper on venereal prophylaxis as follows:
"Prostitution is the main source for venereal diseases. Its suppression
during the present moral evolution of the race is impossible. Moral
regulation of vice solely is a desirable ideal, but impossible of realization.
Reglementation as practised in continental countries is impracticable
here on constitutional grounds and on the ground of its limited hygienic
value. Moral efforts (social, economic, educative, and legislative) com-
bined with sanitary measures are promising of results. As sanitary
efforts under existing circumstances can step in only after infection has
already taken place, a liberal supply of hospitals and dispensaries with
free treatment must be provided for purposes of treating and sterilizing
sources of contagion. Individual prophylaxis is at present the only
feasible means of preventing in part the spread of venereal diseases. It
^ Jour. Am. Med. Assoc, Jan. 24, 1903.

VENEREAL DISEASES. lOt

is the duty of every physician to recommend it. The Section on Cuta-
neous Medicine and Surgery of the American Medical Association should
strive to bring about a uniform nomenclature, and the Association should
institute through this Section a propaganda of action in the different
States; to bring about under its auspices a national meeting similar to the
International Conference for the Prophylaxis of Venereal Diseases which
meets again this year in Brussels."

Ferd. C. Valentine^ summarizes an article on the educational limita-
tion of venereal diseases as follows: "(A) Preliminary education: (1)
Sufficient of the physiology and pathology of the genitourinary apparatus
should be taught, in institutions for higher education, to convey to stu-
dents the dangers of genitourinary diseases to themselves and to others.
(2) Similar instruction should be given in schools attended by boys at
the age of puberty. (3) No man who has ever had gonorrhea should be
allowed to marry until it is proved by a physician that he cannot infect
his wife. (4) Regular physicians should be elected, by their societies, to
deliver evening lectures to the public on genitourinary diseases. (5)
Every father should be taught to warn his sons of the dangers of genito-
urinary diseases. When from incompetence or delicacy the father cannot
or does not wish to do this, the family physician should discharge that
duty. (6) Every medical society should elect its most competent mem-
ber to write at least one article on the subject, worded for laymen's com-
prehension, and to be published under the auspices of the society. That
the essential parts of these suggestions are feasible is proved by the
public teachings established in several institutions, notably, among them,
at Professor Lassar's clinic in Berlin. (B) The segregation of prostitutes
would free reputable neighborhoods from the evil influences, bad example,
demoralization, and infection of this social disease. It would also be of
assistance in the enforcement of the proposed laws, and likewise it would
tend to suppress assignation houses, which are nothing but conveniences
for clandestine prostitutes, the worst disseminators of venereal diseases.
(C) Periodic examination: The concentration of prostitutes in districts
set aside for them would facilitate examination as to their ability to
infect others. Such examinations should be made ever}^ day, as an
approach to effective work. That it cannot be more than an approach
has been elsewhere discussed. (D) Circularization would serve as a si)ecies
of postgraduate education, which would warn men against the dangers
they incur."

Follen Cabot^ presented to the Harvard Medical Society of New
York city printed slips containing instructions for patients suffering
from venereal diseases. These instructions are as follows: "Instruc-
tions to those Imving gonorrhea or 'clap': Gonorrhea or ' clap' is a local con-
tagious disease which requires treatment until the physician pronounces
you cured. To avoid infecting others and to prevent complications, as
bubo, stricture, swollen testicles, etc., the following rules should be ob-
served : (1) During the first few weeks walking should be limited. When
the discharge is profuse, you should keep off your feet as much as pos-

1 Med. Rec, Nov. 8, 1902. ^ Med. News, Jan. 3, 1903.

258 GENERAL SURGERY.

sible. (2) Do not use alcohol in any form, as it always prolongs the dis-
ease. Drink milk, tea, vichy, or seltzer and from 6 to 8 glasses of water
during the day. (3) Avoid all sexual relations until you have been pro-
nounced cured by your physician, as the disease may be given to a woman
even after the discharge has apparently ceased. When it is present you
should avoid sexual excitement, as erections always aggravate the dis-
ease. (4) Always wash the hands after handling the parts. The dis-
charge if carried to the eyes will cause blindness. (5) Sleep alone and
be sure that no one uses any of your toilet articles, particularly towels
and wash cloths. (6) Never lend your syringe to any one and as soon
as you are well destroy it. (7) Be sure that the bowels move every day.
If they are inclined to be constipated take a dose of rochelle salts before
breakfast. (8) Do not use mustard, pepper, horseradish, or stimulating
sauces on your food. Instructions to those suffering from syphilis: Syphilis
is a constitutional disease. It is 'in the blood.' Local remedies and
taking medicine for a few months will not cure you. You must be
treated for 3 years. The effects of this disease are far-reaching, and if
treatment is neglected much trouble and suffering may be caused, not
only to yourself, but to others. The following rules must be observed
during the first year: (1) Sexual intercourse should not be indulged in.
(2) Alcohol in all forms should be avoided as it always aggravates the
disease. (3) Do not smoke or chew tobacco. (4) Sleep alone. (5)
Under no circumstances should any one be allowed to use your toilet
articles, as towels, brushes, combs, razors, shaving-brushes, etc. (6) No
article that has been in your mouth should be used by others, as tooth-
brushes, toothpicks, pencils, pipes, cigars, cigarets, forks, spoons, drink-
ing-cups, etc. (7) You must not kiss any one, especially children. (8)
Brush your teeth night and morning and keep your mouth clean. (9)
If you have bad teeth, have them attended to by a dentist, and be sure
to tell him that you have syphilis, so that he can take necessary precau-
tions and avoid the possibility of infecting others. (10) Acids in food and
drink should be limited."

In discussing the incubation period of gonorrhea in women, G.
Frank Lydston^ states that the disease " may develop : (1) As a discharge
from the cervix, showing a primary infection of the endometrium; (2)
as a metritis without noticeable discharge even from the cervix; (3) as
a pelvic inflammation without preliminary or coincidental discharge of
any kind whatever. In many instances serious pelvic inflammation is
neither preceded nor followed by discharge of any kind. In any case of
possible infection of innocent women it is well to defer judgment until
at least one menstrual period has passed. If the exposure has occurred
within two or three weeks of the preceding period, two periods should be
allowed to pass before an opinion is given. In any case, the question
should not be settled by the appearance or nonappearance of a discharge."

S. T. Rucker^ describes his method of treating inflammatory dis-
eases of the urethra by packing with an antiseptic oiled dressing.
After irrigation with a 1 : 3000 solution of potassium permanganate the

' Intemat. Jour. Surg., March, 1903. ^ Jour. Am. Med. Assoc, Oct. 1, 1902.

VENEREAL DISEASES. 259

penis is grasped with the fingers of one hand and the packer (Fig. 47)
introduced slowly and carefully into the urethra with the other hand.
It is passed back about 4 inches in anterior gonorrhea and back to the
neck of the bladder in posterior gonorrhea and prostatic troubles. The
urethra is then lightly packed with one inch continuous gauze strips, or,

fWl

-3^

Fig. 47. — Backer's instrument for packing tlie uretlira. A, Groove for index and second finger;
B, slide; C, end slightly tapered and curved ; L», edge rounded and smooth (Jour. Am. Med. Assoc, Oct.
1, 1902).

better, a loosely spun cotton cord, saturated with one of the following
solutions :

\i . Iodoform gr. xcv

Balsam of Peru 2 iv

Castor oil q. s. ad 5 iv

Rub iodoform in castor oil, then add balsam of Peru. Or:

R . Ichthyol,

Resorcin, aa gr. xl

Balsam of Peru 5 iv

Castor oil q. s. ad 3 iv

M. Ft. sol.

The instrument is gradually withdrawn as the dressing is pushed through,
and when it emerges from the meatus the cord dressing is clipped with
scissors, leaving about ^ inch of the cord outside of the meatus, which
can be taken between the fingers when the cord is to be removed. A
small piece of cotton is placed over the head of the penis and treatment
is complete. The patient is now instructed to go as long as he possibly
can before urinating, when the cord is slowly removed. The urethra is
packed every day until the discharge ceases, and then on alternate days
for a week. During the intervals the patient uses an injection of pro-
targol.

James MacMunn^ believes that the efficacy of remedies in gonorrhea
is in direct proportion to the extent to which they penetrate into the
tissues. For the purpose of retaining solutions in the urethra he uses
"mechanical fingers which occlude in a self-acting way the urethra where
placed. Their pressure is graduated by the nut a, and they are actuated
by a concealed spring (see Fig. 48). No discomfort whatever follows
their intelligent use. The clamp is pinned to the inside of the inside
shirt, and the patient rests or goes about with that quantity of fluid,
and of proper strength which he finds not uncomfortable, distending his
anterior urethra."

H. M. Christian,^ from a clinical study of argyrol in the treatment
of gonorrhea, concludes: "(1) That it is absolutely free from any
irritating properties, solutions as high as 5 % causing no discomfort. (2)
That the gonococci on and beneath the urethral mucous membrane are

' Lancet, April 18, 1903. ♦ Med. Rec, Sept. 27, 1902.

260

GENERAL SURGERY.

rapidly destroyed. (3) The amount of urethral discharge is in a majority
of cases at once lessened in a marked degree. (4) The actual duration of
the disease is shorter than is obtained by the use of any other silver
salt. In our cases 38 were cured in from 2 to 4 weeks." R. 0. Kevin*
is convinced of the value of argyrol in the treatment of gonorrhea. In
the acute cases a solution of from 1 % to 5 % is used. In chronic cases
the drug may be used of a strength of 20 %. G. K. Swinburne^ states
that argyrol contains nearly 30 % of silver. It possesses but one draw-
back, and that is its staining properties. "This drug has decided gonococ-
cidal powers ; it has a decided effect in reducing and allaying inflammation
of the disease; it can be used safely in almost any strength and at any
stage of the disease; the injection can be repeated almost as frequently

as the fancy of the physician dictates;
I have not seen any unpleasant symp-
toms due to the use of the drug, and
I believe it to be one of the most
valuable remedies given to the profes-
sion in recent years."

Orville Horwitz^ reports an exten-
sive inquiry into the value of the
irrigation method as a means of
aborting and treating acute specific
urethritis, and presents the views of
a large number of genitourinary sur-
geons. His conclusions are as follows:

(1) The irrigation method of treatment
will not abort acute specific urethritis.

(2) It will hasten the terminal stage
of the disease, which is prolonged and
difficillt to cure. (3) Chronic urethritis
and involvement of the deep sexual
organs are common sequences. (4) In
many instances, in order to effect a
cure in the terminal stage of the dis-
ease, the irrigations must be discon-
tinued and other methods of treatment
employed. (5) Irrigation should not

be employed in the acute stage of specific urethritis. (6) Irrigation of
the deep urethra by means of hydrostatic pressure is injurious in the
majority of cases of acute gonorrhea, and is conducive to the develop-
ment of comphcations. (7) Little or no progress has been made in the
treatment of acute urethritis, either in aborting the disease, lessening its
duration, or preventing complication.

H. G. Klotz* writes of the satisfactory results which he has obtained
with albargin in the treatment of gonorrhea. The drug may be used
in solutions as strong as 5 % without injury to the urethra. "Albargin

Fig. 48. — MacMuiin's instiuineiit for re-
taining solutions in the urethra (Luncet,
April 18, 1903).

1 Med. Rec, June 6, 1903.
3 Therap. Gaz., March, 1903.

2 Med. Rec, Oct. 11, 1902.
* Med. News, Nov. 29, 1902.

VENEREAL DISEASES.

261

is a compound of silver nitrate with gelatose, a product of the dissociation
of gelatin; it contains 15 % of silver nitrate or with 63.5 % silver for
the nitrate, 9.52 % of silver against 8.3 % in protargol. Albargin forms
a yellowish or light fawn-colored, rather gross powder of very light weight,
is slightly sticky, and dissolves easily in water of any temperature. It is
clean to handle, does not stain the fingers at all and the clothes but
very little, it is not expensive, not only on account of the actual price
being lower, but also because it is generally prescribed in comparatively
much smaller quantities."

W. W. Townserld^ describes an insufflator for the treatment of
chronic anterior urethritis. "The instrument consists (see Fig. 49) of
a (D) glass rod, 22 French, bent at right angles, perforated by a canal
B bored through it from end E to air chamber C, and with another
canal A extending from air chamber C and having an outlet at Al. The

Fig. 49.— The Townsend duplex insufiiator. Powder container attaciics at E (Amer. Med., June 20,

1903).

air chamber C, as will be seen, is perforated at its proximal end by the
openings of the canals A and B, and its distal end is open except when
in the urethra, at which time the urethral walls fall over the end, thus
making a closed air chamber. When this insufflator tube is attached to
a powder container at E and the powder forced, it will follow the direction
of the arrows, and reaching the air chamber C will become agitated and
a portion will adhere to the mucous membrane of the urethral walls. As
the powder is forced from the container into the insufflator, the tube
is gradually withdrawn, and the mucous membrane of the urethra is
consequently covered with the medicament used." Townsend insuflflates
powders of zinc, copper, or aristol 3 or 4 times a week.

Ferd. C. Valentine^ concludes a paper on the morning drop as fol-
> Amer. Merl., June 20, 1903. ^ Med. News, July 19, 1902.

262 GENERAL SURGERY.

lows: "(1) The morning drop is ordinarily a symptom of local or con-
stitutional disturbance. (2) When it is not due to either of these, it is
maintained by overtreatment or artificial sexual irritation. (3) Accord-
ing to its cause, it must be treated; locally, if due to a local cause, and
constitutionally, if faulty metabolism or food irritation be the provoking
element; if sexual irritation be the cause, this must be stopped. (4) If
the morning drop be due to overtreatment, it must be discontinued. (5)
The cause of the morning drop is not difficult to ascertain. (6) Its treat-
ment is within the sphere of the general practitioner."

From a study of the relation of gonorrhea to tuberculosis of the
genitourinary tract Daniel N. Eisendrath^ draws the following conclu-
sions : " (1) In patients suffering from an acute gonorrhea there may be
an almost imperceptible transition into a malignant type of tuberculosis.
(2) Subacute or chronic gonorrhea may mask the presence of a tubercu-
losis. That these, as well as the acute form, may act as predisposing,
and even at times as exciting, causes of tuberculosis. (3) In patients
who show evidence of local complications of gonorrhea, such as prosta-
titis, vesiculitis, cystitis or epididymitis, one should always bear in mind
the possibility of tuberculosis, and examine the urine for tubercle baciUi,
if antigonorrheal treatment causes no improvement. (4) In patients
with marked tuberculous history an attack of gonorrhea should be care-
fully watched, and the prognosis be guarded. (5) Gonorrhea, both in the
male and female, often prepares the soil for a later invasion of the tubercle
bacillus."

DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

Francesco Durante,^ of Rome, makes certain observations on cere-
bral localizations, from which the following conclusions are drawn:
" (1) Lesions, especially those determined by neoplasms, of the frontal
lobes are nearly always accompanied by very grave phenomena of altered
intelligence; which proves that the frontal lobes, and particularly the
prefrontal, must be considered as the seat of the most elevated functions
of the mind. (2) The cortical center for hearing is situated in the
temporal lobes, each center is in relation with both the auditory nerves,
and the direct auditory bundle must be very much less active and smaller
than the crossed auditory bundle. (3) The site of the center for general
sensibility and for muscular sense is in the parietal lobes, and disturbances
of general sensibility and of the muscular sense may occur in the limbs
independently of any disturbance of motility whatsoever. (4) For the
solution of various problems concerning the functions of the several
regions of the human brain, operative surgery and pathologic anatomy
are more useful than experimental physiology, which has animals only
at its disposal ; the functional arrangement of the brains of such animals
has some analogy with that of man, but certainly cannot be compared
with it in every respect."

The subject of trephining for brain tumors is presented by Ranso-
' Chicago Med. Recorder, Dec. 15, 1902. ^ Brit. Med. Jour., Dec. 13, 1902.

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 263

hoff/ who reports two successful cases. The first case was operated
upon 9 years ago and was reported by Hoppe. The author has per-
formed 8 operations for supposed neoplasm, and but 2 of these operations
were successful. The first patient continues well except for a slight
paresis of the left extremities and epileptic seizures at intervals of 3
or 4 months. The patient was 32 years old at the time of operation;
the tumor was the size of a hen's egg, and situated in the psychomotor
area. There is no evidence of a return of the growth. The second
patient was operated upon the first time on February 11, 1902. The
dura was exposed and was normal in appearance, but devoid of pulsation.
The opening in the skull was 3^ inches long and 3 inches wide. Tem-
porary sutures were introduced and a second operation done 3 days later.
At this time the dura pulsated feebly; it was opened, but no tumor
found. The patient was then put in the sitting posture, which permitted
a much freer palpation of the brain. The tumor was found half an
inch below the surface in the ascending frontal convolution and was
easily removed. A shght paraphasia and inability, except with great
effort, to move the right hand and forearm followed the operation. The
tumor in this case was a solitary tubercle. .Three and a half months
had elapsed at the time of the report, since the operation: the patient
had gained 15 pounds and had had no convulsions of any kind; there
remained, however, a decided weakness of the flexors of the thumb, the
index and the middle fingers. In this case the general symptoms of
brain tumor were absent (that is, headache, choked discs, and vomiting).
The symptoms presented were altogether focal. This is explained by
the fact that when the tumor was removed it displaced 12 gm. of water,
a mass pressure to which the brain accommodates itself. With the
development of symptoms of intracranial pressure the value of focal
symptoms decreases. This explains the frequency of failure to find a
tumor when seemingly unmistakable localizing symptoms are present.
Against 104 collected cases in which operations were successful as to
finding and removing a growth, there are 157 in which the operation
was unsuccessful in one or the other respect. Ransohoff refers to the
great advantage obtained by placing the patient in a sitting posture,
this position causing the brain to recede to such an extent that palpation
is permitted far beyond the limits of the cranial opening. In doing a
two-stage operation the second operation can be done very satisfactorily
under local anesthesia. This plan was successfully followed in the second
case until it became necessary, in order to remove the tumor, to cut
away more bone, when chloroform was administered. Haas has col-
lected 122 operations which were successful as regards the removal of a
tumor, and which presented a mortality of 61 %. The high mortality
is ascribed to shock and hemorrhage. Ransohoff thinks that with the
more general adoption of the two-stage operation this mortality will be
greatly lessened. Tuberculous growths are nearly twice as common in
the brain as any other type. In the cases operated upon, however, this
variety is not so common, being present but 12 times, for instance, in
> Jour. Am. Med. Assoc, Oct. 11, 1902.

264

GENERAL SURGERY.

Haas's 122 cases. Bergmann's dictum that solitar}' tubercle is ordinarily
not suited for operation is believed to be incorrect, a number of cases
having been reported as cured after the removal of tuberculous growths.
[One reason of the very large mortality is that so many cases are operated
on late rather than early. A brain tumor not due to syphihs is a mortal
disease without operation ; hence, if a brief but thorough trial of specific
treatment is not productive of distinct benefit, an operation is indicated
provided the tumor is thought to be in an accessible region. Mills has
demonstrated that an a;-ray picture taken by an expert may show the
tumor. The opening made in the skull should be large. The making of
a large opening does not add materially to the danger; a small opening
may cause us to miss the tumor, and even if we find it the removal
of a large growth through a small opening causes great damage to the
brain. It is well, as Mills advises, to be prepared to close the carotids

temporarily if dangerous
hemorrhage is encoun-
tered. In some cases cer-
tainly the operation should
be done in two stages.]

Chas. K. Mills' dis-
cusses brain tumors from
the neurologic stand-
point, taking as a basis
for his paper his personal
experience in 22 cases in
which operation was per-
formed after a diagnosis
of tumor or cyst had been
made. The author believes
in operations for the re-
moval of brain tumors in
carefully chosen cases even
though the percentage of
failures is high. In almost
every case the outcome
without operation is necessarily fatal, and with more exact localization
and more precise craniocerebral topographic methods and with more
perfect surgical technic the percentage of successes has been and will be
much increased (see Fig. 50). Much is to be hoped for in cases of
fibromas, encapsulated fibrosarcomas, inert gummas, and occasionally in
other forms of neoplasms. Particular attention is paid to the method of
locating brain tumors, the author preferring the Anderson-Makins method.
The causes of failure in operations for brain tumor are enumerated as fol-
lows: (1) Mistakes in localization; (2) lack of exactness in fixing the cranial
areas for operation; (3) excessive hemorrhage; (4) concussion and even
contusion of the brain in osteoplastic operations with chisel and mallet; (5)
prolongation of operations; and (6) the sudden disturbance of the balance
1 Phila. Med. Jour., Nov. 29, 1902.

Fig. 50.— Cranial areas for osteoplastic operations with the
Stellwagen trephine, these areas corresponding to the regions
of the left heraii;erel)rmu, with definite syndromes (Mills, in
Phila. Med. Jour., Nov. 29, 1902).

DISEASES OF THE BRAIN AND XERVOL'S SYSTEM. 265

of pressure in the skull by the removal of large hard tumors. Methods
of locahzation are becoming more and more perfect and mistakes fewer.
Tumors of the cerebellum often present especial difficulties. The ic-ray
is a useful diagnostic measure in certain cases, and the author refers
to several instances in which this means of locating a brain tumor was
proved of value. The exact localization of the tumor and the fixation
of the positions of the various fissures and lobes should not be postponed
until just before the operation. The large osteoplastic operation is the
only one which should be employed for the removal of brain tumors
except when the growth is so located as to render this method inap-
pUcable. Mills thinks very highly of the Stellwagen trephine, and con-
siders it a great improvement over the mallet and chisel. He refers to
several cases in which the flap was made in a short space of time with
this instrument. Unusual difficulties and dangers attend cerebellar or
basal operations for tumors. Still, an operation is justifiable in cases
in which a tumor is probably situated laterally in the cerebellum.
Excessive hemorrhage in several of Mills's cases was the cause of failure
and directly or indirectly the cause of death. It is suggested that the
surgeon should always be prepared to practise compression of the carotids
to control excessive bleeding. In exceptional cases it is believed that the
operation should be done in two stages, as suggested by Horsley and
Macewen. The article closes with a description of a successful operation
by Hearn for a gumma in the motor region. [Hearn and DaCosta each
opened the skull of an adult with the Stellwagen trephine in less than 8
minutes. This is a considerable saving of time over the operation with
the chisel and mallet. Further, the operation does away with forcible
and, we believe, dangerous pounding.]

J. D. Madison^ reports a case of brain tumor occurring in a woman
78 years of age. The rarity of brain tumor at this age is shown by the
fact that in 100 cases collected by Hale White there were only 2 over
70 years of age, and in another 100 cases collected by Mills and Lloyd
there was only 1 case over 70 years of age. The tumor in the case
reported is described as a gliosarcoma containing several cysts. The
growth involved a large portion of the temporal lobe. It reached the
surface only ventrally. It extended to the basal ganglions, but only
slightly involved the lenticular nucleus.

Roughton^ reports a case of cerebellar abscess for which Cunning
operated during the performance of artificial respiration. During the
first 10 days that the patient was under observation his only constant
symptom was an abnormal slowness of the pulse. During this time the
headache, mental slowness, dizziness, vomiting, and tenderness over the
mastoid all improved. Later these symptoms, and also a subnormal
temperature, returned. The only localizing symptoms were an exag-
gerated knee-jerk on the left side and inabihty to lie on the right 'side.
The former turned out to be accurate, but the latter did not. Under
chloroform anesthesia the pulse rose from 42 to 120. Soon after the
administration of chloroform the patient ceased to breathe, and for 80

> Am. Jour, of Insanity, Jan., 1903. ^ Lancet, July 26, 1902.

18 S

266 GENERAL SURGERY.

minutes artificial respiration was kept up, during which time Cunning
explored first the right hemisphere of the cerebellum and then the left,
evacuating from the latter a quantity of foul-smelling pus. The moment
the pus was evacuated there was return of spontaneous respiration. Con-
sciousness returned 3 hours after the operation, and the patient then
developed convulsive attacks and died 3 hours later, or 6 hours after the
performance of the operation,

J. Grant Andrew^ reports a case in many respects similar to that
just described by Roughton. The condition was one of cerebellar
abscess following middle-ear disease in which the abscess was not
drained, although an exploration of the cerebellum was made, and it is
thought from postmortem findings that the needle entered the abscess
cavity but became occluded so that the pus could not flow. Respiration
in this case failed before the operation was commenced and was not re-
established for 80 minutes, during which time artificial respiration was
continuously performed. After the restoration of respiration the opera-
tion was performed. The patient died about 30 hours after the operation.

McCaskey and Porter^ report a case of brain abscess due to latent
typhoid infection and situated in the motor area. The abscess was
drained and the patient did well until the eighth day, when he suddenly
complained of feeling very ill, and became, palhd, and developed labored
respiration and tumultuous heart action. There was no change in the
paralysis which followed the operation nor was there any other evidence
of further cerebral involvement. Death ensued, and it is thought that
it was due to an acute cardiac lesion, very possibly relating to the septic
process in the brain, probably a septic endocarditis with cardiac atony
from toxemia.

In discussing thrombosis of the lateral sinus, Ballance^ states that
before or during operation the surgeon should decide whether his patient
is suffering from an acute systemic infection or from a systemic disturb-
ance depending upon a local process. Operation upon the vein should
be done: (1) in acute pyemia and acute septicemia, whether the sinus is
occupied by a clot or by fluid blood; (2) if the sinus is gangrenous or its
contents are putrefying, unless it is quite clear that the sinus is blocked
on both sides by noninfected clot, and this is rare; (3) if it is known
or suspected that the blood in the jugular bulb is in part or wholly
clotted; and (4) if the jugular vein is thrombosed. When it has been
decided to deal with the vein before beginning to operate, the operation
on the vein should precede that on the temporal bone. Ablation of the
vein is better than ligation. After dealing with the vein the sinus should
be thoroughly exposed for a distance of at least f of an inch beyond
the area of inflammatory change. The freest exposure of the sinus is
required. The method of curetting away putrefying clot through an
opening in the sinus is one which should be aboUshed from surgery.
The sinus should be slit up, if necessary, from torcula to bulb. The cases
demanding operation and the procedure to be carried out in each par-

' Brit. Med. Jour., May 2, 1903. ^ Jour. Am. Med. Assoc, May 2, 1903.

3 Lancet, Sept. 20, 1902.

DISEASES OP THE BRAIN AND NERVOUS SYSTEM. 267

ticular case require the greatest surgical judgment. The surgical treat-
ment should be the same whether the condition is chronic or acute.

Eugene Wasdin/ of the Marine Hospital Service, reports an instructive
case of gangrenous destruction of the pituitary body with disintegra-
tion of the blood following a fracture of the sphenoid bone and subse-
quent infection. The author was unable to understand the condition
in this case until he read Sajous's article on the internal secretions. The
patient was a man aged 24 years who was admitted to the hospital for
a fracture of the ramus of the jaw. Great care was taken to prevent
infection and the patient did well for some days. He presented no
symptoms indicating a possible fracture of the base of his skull until
the thirteenth day, when he developed a delicate yellowing of the skin
of the face and body, and some discoloration and edema of the cheek.
As there was great pain in the fracture on the tenth day, the soft tissues
over it were divided but no pus was found. On the sixteenth day the
bronzing of the skin was much more marked, there was nothing to indicate
an implication of the liver, and the edema and discoloration about the
exit of the right infraorbital foramen were distinct. The spleen later
became tender and a few small skin extravasations developed which in-
creased both in number and size. On the nineteenth day there was
marked exopthalmus with edema of the conjunctiva. Repeated exam-
inations of the blood were made. The hemoglobin was below 50 % and
marked disintegration was present. A diagnosis of fracture of the sphe-
noid was made. The patient died and at the autopsy the' pituitary
body was found to be gangrenous; the process also involved all the
contents of the sella turcica. The middle and posterior clinoid processes
were necrotic. There was a dark green mass near the carotid opening
of the petrous bone involving the gasserian ganglion. Cultures were
taken from various organs, but all proved sterile save those from the
pituitary mass and one from the liver. The former culture showed a
short thin rod-like bacterium which grew more readily in air than with-
out oxygen. The culture from the liver was the colon bacillus.

Coutts^ reports a case of acute ependymitis occurring in an infant
3 months old. The condition was described as one of postbasal menin-
gitis. During the 6 weeks that the child was ill it was necessary to
feed it through a nasal tube. Convulsions frequently occurred during
the illness. The anterior fontanel bulged distinctly, and through it a
futile attempt was made to remove fluid from the lateral ventricle.
Upon postmortem examination the lateral ventricles were found distended
with offensive pus, and the foramen of Majendie appeared to be com-
pletely blocked. There was no macroscopic dilation of the central canal of
the spinal cord. The bacteriologist is doubtful whether a bacterium which
was found was a variety of the pneumococcus. Coutts believes that this
case was one of primary acute inflammation of the ventricular ependyma.
It has always been, as it was in this case, impossible to diagnosticate
the condition. The onset of the symptoms was much more severe and
persistent than in an ordinary case of postbasal meningitis. The
> Phila. Med. Jour., March 7, 1903. ^ Lancet, April 25, 1903.

268 GENERAL SURGERY.

temperature also toward the end of the third week began to rise, while in
most cases of postbasal meningitis it has by that time reached normal
or fallen below it.

Sheild and Shaw^ report an interesting case of linear fracture of
the skull. In this patient symptoms of early general paralysis of the
insane developed. The patient was a healthy man 30 years of age
who 3 months after sustaining a scalp wound in the left frontal region
developed a peculiar mental condition. At the time of the injury no
fracture was found and the man was confined to bed for a short time
because of concussion. He was perfectly well for some weeks, but about
a month after the injury commenced to suffer pain in the head, and
developed loss of memory, and sudden and violent outbursts of passion.
These symptoms continued until the patient reached a mental condition
of dementia. There being no history of alcoholic excess or of syphilis,
the symptoms appeared to be directly attributable to the injury, Shaw
trephined the skull at the point of injury and found a healed linear
fracture with a depression of the inner plate. Immediately after the
operation there was a most marked improvement in the patient's con-
dition. Whereas before the operation he could not read or sign his
name, a short time after the operation he could read as well as ever
and walk without difficulty. He ultimately recovered.

BuUard,^ after considering the indications for operations in head
injuries, reaches the following conclusions: "(1) Operate in all cases of
compound depressed and compound comminuted fracture of the cranium.
It is usually advisable to operate on any compound fracture. (2) Simple
fracture of the cranium without symptoms does not, as a rule, demand
operation. (3) Absence of unconsciousness does not contraindicate
operation. The degree of unconsciousness is not in all cases propor-
tionate to the severity of the injury. (4) The duration of unconscious-
ness is important, and when it lasts more than 24 hours, — no other cause
than the injury being present, — operation should be considered. (5)
Marked rise of temperature after uncomplicated head injury suggests
serious injury to the brain. It is not necessarily an indication for opera-
tion. A subnormal temperature without other symptoms has no special
significance. When accompanied by unconsciousness and lasting 24
hours or more it suggests edema of the brain or intracranial hemorrhage.
(6) Severe pain in the head continuing for some time after a head injury,
if organic, indicates operation. Pain in the head following injury may,
however, be functional and due to general nervous conditions. (7) Con-
vulsions, when clonic and diffuse, suggest epilepsy or other complication.
When localized they are of value as indicating the side of the brain on
which the lesion producing them is situated. Taken in connection with
other symptoms their presence usually favors operation. (8) The pres-
ence of paralysis of the limbs in adults, if marked, usually indicates
immediate operation. Partial hemiplegias and paralysis of the limbs
may occur in edema of the brain following injuries. (9) The above
statements refer to adults only. In children paralyses are more apt to
pass away and the indication for operation is not so decided."

' Lancet, Feb. 14, 1903. ^ Boston M. and S. Jour., July 31, 1902.

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 269

E, W. Dwight^ presents a discussion of the indications for opera-
tions in head injuries based upon a collection of 650 cases in which
a fracture of the skull was demonstrated either by autopsy or operation.
A study of these cases shows the great variability of symptoms in the
various lesions of the brain. So variable in fact are these symptoms that
the author is only able to formulate a guide as to whether or not operation
should be undertaken. He concludes as follows: "Given positive signs
of intracranial disturbance following an accident which might well cause
such a condition, but without definite signs of fracture, I should explore.
Given a case in which there is probable evidence of fracture, and a
probabiUty of interference with the brain, I should operate. I have
never seen fatal or serious results follow trephining by skilful hands, even
when 2 or 3 openings in the skull were made, and I have seen many
lives saved by exploratory operations in this very large class of doubtful
head injuries."

Newman^ gives a report of 3 cases of motor aphasia from head
injury, in 2 of which operation was done and recovery followed. In
the first case reported the patient had a fall from a bicycle followed
by unconsciousness and incontinence of urine, and, after 3 days, by
epileptiform seizures which increased in frequency. Consciousness re-
turned and showed the presence of motor aphasia. On the ninth day
after the accident palsy of the right leg and arm began to develop,
and on the tenth day it was complete. The epileptiform seizures at this
time were also increasing in frequency. The patient was trephined over
the motor area, and when the dura was opened about an ounce of blood
escaped. Drainage was established and rapid recovery ensued. The
operation was followed by immediate cessation of the epileptiform
attacks and a rapid recovery of motion in the paralyzed leg. Speech
was restored in 2 weeks. The second case was one of compound fracture
of the skull. The symptoms presented were those of concussion with
complete unconsciousness. On the fourth day slight twitchings of the
right arm and leg were noticed and the patient develoj^ed an epileptiform
attack; no paralysis was present. The patient was trephined on the
fifth day, unconsciousness being so complete that no anesthetic was
required. Epileptiform attacks disappeared after the operation, but
upon the return of consciousness the man was found to be aphasic.
Complete recovery had taken place by the twenty-eighth day after opera-
tion. The third case was one of a man who was injiu-ed by a fall from
a bicycle. The fall was followed by complete unconsciousness and in-
continence of urine. The patient was unconscious 11 days and the
incontinence of urine continued for a month. There were no epileptiform
attacks and there was no paralysis of the limbs. Evidence of motor
aphasia was shown on the eleventh day after the injury. At the end
of 4 months the man had recovered from the aphasia.

Gushing,^ in his Mutter lecture before the College of Physicians of
Philadelphia, makes some experimental and clinical observations

' Boston M. and S. Jour., July 31, 1902. ' Lancet, July 26, 1902.

3 Am. Jour. Med. Sci., Sept., 1902.

270 GENERAL SURGERY.

concerning the states of increased intracranial tension. The sub-
ject is dealt with at great length and most minutely, the author showing
beyond a doubt that as long as the vasomotor system maintains the
blood-pressure at a level higher than the intracranial tension^ so as to
keep the respiratory center nourished, respiration will continue. If, on
the contrary, it falls below the intracranial tension the patient succumbs
with a low blood-pressure and a rapid heart action. At this time if
artificial respiration is employed the patient may live for hours. Gushing
closes his address by dwelling with emphasis upon certain points: "In
the first place, the venous stasis, which becomes apparent on but a
moderate increase of tension, fortunately gives early evidence of itself
in the eye-grounds except in those cases of local compression, in posterior
basic meninges, for example, so remotely situated that the compression
effects are not readily transmitted as far as the cavernous sinus and
ophthalmic veins. Furthermore, local pathologic processes, such as are
confined to the hemispheres, may be responsible for local circulatory
disturbances sufficient to cause a cessation of function of a large part
of the forebrain without leading in any way to a corresponding implica-
tion of the medulla. When, however, the local process is in the near
proximity of, or, if remote, when its effects are so far-reaching that the
vital centers of the bulb are compromised, the one symptom which with
regularity is called forth, and which betokens a serious alteration in the
local circulation, is a persisting rise in blood-pressure, which may or may
not be associated with a pronounced vagus pulse, with rhythmic altera-
tions in blood-pressure and with a retardation of periodicities of the
respiration approaching a Cheyne-Stokes t5rpe. The first and minor
symptoms of compression are found in association with varying degrees
of intracranial venous stasis, the major symptoms of 'Himdruck,' with
an approaching capillary anemia of the medulla."

A later contribution^ from the same author on the same subject,
which is called a sequel to the Mutter lecture, is summarized as follows :
"Varying degrees of rapid increase in intracranial tension produce cor-
responding disturbances in the intracranial circulation. To these circu-
latory disturbances the symptoms of compression are solely due. The
condition known as acute cerebral compression may be conveniently
subdivided into 4 stages, dependent upon the degree of circulatory altera-
tion which has been reached. Each of the stages has its own more or
less characteristic symptom-complex. The major or underlying symp-
toms originate in the centers situated in the medulla, and are called out
only when the degree of intracranial tension begins to approach the arterial
tension so that anemia is threatened. A circulatory condition in the
medulla which borders upon anemia has the effect of stimulating the
vasomotor center. Thus, a rise in blood-pressure is occasioned which
restores the local circulation. The extent of this rise may be taken as
an indication of the degree of advancement of the compression. Beyond
a certain point, however, this reaction cannot take place. The vasomotor
center under these circumstances fails, and the respiratory efforts cease
^ Am. Jour. Med. Sci., June, 1903.

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 271

entirely. In conjunction with other symptoms, a progressive increase in
arterial pressure or a high degree of the same, which has been already
reached, or a pressure which exhibits from moment to moment great
alterations in level may be taken as a certain indication of the advisability
of early operative intervention. In case there are localizable symptoms
the site of trepanation is plainly indicated. In case of generalized com-
pression from widespread hemorrhage when there are no localizing indi-
cations, the intracranial tension should be reheved by the elevation of
a large osteoplastic flap from one hemisphere or the other nith a cor-
responding opening in the dura."

Frederic S. Dennis^ discusses the indications for operative inter-
ference in intracranial tension, illustrating his remarks with a number
of, cases. The former classification of concussion and compression of the
brain is no longer sufficient. Concussion has to do with the fluid equilib-
rium and is usually of momentary duration. If it is severe, spasm of
the vasomotor system Occurs and the condition simulates surgical shock.
Dennis has observed that the more highly the nei'vous system is devel-
oped, the more sensitive the patient is; and that the more highly the
intellectual faculties are cultivated, the greater the concussion following
head injury. Dennis refers to a unique case of a child who fell to the
pavement from a third story, suffering an indented fracture of the parietal
bone. The compression was sufficient to produce hemiplegia of the
opposite side and deep coma. Dennis so manipulated the sides of the
head as to cause the indentation entirely to disappear. As soon as the
bone sprung back to its normal position the child passed at once from
deep coma into complete consciousness and the hemiplegia instantly
disappeared. Contusion is present in nearly every head injury to a
greater or less degree. Laceration is an important etiologic factor in
the production of intracranial tension. The hemorrhages are generally
so profuse as to disorganize the brain tissue completely. Laceration may
cause death in itself, whereas contusion produces death only secondarily,
and then from inflammatory changes. Cerebral compression means the
application of any force acting from without upon a part of or upon
the entire brain. These forces may be in the form of blood, bone, pus,
or a foreign body. Cerebral pressure, on the contrary, means the apph-
cation of any force acting from within the brain, and is seen in cases
of traumatic hydrocephalus, in diffuse meningitis, and in extravasations
of blood in the subdural spaces, etc. Several interesting cases of cerebral
pressure are described. In one of these cases the intracranial tension
was so great that the clot, which was about the size of an English walnut,
escaped from the ventricle through the opening made in the cortex, dura,
and skull, and shot into the air some feet above the operating table.
Intracranial hemorrhage is one of the most frequent causes of intracranial
pressure. The indications in this condition are in some cases perfectly
clear, while in others they are not sufficient to warrant intervention.
Deep coma following a head injury calls for immediate operation. If
the coma is not profound, but the symptoms of intracranial pressure are
* Med. News, March 21, 1903.

272 GENERAL SURGERY.

on the increase, trephining should be done. If coma is not present, if
the blood-pressure is not increasing, if the leukocytes are not rising, if
the red blood-cells are not increasing, if the urine is not becoming gly-
cosuric, and if the cephalalgia is not increasing, operation is not indicated.
If these symptoms having been stationary begin to increase, operation
is called for.

H. P. Frost^ makes a final report on a case of extensive head injury
which for the past 40 years has interested the medical profession.
The case is that of a man who at 23 years of age received an injury
which tore from the skull the entire parietal and a portion of the squamous
and frontal bones. These portions of bone were torn entirely free and
shown to the physician when he first saw the patient. The case was
first reported by Rutherford,^ of Harrisburg, Pa. The patient was suffer-
ing but slightly from shock, he sat up while the wound was being dressed,
and subsequently changed his clothes without assistance. His mind
was clear and there were no symptoms of concussion. The wound
suppurated extensively, but ultimately healed, and the patient returned
to his work. The next report of the case was made in the "Buffalo
Medical and Surgical Journal,"^ when the patient was in vigorous health
and suffering no inconvenience from the injury except a sense of fulness
in the head when he stooped or exerted himself actively. Further reports
of the case were made by Gray* and by Bergtold.^ In this last report
the patient was described as suffering from a paralysis of the left leg
and arm and right side of the face. This condition had begun with an
unsteadiness of gait 26 years after the injury. Thirteen years after the
development of the paralysis the patient came under Frost's care in the
Buffalo State Hospital for the Insane. He was quite helpless and his
mental faculties were markedly affected. These symptoms increased,
and he finally died. At the autopsy the condition of the skull described
by Rutherford was confirmed and a peculiar condition of degeneration
of the brain was revealed. The superficial area of that region of the
corona radiata supplied by the middle cerebral artery had degenerated
and disappeared, while the cortex overlying this area, although eroded
from beneath in some spots and shrunken considerably from its normal
thickness, had continued to receive sufficient nourishment to maintain
its particular integrity to an extent which prevented any indication of
the degenerated condition on inspection of the surface. It is not believed
that at the time of the injury the brain suffered a degree of laceration
or contusion sufficient to set up an encephalitis and thus lead to this
degeneration and loss of substance — the entire absence of all symptoms
of such damage to the brain having been noted. Furthermore, the
paralysis, if dependent upon a lesion produced at that time, would not
have delayed its appearance for 26 years. Neither is a possible infection
from the suppurating wound accepted as the cause of this condition.
This would have declared itself clinically; it would not have spared the

' Am. Jour, of Insanity, April, 1903. ' Phila. M. and S. Reporter, Sept., 1857.
3 October, 1873. * Am. Jour, of Insanity, April, 1876.

* Med. Press of Western New York, vol. iii, 1888.

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 273

cortex; it would have caused adhesion of the meninges; and, again, the
hemiplegia resulting would have been manifest directly.

The surgical treatment of hemorrhagic pachymeningitis is dealt
with by John C. Munro/ who reports 11 cases of this condition, 5 of
which were operated upon and 1 of which recovered after operation.
From a study of these cases the following conclusions are reached: "(1)
Hemorrhagic pachymeningitis is found in the insane and in infants, but
for the most part in men not insane after middle life. (2) Alcohol,
syphilis, acute and wasting diseases, and trauma apparently bear some
causative relation. (3) The symptoms are those of diffuse subdural
hemorrhage, coming on slowly, producing mental irritation, spasm and
rigidity of the extremities, convulsions, and, later, paralysis, the sequence
being more or less irregular. (4) The cranial nerves are not liable to be
affected. (5) The treatment is surgical, and should be instituted as
early in the disease as possible. (6) Without operative relief in cases
with pressure symptoms the prognosis is practically hopeless. Early
operation is not serious and gives the best chance for recovery."

Roswell Park,^ after an interesting discussion of the surgical treat-
ment of epilepsy, reaches the following conclusions: "(1) Epilepsy is
the last disease to which surgical measures should be indiscriminately
applied. In judiciously selected cases, radical operations of various
kinds, suited to the individual needs of each case, have given far more
satisfactory results than has nonoperative or medicinal treatment. (2)
Every case must be studied as a problem by itself. The only general
laws applying are those regarding the removal of peripheral or local
foci of irritation and the destruction of paths of conduction which convey
disturbing impulses. In each case we must decide as to the operative
method by which we may best meet these indications. (3) In order to
attain the best results patients should be seen early. It would be well
to have every epileptic carefully studied by an accomplished surgeon,
who should review the case with a view to the possibility of surgical
intervention. (4) Operation, when indicated and undertaken, should be
regarded as a first measure to be followed, and often preceded, by others
looking to a correction of all faults of diet, of elimination, etc. Long-
continued attention to these matters is the price of eventual success. (5)
In those cases characterized by blanching of the face, when seizures can
be warded off or mitigated by prompt use of anwl nitrite, we may well
consider the propriety of an exsection of the cervical sympathetic."

Schaefer^ describes a new instrument to protect the brain while
doing craniotomy. The objection to the use of the Gigli saw is the
danger of injuring the brain and its membranes. The instrument devised
by the author consists of a flat, flexible strip of metal which is passed
under the skull after the trephine openings are made, which acts as a
shield to the structure beneath. The Gigli saw is drawn through on top
of this shield by means of a section of watch-spring, which is passed
under the skull with the protector.

' Chicago Med. Recorder, Dec, 1902. ' Amer. Med., Nov. 22, 1902.

3 Jour. Am. Med. Assoc, Jan. 24, 1903.

274

GENERAL SURGERY.

J. Chalmers DaCosta^ describes the use of a new trephine devised
by Stellwagen for the purpose of making an osteoplastic resection
of the skull. In the case operated upon by DaCosta the instrument
proved most satisfactory. The instrument is shown in the accompany-
ing cut. In using the trephine the index-finger is hooked beneath
the finger-guard on the bar, and not extended along the shaft
of the instrument, which is the method employed in using the ordi-
nary trephine. The manner of holding this instrument should be most
particularly observed, as the success of the manipulation largely
depends upon absolutely controlling, at the same time, the saw and the
center-pin. By holding it correctly, the greatest amount of power is
obtained with the least resistance and the sUghtest pressure; thus, the
control and power of the instrument are much increased. Fig. 51 shows
a knife for making the incision through the scalp and periosteum, which

device was suggested by W. J. Hearn.
The employment of this knife shortens
the time required to incise the flap
and expose the bone, and it makes
the scalp incision accurate; this is
necessary when we are going to use
a bone-cutter which moves with ab-
solute accuracy. Furthermore, the
consequent cicatrix is neater than
when the incision has been made
with a knife. It is difficult or im-
possible to make an absolutely cir-
cular cut with a knife. Even if we
attempted to cut a half-circle, there
would be irregularity and nicking of
the edges Fig. 51 also represents the
saw, the diagram being of the actual
size. A saw of this character and size
has been found to be the most successful. This saw is easily kept in
order, and can be readily sharpened. It must be thick enough to cut
a fairly wide groove; must have long teeth, properly set, pohshed, and
sharpened. A saw of the character shown in the cut will make the bone
section without jamming or clogging with bone dust. The surgeon should
have several saws of different lengths until he becomes accustomed to
the use of the instrument. When the kerf is deep and the skull thick,
a longer saw may be inserted. This would prevent sudden plunging of
the blade into the dura. The shoulder, which is shown in the cut, will
prevent such slipping. Fig. 51 also shows the plate, the pins of which
pass through the scalp around the center of the circle selected for opera-
tion. When they engage the bone, a few Ught blows of the mallet will
cause their entry into the skull." [Since the pubUcation of this paper
the instrument has been used a number of times by Hearn and bj^
DaCosta. With additional experience the time required is shortened.
1 Ann. of Surg., July, 1902.

Fig. 51. — Stellwagen's trephine. Sliows the
saw, the plates, and tlie Icnife and also the
in.struiuent put together and ready for cutting
the bone. (DaCosta, in Ann. of Surg., July,
1902.)

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 275

As a rule, a skull of ordinary thickness is cut through in from 8 to 10
minutes.]

Willard Bartlett^ presents a contribution to the surgical anatomy
of the middle cranial fossa, with special reference to operations for
the removal of the gasserian ganglion. This article shows a careful
study of the middle fossa and is illustrated by a number of cuts showing
the variabihty of the course of the middle meningeal artery. It was
the author's hope in undertaking this study to be able to formulate
some rule for avoiding the middle meningeal artery in making the bone
opening necessary for the removal of the gasserian ganglion. "This is,
however, manifestly impossible in dealing with a structure which is so
irregular that in 100 middle fossas it can hardly be said to foUow identi-
cally the same course in any two. Not possessing an ideal routine, it
is then next in importance that we reahze the possibility of meeting the
artery at almost any point in the temporal fossa — it may be lying upon
the inner surface of the bone, embedded within the same, or, in rare
instances, outside the protecting wall."

A complete review of the subject of excision of the gasserian gan-
glion is presented by Murphy and Neff.* The authors report briefly 10
cases operated upon by the Hartley-Krause method. After speaking
of the anatomy of the fifth nerve, they discuss the pathology, etiology,
symptomatology, and prognosis of tic douloureux. The pathologic
changes are both varied and inconstant and range from slight irregu-
larities in the size and shape of the nerve-cells and fibers to the grosser
lesions, such as tumors, endarteritis of the vessels supplying the ganglion,
and marked connective-tissue hyperplasia. Tumors are rare, Keen being
able to find but two in addition to his own case. After enumerating
the various causes of the conditions and mentioning its greater frequency
in women than in men, the authors state that probably in the great
majority of cases the disease process is ascending, beginning in the
peripheral nerve-filaments and later progressing to and involving the
ganghon. Heredity plays no part in the etiology. Without operation
the condition goes from bad to worse, and finally becomes intolerable.
Castor oil and strychnin are the remedies which accomplish the most
good, but these at best afford only temporary relief. In the later stages
mental derangement is not uncommon. Dana takes a more optimistic
view of the prognosis than that just given. Removal of the ganglion
in the great majority of cases effects an immediate and permanent cure.
The authors present a r^sum^ of the various operations devised for the
relief of tic douloureux. Neurotomy was first suggested by Albinus and
Galen, and was carried out on the infraorbital branch by Schlichting in
1748. Neurectomy was first performed by Abernethy in 1793. The
removal of the gasserian ganglion was first recommended by J. Ewing
Mears in 1884. It was first performed by WiUiam Rose, of London, in
1890. The authors minutely describe the Hartley-Krause operation and
Cushing's operation. The most serious complication in the performance
of intracranial operations is hemorrhage. This may arise from the
* Ann. of Surg., Nov., 1902. ^ Jour. Am. Med. Assoc, Oct. 11 and 18, 1902

276 GENERAL SURGERY.

middle meningeal artery, from the vense Santorini, and from the cavernous
sinus. For venous hemorrhage the tampon is all-sufficient, whether the
blood comes from the venae Santorini or from the sinus. Tampons should
not be used to control bleeding from the middle miningeal artery unless
the tampon is inserted in the foramen and allowed to remain. When
the artery runs in a canal in the bone, the canal wall can be readily
compressed with a punch. . When a tampon is employed to control this
arterial bleeding and is not pushed into the foramen, it only serves to
cover up the point of hemorrhage. The ligation of the external carotid
is legitimate and rational in case of hemorrhage, but it is not thought
necessary as a preliminary measure. The greatest trauma to the brain
has been produced by tampons during and after operation. Sepsis is a
complication which has occasionally arisen after operation. In one of the
cases reported by the authors the patient died of septic meningitis. It
is extremely rare for pain to recur after the removal of the ganghon.
The mortality of the operation is about 15 %. The operation should
always be considered a grave procedure. It is justifiable only when one
of the following indications is present: (1) When all internal medica-
tion and the removal of external irritants have failed. (2) When all
branches of the nerve are involved in the pain; here it should be a pri-
mary operation. (3) When individual branches only are involved and
relief has not been secured by peripheral operation. (4) In cases in
which formerly divisions at the base were indicated.

Frazier and Spiller^ make a further report upon a case of tic dou-
loureux treated by the division of the sensory root of the gasserian
ganglion. (See Year-Book, 1903.) This patient was a man 68 years
of age who was operated upon in October, 1901, and the case was soon
afterward reported. The authors now state that the patient has re-
mained entirely free from pain since the date of operation. The area
of anesthesia remains the same as upon his discharge from the hospital.
The cornea and conjunctiva on the affected side are completely anes-
thetic. The patient's mental condition shows marked improvement
since the operation. The advantages claimed by the authors for this
operation are the avoidance of hemorrhage or injury to adjacent struc-
tures, and reduction in the mortalitj^-rate. Spiller repeats the statement
that the possibility of regeneration of the sensory root after division
is remote. The hope of avoiding ocular complications is one of the
reasons for urging the division of the sensory root. The authors do not
wish to claim more for the operation than is justified by the results of
one successful case. Reference is made to a case of Keen's in which
neither he nor Frazier were able to identify the motor root as distin-
guished from the sensory.

Subdural interposition of rubber tissue without removal of the
gasserian ganglion in operations for tic douloureux is recommended
by Robert Abbe. ^ The failures of the peripheral operations have driven
surgeons into a field of operation of great danger and difficulty. In a
recent article by Lexer, who is a strong advocate of the complete

1 Phila. Med. Jour., Oct. 25, 1902. ^ Ann. of Surg., Jan., 1903.

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 277

removal of the ganglion, it is said that out of 201 cases collected from
the hterature of the past 10 years, 83 % survived the operation and
77.6 %, or 156 of the 201, could be regarded as permanently cured.
"Of the 33 cases of death, 17 died at the close of operation; 11 died
of collapse without regaining consciousness, 7 of meningitis, 1 from
infection from without, in which the patient tore off the bandages in
delirium; 2 of brain tumor, 1 of brain-abscess, 1 of softening of the
temporal lobe, 2 cases of postoperative pneumonia, 1 of heart-failure,
1 of hemorrhage, 1 of uremic coma. Three died without cause of death
reported. In 2 cases, at death, brownish softening of the cortex of the
temporal lobe was found, and in 1 of these edema of the pia mater.
Moreover, he says, in other fatal cases temporal lobe injuries were found
in addition." These statements show the gravity of the operation of
removing the ganglion. Abbe reports a case in which 6 years ago he
made 3 unsuccessful attempts to remove the gasserian ganglion, but in
each instance was obhged to desist because of hemorrhage. At the
third operation he was, however, able to remove a portion of the nerves
at their origin from the gasserian ganghon and interpose between them
and the ganglion a small sheet of sterile rubber tissue. The patient left
the hospital in 3 weeks and has had no pain since. This was 6 years
ago. In discussing the nature of tic he states that pathologically, ex-
cept in cases of bony tumor or disease of the cranial bones like exostosis,
he believes that the disease of the nerve is always located anterior to
the gasserian ganglion. Considering the ability of resected nerves to
regenerate, it is thought reasonable to suppose that in the case reported
the rubber tissue which was used has maintained its integrity and pre-
vented nerve regeneration. Abbe has used the same method of pro-
cedure in 4 other cases, and states that the results have been perfect.
One of these patients has been well for 5 years, one for 2^ years, one
for 21 months, and one for 6 months. He refers to another case in
which he did the Salzer operation, 4^ years ago. Anterior to the skull
he laid a piece of rubber tissue over the resected nerve-ends in the
sphenomaxillary fossa. This patient also remains perfectly well. The
technic of the operation is described as follows: "The external carotid
artery may be ligated with advantage in controlling hemorrhage. A
vertical incision over the middle of the zygoma carried through the
temporal muscle to the bone divides no important nerve or vessels. The
muscle is scraped to either side and held by retractors. A small opening
is then quickly made by mallet and gouge, and this is enlarged rapidly
and safely to 1-^ inches diameter. No better exposure can be had by
any incision than this simple straight one. The dura is then pressed
away from the middle fossa until the nerves are exposed. The much
complained of hemorrhage from venous sinuses on dissecting up the
periosteum can be best controlled, and very quickly, by pressing a strip
of rubber tissue upon the place with a firm pad of gauze in strips. The
clotting of blood under the rubber tissue takes place very quickly, while
if plain gauze is put in contact with the bleeding point, the blood being
sucked up into it, prevents clotting. The nerve-trunks I grasp in separate

278 GENERAL SURGERY.

artery clamps, divide each close to the foramen of exit, and, either by
cutting or by rotation of the forceps, separate them from the gasserian
ganglion. The wound is packed for a few moments with narrow strips
of iodoform gauze until dry. A piece of thin gutta-percha tissue, stiff
enough to be easily handled, is sterilized by rubbing with mercuric
chlorid solution, and kept in salt solution for a few moments before
operating. This is cut 1^ inches long and f of an inch wide. This is
laid carefully over both the foramen rotundum and ovale, where the
nerves have been separated, and pressed carefully into place by iodoform
gauze. In a very few moments the gauze may be drawn away and the
gasserian ganglion allowed to settle down upon the rubber tissue. A
small drainage-tube should be placed in the angle of the wound for a
few hours to insure a perfectly dry heahng." All agree that there is no
need for the removal of the first division of the ganglion in any case
of grave tic douloureux unless the pain is due to the existence of a tumor
in or by the gasserian ganglion or behind it.

C. A. and H, A. Ballance and Purves Stewart^ present their experi-
ence in the surgical treatment of intractable facial paralysis. The
authors maintain that the regeneration of peripheral nerves takes place
from the peripheral stump of the divided nerve as well as from the
proximal end, and therefore it is maintained that to unite the peripheral
portion of a facial nerve which has been damaged to another nerve,
such as the musculospiral or hypoglossal, is a reasonable procedure.
They have done a large amount of experimental work in this connection,
and are convinced that in cases of facial palsy which do not respond
to treatment, and in which the survival of muscular fibers on the paralyzed
«ide of the face is determined by electricity, the operation of nerve
anastomosis is the treatment which should be instituted. In all but one
instance the nerve which was anastomosed with the distal portion of the
injured facial nerve was the spinal accessory. In the exceptional case
the hypoglossal nerve was chosen, and it is this nerve which the authors
beheve to be best suited for the purpose. One of the disadvantages of
uniting the spinal accessory to the facial nerve is the subsequent asso-
ciation of facial and shoulder movements. The centers for the face and
for the tongue, however, are closely associated in the cerebral cortex,
and it is thought that the results of this anastomosis will prove more
satisfactory. In none of their cases in which the spinal accessory was
used were the facial movements unassociated with some movement of
the trapezius and sternomastoid. Those cases are suitable for operation
in which the paralysis has lasted so long that recovery cannot be ex-
pected without operation. Nerves which have suffered from infective
neuritis give a less favorable prognosis than traumatic cases.

A review of the surgical treatment of facial paralysis by nerve
anastomosis is presented by Gushing,^ who also reports an interesting
case. Faure, acting upon a suggestion of Furet in 1898, was the first
to attempt an anastomosis between the peripheral end of the facial
nerve and that portion of the spinal accessory which supplies the

1 Brit. Med. Jour., May 2, 1903. ^ Ann. of Surg., May, 1903.

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 279

trapezius muscle. The operation failed. Numerous experiments upon
the lower animals have been performed by a number of investigators,
among them Manasse, of Berlin, and Barrago-Ciarella, Naples. Robert
Kennedy, of Glasgow, was the first to successfully carry out anastomosis
between the facial and spinal accessory nerve. In this case the facial
nerve was divided for the relief of severe facial spasm and the anasto-
mosis was immediately performed. The spinal accessory nerve was only
incompletely severed at the point of anastomosis. His postoperative
observation on this case demonstrated that tlie spinal accessory alone
ultimately served as a path for transmission of impulses to both motor
territories. When he operated upon the case reported. Gushing had no
knowledge of the previous work of either Faure or Kennedy. The case
reported is that of a young man, 30 years of age, who some hours pre-
vious to admission received a bullet-wound from a 38-caliber pistol held
close to the skull and discharged just behind the right ear. There was
at this time complete paralysis of the right side of the face. At no time
was there unconsciousness or other evidence of intracranial injury. The
bullet was removed from the bone, its tract cleaned and allowed to heal.
The patient suffered from facial palsy. Gushing did not attempt opera-
tion until the postauricular wound had entirely closed, because he was
afraid that the unhealed wound might be the means of infecting the
one which he proposed to make. Six weeks later under ether anesthesia
Gushing made an incision and the spinal accessory was readily located and
exposed at its point of entrance into the sternocleidomastoid muscle. The
nerve at this point consisted of one trunk and was not split in two porions,
as is often the case. The facial nerve was exposed by incising the posterior
border of the parotid gland, the incision running in the same direction
as the skin-wound. Before operating on this case. Gushing performed a
number of anastomoses upon the cadaver and found that the facial
nerve was most easily exposed by incising the gland rather than by
searching for the main trunk posterior to the gland. Having located
the two main branches in the gland, these can be traced back very
readily to the main trunk. The nerve was divided as near as possible
to the scar tissues at the side of the stylomastoid foramen. The spinal
accessory was divided close to its point of entry into the muscle; both
nerves were then freed far enough to enable them to be brought together
over the posterior belly of the digastric muscle. The sheaths of the nerve-
stumps were sutured together at three points by means of fine curved
intestinal needles threaded with the most dehcate strands of spHt silk.
The first improvement noticed was on the day after the operation, when
the patient announced that he was no longer troubled with lachrymation
and that he could read without the annoyance of an overflow of tears.
He was also less troubled with a flow of saliva and could more easily
dislodge food from his flaccid cheek. Gushing has no explanation to
give of these early assurances of improvement. On the tenth day the
man returned to his home with a small galvanic battery, to the use of
which is attributed a large part of his subsequent improvement. Thir-
teen days after the operation the man was able to eat with a fork without

280 - GENERAL SURGERY.

soiling, and his face when at rest was less asymmetric. There was
marked improvement 81 days after the operation. When the patient's
face was at rest, the asymmetry was hardly noticeable. The following
is the note made 207 days after the operation: "Considerable improve-
ment appreciable, though the patient has entirely neglected exercises
during the past month. Coordination of individual movements of ex-
pression better, without calKng other muscles into play. It is still
impossible to move the head to left (action of M. sternocleidomastoideus)
or to elevate the shoulder without caUing facial muscles into action. In
case of shoulder elevation, however, the face can subsequently be almost
completely relaxed." The electric reactions were found to be practically
normal to faradic and galvanic stimulation, whether applied directly to
the muscles or indirectly through the nerves, 287 days after operation.
In discussing this operation Cushing states that had he been aware of
the previous operations of Faure and Kennedy he might have attempted
likewise to preserve a portion of nerve-supply to the sternomastoid and
trapezius muscles. He, however, states that "at present, with the
knowledge of Faure's failure and of the more pronounced associated
shoulder and facial movements which persisted in Kennedy's case, it
seems possible that the complete division of the nerve and abandonment
of the M. cucuUaris and M. mastoideus may be the better plan." The
success of the procedure depends largely upon the delicacy with which
the nerves are handled, upon their accurate approximation with the
least possible suture material, and that placed only in the nerve-sheath,
upon absolute hemostasis, and upon the care with which the tissues
covering the wound are handled, since it is of the utmost importance
that there should be a minimum of cicatricial formation. It can be
readily understood that this operation is especially well suited to those
cases in which there is a lesion of the facial proximal to the stylomastoid
foramen. The time which may elapse after the reception of an injury
to a motor nerve and still allow of restoration of function through nerve
anastomosis is necessarily uncertain and dependent entirely upon the
condition in which the muscles have been kept by massage and the
use of the electricity. When the muscles have, however, become so
atrophied as not to respond to galvanic stimulation, probably no hope
can be entertained of recovery. Regarding the course of the nerve
impulses in this case, Cushing offers the following conjectures: "(1) That
the cortical centers concerned in shoulder movements (trapezius) and
rotation of the head (sternocleidomastoid) may themselves in the course
of time be educated by training to coordinate the impulses, which have
been side-tracked into the motor area of the facial nerve, so as ultimately
to lead to expressional movement. (2) That the cortical centers origin-
ally presiding over movements of the face continue to play a part in
the coordinate action of these muscles, po-^sibly influencing the higher
neurones of the N. accessorius through the intermediation of connecting
tracts in the cortex." [This article is profusely illustrated with photo-
graphs showing the gradual improvement of the patient and the action
of the different muscles.]

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 281

Cotton and Allen^ report 4 cases of brachial paralysis following
the administration of an anesthetic. Each of the cases was quite
difficult. The arms had been fixed over the head, the palsy was com-
plete or nearly so, and gradually disappeared. The authors have been
able to collect 30 cases of this condition. They have excluded from con-
sideration cxises of paralysis having a central or reflex origin or those
evidently due to direct pressure on the peripheral nerve-trunks, such as
pressure of the table-edge on the musculospiral nerve. Emphasis is laid
upon the following points: "Paralysis of part or all the muscles suppUed
by the brachial plexus with some sensor}'' involvement is not very un-
common after narcosis, though rarely mentioned. Its cause is not toxic
but mechanical. It occurs only when the arms are long held above the
head or lie in abduction — never if they lie flexed on the chest. The
mechanism is a pressure on the nerve-roots, probably between the clavicle
and the muscles over the transverse processes of the cervical vertebras,
or from stretching over the head of the humerus in abduction. The
trouble is essentially functional without knowoi lesions. The lost function
returns in part very early. Total recovery is often long delayed, but
apparently is to be counted on. The possibility of the accident should
be impressed on students, on house officers, and on all of us. In view
of this risk the arms of a patient under ether should always, where
possible, be flexed with the hands on the chest. If other positions are
unavoidable they should not be continued long without change."

Robert Kennedy^ deals with the surgical treatment of birth paraly-
sis of the upper extremity, what is known as Duchenne's palsy, and
reports 4 cases, in 3 of which he has operated. In all of these cases
the muscles affected were identical — the deltoid, the infraspinatus, the
biceps, and the brachialis anticus. With one exception the electric
reactions in the muscles were abolished and the cutaneous sensation
normal. The palsy results from traumatism during delivery and is
usually caused by forcible depression of the shoulder while the head is
bent to the opposite side and rotated. The palsy is evident as soon
as the child is born. Many cases recover with or without treatment;
others make partial recoveries after the lapse of a year or more; and
many cases show no improvement. Recovery may be complete if there
is nothing to prevent the reunion of the nerves ; but if there is cicatriza-
tion in the neighborhood as the result of the injury, the union will not
be complete and some palsy will always remain. Nothing should be
done immediately for the relief of the condition, but when the child is
about 2 months of age the electric reactions of the muscles should be
tested. If the muscles respond to the faradic current the case ought
to be left for a further period and the contractions be tested again.
If they still show improvement, the patient may be expected to recover
without operation. If, however, after 2 months no resjsonse can be got .
in the muscles with the faradic current, although the galvanic current
evokes vigorous contraction, it is safer to proceed with the operation than
to put it off in the hope that recovery will take place later. The brachial

1 Boston M. and S. Jour., May 7, 1903. ^ Brit. Med. Jour., Feb. 7, 1903.
19 S

282 GENERAL SURGERY.

plexus is exposed through an incision extending along the outer border
of the sternal mastoid, from the middle and lower thirds to the juncture
of the outer and middle thirds of the clavicle. Stress is laid upon the
necessity of resecting all cicatricial tissue, even though considerable por-
tions of both nerve-ends are sacrificed. The fifth and sixth nerves are
divided proximally and the suprascapular nerve and the branch to the
outer cord and branch to the posterior cord distally. The division should
be made through healthy nerve tissue. The three peripheral ends are
then sutured to the two central ends by means of a single thread of fine
chromicized catgut passed through the entire thickness of the nerve.
The shoulder should be raised and the head turned to the affected side,
in order to permit suturing, and fixed in this position so that the sutures
will not be put on the stretch. The dressing should be kept in place
for 12 days. In but 1 of the, 3 cases operated upon has sufficient
time elapsed for recovery to be well advanced. The improvement in this
case has been most satisfactory. Sufficient time has elapsed in the others
for some commencing restoration of movements. One of the patients
operated upon was 14 years of age, and in this case it is not expected
that the outcome will be very satisfactory.

Henricksen,^ in an article on nerve-suture and nerve-regeneration,
reports in detail a number of interesting experiments. Among other con-
clusions the author claims that only after a lapse of some time will a
nerve lose its motor conductivity when divided. Regeneration begins
immediately after the division of the nerve and occurs together with
degeneration, so that, after a short interval (7 days), long threads are
found that ultimately develop into active nerve-fibers. In the rabbit,
after the thirtieth day, an advanced development of the myelin sheath
is found in the newly formed fibers of the peripheral part, and at the
same time motor power may be observed, and later an increase in muscle
weight. After some time has elapsed there is found electric reaction.
The further from the periphery a nerve is injured, the longer the time
before the affection of motor power and the slower the recovery. This
is not evidence, however, that the nerve is growing from the central
end. Experiments on animals show that a divided nerve unites equally
rapidly whether sutured or not, therefore suture is not always necessary,
but it should not be omitted, as conditions sometimes arise which prevent
the union and function of the nerve; for instance, infection leading to
the formation of dense scar tissue. If union of the nerve has not taken
place or is incomplete, examination of sensation will determine when
interference is necessary. The time that may elapse before an operation,
with the risk of slow and perhaps incomplete recovery, is scarcely more
than a month. The nerve-fibers grow with most activity in the first
few weeks and the recovery of sensation will rapidly succeed union.
If sensation does not return or is incomplete or is progressing slowly
at the time of the formation of scar tissue, it must be considered as an
indication that serious obstacles to nerve union are present and that
entire recovery cannot be expected without operation. Sensation, there-

• Lancet, April 18, 1903.

DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 283

fore, is of the greatest importance in diagnosis and prognosis. Both in
primary and secondary nerve suture the kind of suture material used
and the way in which the suture is introduced are minor matters, an
aseptic operation being the essential consideration. In secondary suture
it is of the utmost importance that all scar tissue and the outer portion
of the nerve-ends be removed.

Moyer^ reaches the following conclusions, after dealing with the
surgical relations of traumatism of the peripheral nerves: "(1)
Section or laceration of a nerve, if of some size, is usually recognized
at the first examination. (2) Contusions of nerves are common, the
symptoms often being latent until neuritis develpps; the latter may be
delayed some days. (3) Contusion of a nerve may complicate any frac-
ture or dislocation, but is especially frequent in dislocations of the
shoulder. (4) Injury to the circumflex nerve merits special mention be-
cause of its frequency, the ease with which it is overlooked, and its serious
consequences. (5) The reflex paralysis after joint injury is probably due
to a traumatic neuritis. (6) The management of the joint, tendon, and
muscular complications comprises in the main the treatment of trau-
matic neuritis."

Bowlby^ states that primary nerve-suture should always be em-
ployed when it is possible to do so, and the chief cause of its failure is
sepsis. In performing secondary suture it is well to remember that the
nerve can be most easily found above and below the scar; therefore, free
incision should be made. After free exposure of the nerve it should be
separated from the scar tissue, its ends freshened and brought together
by suture. In cases in which the nerves have been divided for a great
length of time, the lower end is often shrunken and much smaller than
normal. Nerves will stand considerable tension; this tension, however,
should be relieved by flexing the part. The sooner the nerve-suture is
inserted, the greater the chance of benefit. The restoration of sensation
and motion after nerve-suture is most irregular in its appearance ; sensa-
tion usually appears first. The function of some nerves seemed to be
more easily restored than that of others; for instance, better results are
obtained from suture of the perineal and musculospiral nerves than are
obtained after suture of the median and ulnar. It is seldom or never
possible to restore the function of the part absolutely. When nerves are
partially divided, operation is indicated according to the amount of
division, and this can be estimated by the muscles involved. Cases of
partial division tend to spontaneous union. Bowlby refers to a number
of interesting cases of contusions of nerves in which absolute palsy
resulted and remained for varying periods. In such cases it is not con-
sidered wise to attempt any operation. It is proper to employ massage,
galvanism, and use of the part. There has been no case of nerve-suture
reported in which motor power has been restored after an interval of 4
years.

Bloodgood' reports 3 cases of angioneurotic erythema, in one of

* Jour. Am. Med. Assoc, Oct. 25, 1903. * Lancet, July 26, 1902.

' Johns Hopkins Hosp. Bull., May, 1903.

284 GENERAL SURGERY.

which the condition was relieved by division of the nerve supplying
the part. This case was one of angioneurotic edema of both cheeks
secondary to drainage of the antral cavities. The condition was relieved
by neurectomy of the infraorbital nerve. A second area developed on
the left side of the abdomen and was relieved by the division of the
intercostal nerves. A third area in the lower abdominal zone is still
under observation. In the second case the condition was confined to
the region over the mastoid. An exploratory incision was made under
local anesthesia for the purpose of excluding disease of the bone itself.
The patient was free from pain and erythema for about 3 weeks. Since
the operation there haVe been intermittent attacks. The third case was
one of angioneurotic edema of the elbow- joint.

DISEASES OF THE MUSCLES, FASCIA, ETC.

F. B. Lund/ of Boston, calls attention to the iliopsoas bursa and
its surgical importance, reporting briefly 3 cases of inflammation of
this bursa in which he has operated. The first case was one of iliopsoas
bursitis complicating osteoarthritis of the hip. The symptoms were
spasmodic pain and fluctuating tumor elevating the femoral artery. The
condition was diagnosed as a deep abscess in front of the hip- joint and
was incised. The evacuation of the bursa gave relief of pain and dis-
ability. The second case was one of gonorrheal arthritis complicated by
iliopsoas bursitis; incision and drainage of the bursa and joint; imme-
diate relief of symptoms and gradual recovery. The third case was one
of iliopsoas bursitis due to suppurative arthritis of the hip; incision was
followed by death from septicemia. The author's conclusions are as
follows: "(1) The iliopsoas bursa possesses surgical importance, owing
to its position and its frequent connection with the hip-joint. It fre-
quently extends above the pelvic brim. (2) It may be involved in
osteoarthritis, gonorrheal infection or suppurative arthritis of the joint,
and the symptoms due to the disease of the bursa may dominate the
clinical picture. (3) In gonorrheal arthritis incision of the bursa affords
an easy method for reaching and draining the joint. (4) In .osteoarthritis
relief of pain is afforded by incision of the bursa. (5) The bursa is best
reached by a vertical incision just below Poupart's ligament, between the
anterior crural nerve and the. femoral artery. The iliopsoas muscle may
be drawn inward, or, as is perhaps more direct and preferable, the fibers
may be separated by blunt dissection in the line of the incision. (6)
When the bursa is connected with the joint a ready diagnosis of the
condition of the head of the femur and acetabulum may be made by
passing the finger through the opening in the bottom of the bursa, (7)
Iliopsoas bursitis should be more often considered in the differential
diagnosis of obscure tumors in the groin, and such a diagnosis should
be possible in cases in which the hip- joint is known to be diseased and
a tumor suddenly appears in front of the joint, under the anterior crural

1 Boston M. and S. Jour., Sept. 25, 1902.

DISEASES OF THE MUSCLES, FASCIA, ETC. 285

nerve and femoral vessels, which is very painful and tender, and perhaps
gives to the palpating finger a sensation of deep fluctuation."

Fere^ suggests heredity as a cause of synovial ganglions. He
refers to a case of a woman who had synovial ganglions on both hands
and who transmitted the tendency to 7 out of 17 descendants extending
through 3 generations. In each case there was some slight traumatism
which acted as an exciting cause of the condition. This synovial ten-
dency. Fere suggests, may correspond to the weakness of aponeuroses
which has been often observed in individuals belonging to neuropathic
families.

Certain principles and methods in the surgery of the paralyses
of children are discussed by Jones, ^ who states that operation in order
to be successful must be followed by prolonged, intelligent, and careful
after-treatment. No half-hearted surgeon with want of faith in the
treatment can accomplish much. To operate upon these patients and
neglect their after-treatment would be comparable to a physician making
a diagnosis and leaving the treatment to the druggist. The mechanical
after-treatment is inseparable from the operative treatment, and the
surgeon who is not a mechanic, is little better than the old orthopedic
surgeon who worked entirely with mechanical appliances. Jones lays
stress upon the prevention of deformity in acute infantile paralysis. The
deformity which results in these cases is. as much due to posture as to
the antagonistic and unparalyzed muscles. Too much attention has
been paid to the pathologic and not enough to the clinical aspect of this
condition. Because certain groups of muscles have barely responded
to stimulation and have remained inactive, it is too often assumed that
this is due to cell destruction in the motor area. If this were true,
whatever the surgeon might do would be futile. Cell destruction is not
so extensive as would appear, and in the majority of cases is transient.
Two cases are reported to show the error of mistaking muscles which
were powerless from desuetude for muscles paralyzed from cell destruc-
tion. For instance, in one case the whole arm was paralyzed. The
flexors first recovered and later the extensors. The flexors, having first
regained their function, overpowered the extensors and, aided by gravity,
became shortened or contracted, while the extensors were lengthened.
The muscles thus placed at a disadvantage had become practically
impotent from desuetude. The method of testing whether treatment will
be of avail in these cases is to make the supposedly paralyzed muscles
as tense as possible and then ask the patient to move them. If he suc-
ceeds ever so little, a favorable prognosis may be given. If he fails,
treatment will be of no avail. The treatment consists in slowly stretching
and lengthening the flexors and placing the extensors in such a position
that structural shortening will ensue. We should not attempt to treat
a Aveakened set of muscles without first rescuing them from a condition
in which they are overstretched. Restoration of elongated muscles takes
place by maintaining them in a slackened posture. Stress is laid upon
the importance of not confusing muscles which for years have been
> Rev. de Chir., No. 10, 1902. ' Lancet, Feb. 14, 1903.

286 GENERAL SURGERY,

useless, with muscles which are positively paralyzed. It is this confusion
which hinders both physician and surgeon in accurately gauging the
potentialities of recovery, Jones next speaks of tendon transplantation
and refers to excellent results which he has obtained in an experience
of over 50 operations in cases of this character. Arthrodesis is recom-
mended in paralytic joints which are either hopelessly flail-like or suffi-
ciently so to demand unceasing mechanical attention. In this operation
the part is put in the most useful position, the articular cartilages are
removed, and the joint is allowed to become permanently ankylosed. In
discussing cerebroparalysis of the spastic type, Jones states that cerebral
diplegia is by far the most serious condition met. The treatment of
spastic paralysis has been too long solely in the hands of the physician,
since many of these patients may be improved in both body and mind
by surgical efforts, and frequently may be enabled to walk with com-
paratively little difficulty. Beyond remedial art are to be placed the
idiot, the microcephalic, and that violently irritable type of diplegia
subject to fits and active athetotic moments who has generally lost all
control over his secretions. In most cases treatment may be required
for two years, and if the patient cannot be under observation for that
length of time the treatment will accomplish little, since it divides itself
into operative and postoperative. If the paralysis is complete, that is,
if the patient is never known to relax spasm, the treatment is futile.
Tenotomy in these cases is of great value, but unassociated with careful
after-treatment is disappointing.

DISEASES OF THE SPINE.

A. R. SmalP reports a case of spina bifida without a sac. At the
end of a week granulations had covered the spinal cord.

P. Tytler and R. T. WiUiamson^ report a case of compression mye-
litis from hydatid cysts. There was complete paralysis of both legs,
anesthesia of both legs and the lower half of the trunk, and complete'
paralysis of the bladder and rectum. Laminectomy was performed and
15 extradural hydatid cysts removed from the thoracic portion of the
spinal canal. The patient gradually recovered the sensation which had
been lost and the control over bladder and rectum. Two and one-half
years after operation the patient is able to walk with the aid of a cane,
but the limbs are still spastic.

Putnam, Krauss, and Park^ report a case of sarcoma of the third
cervical segment in which excision of the growth was followed by
recovery. The patient was a male, aged 45. Below the clavicles all
sensation was lost. The left arm and leg were paralyzed, but slight
motion remained on the right side. The left pupil was smaller than the
right, but both reacted to light. All the reflexes were exaggerated and
there was loss of control over the bladder and rectum. Ten weeks after

1 Chicago Med. Recorder, Feb. 15, 1903. = Brit. Med. Jour., Feb. 7, 1903.

3 Am. Jour. Med. Sci., Jan., 1903.

DISEASES OF THE KIDNEYS AND URETERS. 287

operation motion but not sensation had returned on the right side, and
sensation but not motion on the left.

Henschen and Lennander^ report the successful removal of a sarcoma
of the cervical portion of the spinal cord. The patient was a man
aged 59 years who progressively lost power in the lower limbs and sensa-
tion over most of the body, including the arms. The upper end of the
tumor corresponded to the fifth cervical vertebra. Eight months after
operation the patient was able to walk.

Joseph Collins^ gives abstracts of 70 cases of .spinal cord tumor col-
lected from the literature of the last 6 years. Surgical operation was
undertaken in 30 instances. The results of operation in these 30 cases
were as follows: Successful in 12, partially successful in 8, and wholly
unsuccessful in 10. The operation was considered successful when there
was cessation of pain and recovery of motor power, partially successful
when there was relief from pain, cessation of progress of the case, and
slight restoration of motor power; unsuccessful when followed by death
in a few weeks. The nature of the tumor is not stated in all the cases,
but so far as could be determined there were 6 fibromas, 12 sarcomas,
3 endotheliomas, and 1 myolipoma. The cause of death as given in 9
cases was sepsis in 4, collapse and exhaustion in 2, shock and hemorrhage
in 2, and pneumonia in 1 case. Spinal tumors are twice as frequently
operable as brain tumors, and the results of operation are twice as
successful.

DISEASES OF THE KIDNEYS AND URETERS.

Ramon Guiteras^ formulates the following principles as guides to
the diagnosis of surgical diseases accompanied by pyuria: "(1)
Ciiven a case of pyuria, the seat and the nature of the lesion should be
determined by all the methods at our command before an exploratory
incision or an operative procedure is attempted. These methods include,
in addition to the general and physical examination : (a) Examination of
the urine, including cryoscopy and the phloridzin test; (b) cystoscopy;
(c) ureteral catheterization ; (d) segregation of the urine from each kidney
by appliances introduced into the bladder and not into the ureters; (e)
radioscopy. (2) The examination of the patient's urine in such cases
should be considered as of the utmost importance and should be in-
trusted only to men thoroughly trained in this line of work, particularly
in the microscopy of urinary sediments. (3) It is possible, by a careful
study of the pus, blood, casts, and particularly by a study of the epithe-
lial elements of the urinary sediment, to determine the nature of the
lesions and the seat thereof in the urinary tract. (4) A renal lesion of '
suppurative character being found, it becomes necessary to locate it in
one or the other kidney, or to determine whether the opposite kidney
is present and healthy. This may be done with the aid of cystoscopy,
ureteral catheterization, combined with the phloridzin test, and followed

1 Mittheil. a. d. Grenzgebiet. d. Med. u. Chir., Bd. x, Heft 15, 1902.

^ Med. Rec, Dec. 6, 1902. ^ Med. Rec, Nov. 8, 1902.

288 GENERAL SURGERY.

by the examination of the urines from each kidney; with the aid of the
Rontgen rays, and, if need be, in case of doubt, of exploratory incision.
(5) An omission of one or more links in the chain of methods of examina-
tion here enumerated may give rise to grave errors in diagnosis, and
nephrectomy is never justified when we are not in the position to say
that the opposite kidney is present and in good condition on the basis
of the tests herein mentioned."

Peter Peterson^ reports a case of nephrectomy for carcinoma in
which he employed a lateral extraperitoneal incision. "An incision was
made on the left side extending from the tenth costal cartilage to a
point an inch internal to the anterior superior iliac spine. All the struc-
tures down to, but excluding, the peritoneum were divided in this line.
The serous membrane was then reflected from the abdominal walls til
the whole of the anterior surface of the kidney and a considerable part
of the renal vessels were exposed. The advantages of this method far
outweigh its disadvantages. The organ is easily accessible; there is no
stretching of, or tension on, the vessels; large tumors can be removed
through the wound; while the ureter, if necessary, can be exposed almost
down to the bladder. The intestines do not come into the field of opera-
tion, the blood-supply of the colon is not interfered with, and the shock
consequent on opening the abdominal cavity is obviated, while the wound
is not any deeper than in the transperitoneal method. In the case of
stone the viscus can be thoroughly examined between the fingers. In
septic conditions the peritoneal cavity is not infected. Adhesions, both
anteriorly and posteriorly, are easily reached, while in those cases in
which the peritoneum is so adherent to the kidney that it cannot be
stripped off and the abdominal cavity has to be opened this part of
the operation is much easier than by the lumbar incision and is not
any more difficult than by the abdominal route. The disadvantages are :

(1) that the opposite kidney cannot be examined through the wound and

(2) that a risk of ventral hernia is incurred; but in the case of wounds
taking an aseptic course the latter objection is more theoretic than real."

J. A. Schmitt^ formulates the following conclusions from a study of
the literature of the surgical treatment of Bright's disease: "(1) In
acute infectious diseases anuria with uremic symptoms threatening the
life of the patient can be successfully combated by capsular incision or
renal cleavage, which relieves congestive swelling and excess of intrarenal
pressure. Operation on one side is sufficient to bring about an abundant
urinary secretion, followed by a subsidence of the alarming general
features. Whether the other kidney gains time to recuperate and re-
assume its function, or whether reflex action plays a predominant role,
are debatable points. At all events nature seems to get along with a
small portion of functionating kidney tissue. (2) Anuria with uremic
symptoms, occurring in the course of chronic Bright's disease, has afforded
an occasion for surgical procedure. To recognize such an indication on
reasons which are analogous to those above mentioned is, of course, a
matter of individual judgment. Temporary relief, in some instances,

1 Lancet, March 14, 1903. ^ Med. Rec, Sept. 13, 1902.

DISEASES OF THE KIDNEYS AND URETERS. 289

has been gained — a permanent cure, however, has never been effected.
(3) When the kidney has been operated upon directly for the cure of
chronic Bright's disease the outcome has been a failure. The apparent
benefit manifested in the disappearance of dropsy, dyspnea, etc., occurs
just as regularly in the ordinary course of the treatment by medication
and capillary drainage or puncture. (4) In exceptional cases colicky
pains and hematuria are caused by chronic Bright's disease. Capsular
incision or cleavage of that kidney to which the disturbances were trace-
able has been attended by excellent results ; there can be no doubt that,
when medical expedients have failed, surgical interference has succeeded
in checking the hemorrhages and alleviating the pains, but it does not
inhibit the progress of chronic Bright's disease. (5) Nephropexy may
cure the ailments incident to movable kidney; it may remove albumin-
uria, if this be the result of local irritation, consequent upon the displace-
ment; if, however, the movable kidney is affected by chronic Bright's
disease, this affliction will remain uninfluenced by operation."

George M. Edebohls^ analyzes 51 cases of renal decapsulation for
chronic nephritis which he has performed up to date. Twenty-nine were
in females and 22 in males. With the exception of a girl of 4^ years,
all the patients were adults. The length of time intervening between the
first recognition of disease and operation in 41 patients varied between
1 month and 19 years, the average duration being 3 years and 4 months.
Many of the cases were complicated by circulatory and pulmonary dis-
orders. Twenty-nine had chronic interstitial nephritis, 14 had chronic
diffuse nephritis, and 8 had chronic parenchymatous nephritis. In all
cases of chronic diffuse and chronic parenchymatous nephritis both
kidneys were affected. In the 29 cases of chronic interstitial nephritis
the disease was limited to one kidney in 9 instances. "There were 47
operations upon both kidneys and 4 operations on one kidney only; 7
patients died within 17 days after operation; 7 patients died at
periods after operation varying between 2 months and 8 years, the
average period of life after operation being 20 months; 2 patients do
not show improvement satisfactory in every respect; 22 patients are
in various stages of satisfactory improvement and progress toward
health at periods varying between 2 months and 15 months after
operation. The urine of several of these is at present free from al-
bumin and casts. They have not, however, passed the probationary
period of 6 months of normal urine, before the expiration of which no
patient is entitled to a place on the list of cures. One patient, after a
cure extending over a period of 4 years, again has chronic Bright's dis-
ease. One of her kidneys only was operated upon. Nine patients were
cured of chronic Bright's disease and remain cured at periods after
operation varying from 21 months to 10 years, the average duration
of cure being over 4 years. Three patients disappeared from observation
after leaving hospital, and no trace of them can be found." A rest in
bed for a few days is advisable by way of preparation for each case.
There are 3 conditions which may make renal decapsulation a difficult
1 Med. Rec, March 28, 1903.

290 GENERAL SURGERY.

operation. The first is great length and coliquity of the twelfth rib,
with narrowness of the space between the last rib and the ilium; this
difficulty may be largely overcome by placing the subject in a proper
posture and by making an oblique incision. The second difficulty is
that the kidney is fixed well up under the ribs. The procedure under
these circumstances is to incise the capsule proper at any portion of
the kidney surface that can be reached, to seize the edges of the capsule
with forceps, and to complete the separation of the capsule with the
finger in the depths of the wound. As the kidney tissue is liable to
become friable during the progress of chronic inflammation, great caution
should be exercised in order to avoid the danger of tearing or fracturing
the organ. The danger from the anesthetic is greater than is that of
the actual operation. One hour should be the limit of time allowed for
the decapsulation of both kidneys. Ether is a satisfactory anesthetic.
In all but one case the wounds were completely closed, and primary
union was obtained. A certain degree of cardiac degeneration accom-
panies every case of chronic nephritis, and if uncomplicated is not a
contraindication to operation. When, however, the cardiac and vascular
changes have advanced far and have become widespread so that im-
provement is out of the question, it is not worth while to take the risks
of operation. The first effect of the operation upon the urine is shown
in an increased daily output of urea. Of the casts present before opera-
tion, those which denote advanced destruction of the secreting structures
of the kidney disappear first from the urine, such disappearance usually
requiring from a month to a year. The albumin persists in the urine
for a greater or less time after the permanent disappearance of all casts.
Chronic Bright's disease, before irreparable damage has been inflicted
on the kidneys, the heart, the bloodvessels, and the nervous system, is
curable or susceptible of amelioration by renal decapsulation. Renal
decapsulation in the early stages of chronic nephritis is, in competent
hands, attended with little or no risk to life.

"From a study of 17 cases which he has operated on for various
forms of chronic nephritis, Rovsing^ formulates some rules as to the
proper treatment in such cases. He divides the cases into aseptic and
infectious nephritis. In the aseptic cases he found that diffuse parenchy-
matous nephritis was not influenced by operation. A case which he
classed as chronic glomerulonephritis recovered after operation, he be-
lieves, more from rest in bed than from any favorable result from the
operation. In diffuse hemorrhagic nephritis there is much danger in
operating and the results are not satisfactory. In 4 cases of interstitial
nephritis and perinephritis fibrosa occurring with uric acid and oxalic
acid diatheses his results were satisfactory. Operation is frequently
undertaken with a diagnosis of stone in the kidney in such cases and gives
relief without any stone being found. The severe pains which are present
in these conditions he believes indicate operation. Pain always indicates
tension within the kidney capsule, it does not matter what form of
nephritis exists. But the most important group of cases is that caused

* Mittheilungen aus den Grenzgebeiten der Med. u. Chir., 1902, vol. x, p. 288.

DISEASES OF THE KIDNEYS AND URETERS. 291

by some form of infection. Eight of his cases were of this character
and the condition was discovered only after most painstaking examina-
tion. Urine obtained under aseptic precautions should be accurately
examined chemically, microscopically, and bacteriologically in every
case, whether we suspect that we have to deal with an infection or not.
In case pathologic constituents are found, cystoscopy and catheterization
of the ureters should be employed. In his cases Rovsing found infections
of the urine from Staphylococcus aureus. Staphylococcus albus, Strepto-
coccus pyogenes, and Bacterium coli. The entire chnical picture did not
differ in these cases from that in the aseptic forms of nephritis. Neither
was there any difference in the chemical constituents of the urine nor of
the appearance of the kidney when it was exposed. The results of
operation in these cases were very much more satisfactory, however,
than in aseptic cases, and Rovsing believes that his cases show definitely
that unilateral chronic nephritis may be of infectious origin ; that it may
affect a greater or smaller part of the kidney, or that we may have a
double partial infectious nephritis. Stripping of the kidney capsule,
which gives such favorable results in cases of aseptic interstitial nephritis
with perinephritis and severe pain, also has a favorable influence on
inflammatory processes. In hemorrhagic cases he believes that splitting
the kidney will give favorable results in the milder infections, such as
by Bacterium coli, but it is dangerous in the more virulent infections.
Resection of the diseased part in case of local infectious nephritis which
entirely resembled chronic aseptic nephritis led to cure in two of his
cases."

A. D. Bevan^ presented a paper on the surgical treatment of anuria
before the Chicago Surgical Society, January 5, 1903. After discussing
the literature and one of his own cases he submitted the following con-
clusions: "(1) The clinical importance of recognizing the three forms of
anuria — obstructive, reflex, and nonobstructive. (2) The imperative
necessity of surgical interference in the obstructive and reflex forms, and
its possible value in the nonobstructive cases. (3) In the first two
varieties a rapid nephrotomy on the side of pain, tenderness, and mus-
cular rigidity is the operation of choice. If necessary, do not hesitate to
make a double nephrotomy. (4) Nitrous-oxid anesthesia is probably to
be preferred. (5) Time-consuming operations to relieve permanently
the obstruction are to be postponed to a later period, after the patient
has recovered from the anuria. (6) Operate by the beginning of the
third day."

A. Pousson,^ in a review of the subject of surgical intervention
for nephritis, divides the disease into acute toxic infections and the
true Bright's disease. Pousson has operated upon 4 cases falling under
the heading of acute toxic infections, performing nephrotomy in 2 and
nephrectomy in 2; 3 of the patients recovered. The infection in 1 case
was influenzal, in 2 it was due to the colon bacillus, and in 1 was an

» Med. News Jan. 17, 1903.

* Ann. des Mai. des Organes Genito-Urinaires, Nos. 5, 6, 7, May, June, and
July, 1902.

292 GENERAL SURGERY.

acute exacerbation of an old pyelonephritis. Nephrotomy is the opera-
tion of choice in the acute infectious cases. In 6 cases of Bright's disease
the author performed nephrotomy; 4 were improved and 2 died.

C. H. Chetwood^ reports a case of hematuria of 4 years' duration
in which there was a relatively small amount of deterioration in the
general health and in which the urinary analysis revealed nothing ab-
normal present except blood. A cystoscopic examination demonstrated
blood flowing from the right ureter. At the operation the kidney ap-
peared normal even after bisection. A microscopic study of a small
section removed at the time of operation showed chronic parenchymatous
nephritis. The hematuria ceased after operation.

Horace J. Whitacre^ reports a case of suppression of urine which
had endured 8 days and which was relieved by decapsulation of both
kidneys.

David Newman^ reports a case of acute nonsuppurative perineph-
ritis following an attack of pleurisy. There was great pain and ten-
derness in the right renal region, and in this region was a firm mass.
There were no constitutional symptoms and the urine gave no evidence
of renal trouble. An incision revealed a normal kidney surrounded by
a mass of inflammatory material mixed with fat. The patient recovered.

Jos. Ransohoff* reports a case of unilateral chronic nephritis
which was mistaken for a case of kidney stone and in which exploratory
splitting of the capsule was followed by recovery. The diagnosis of
chronic nephritis was made from a microscopic study of a section re-
moved at the time of operation.

Frederic Bierhoff ^ published a method for diagnosing renal calculus
which is as follows: "A good-sized ureteral catheter is passed up into
the renal pelvis, and through this tepid, sterilized 1 % boric acid solution
is gently injected until the patient complains of a sensation of pressure
in the renal region, usually about 30 cc. being required. The fluid is
then allowed to flow off, and the maneuver is repeated until 250 to
300 cc. in all has been employed." When a stone is present, the pro-
cedure is followed by hematuria within 24 hours ; when no stone is present,
no hematuria follows. This method has been employed in 5 instances.
"In two, as a result, a positive diagnosis of calculus was made, which
was confirmed by a subsequent radiograph in one instance, and by
operation in both. In the second of these two cases, repeated a;-ray
examination by an expert radiographer would not permit of positive
corroboration by this means. In three instances a negative diagnosis
was made, to be corroborated by radiography in two instances, and by
operation in the third."

An unusually interesting case of renal calculus is reported by Fer-
guson,® The patient was a boy upon whom Ferguson first operated for
a pyonephritis complicated by stone and urinary fistula. At this time
nephrectomy was done. A few weeks subsequent to this operation the

1 Med. News, Feb. 7, 1903. ^ Jour. Am. Med. Assoc, May 23, 1903.

5 Brit. Med. Jour., July 19, 1902. * Jour. Am. Med. Assoc, May 30, 1903.

5 Med. News, Oct. 11, 1902. " Jour. Am. Med. Assoc, July 5, 1903.

DISEASES OF THE KIDNEYS AND URETERS. 293

patient developed obstruction of the opposite ureter by a calculus. The
stone was found two inches below the kidney, was pushed back into the
pelvis and removed. Before the patient left the hospital he developed
obstruction of the urethra from lodgment of a stone, which was removed
after splitting the meatus. About a month after the operation the
patient presented symptoms of calculus in the urinary bladder and
suprapubic cystotomy was performed. Two months and a half after
this operation the patient was quite well.

H. H. Young^ reports 4 cases of calculus in the lower end of the
ureter. Case I: Calculus impacted in the lower end of the left ureter
for probably 27 years. Removal by extraperitoneal ureterolithotomy
through an iliac incision. Intravesical ureterotomy for stricture of the
lower end of the ureter. Recovery. Case II: Calculus impacted in the
lower end of the ureter. Extracted by means of a ureter catheter cysto-
scope. Case III: Calculus impacted in the right ureter about 2 cm.
above its lowest orifice. Demonstration by cystoscope and catheter and
byrc-ray. Complete disappearance after water cure. Case IV: Removal
of 3 large calculi from the lower end of the left ureter through an extra-
peritoneal (iliac) incision. Recovery. Calculi may be extracted from
the lower end of the ureter by the intravesical route, by the cystoscope,
by the perineal route, by the intrarectal route, by the pararectal route,
by the sacral route (resection of a portion of the sacrum), by the intra-
peritoneal route, and by the iliac extraperitoneal route — the best, accord-
ing to Young. With careful history, vigorous repeated bimanual rectal
examination, radiographs, and the cystoscope, the diagnosis of calculus,
its location, and the relative condition of the kidneys are easily and
certainly determined.

J. F. Percy^ reports a case of hypernephroma which was treated
by nephrectomy. The patient, a boy of 15, later died of metastatic
growths in the brain and lungs.

Borelius^ says polycystic kidney may manifest itself in one of three
forms. The first simulates small contracted kidney, there being the
same condition of the urine and of the heart. The differential diagnosis
is made by palpating the enlarged organs. The second form resembles
nephritic colic. The third form is that in which the patient has reached
the stage of uremia. The finding of large kidneys on palpation is the
principal diagnostic sign. Hematuria and albuminuria are not topical.
Heredity plays an important part; three of the 4 cases observed by the
author occurred in a man, his son, and his nephew. Aspiration is some-
times of value for diagnostic purposes. Large kidneys associated with
a diminished amount of urea in the urine constitute a contraindication
to operation. In two of Borelius's cases a renal tumor was supposed
to exist. The condition probably begins at birth and slowly develops
during the remaining portion of life.

Edgar Garceau* analyzes 415 cases in which some operation was
performed for tuberculosis of the kidney.

» Amer. Med., Aug. 9, 1902. =• Clin. Rev., Aug., 1902.

' Nord. Med. Arch., xxxiv, No. 4. * Boston M. and S. Jour., July 3, 1902.

294

GENERAL SURGERY.

OPERATIONS.

Nephrectomies 257

Nephrotomies 42

Nephrotomies followed by nephrectomies 84

Nephrectomies and total resection of the ureter 16

Limibar nephrectomy and partial resection of ureter 10

Resections 6

Total 415

GENERAL SUMMARY.

Total number of cases 415

Total number of deaths , 122

Immediate deaths (within one month) 74

Deaths later 48

Percentage of immediate deaths 17.8

General mortality 29.4

Deaths from tuberculosis elsewhere in body 49

SURVIVALS.

Total number of survivals 293

Time not stated 95

No improvement 3

Improved only and still affected by the disease 49

1 year or under

2 years.
3

Recoveeies.

4
. 5
6
7
8
9

10
11
12
21

20
11
13
3
3
1
2
1
0
2
1
1

293

Total survivals two years or more 58

Percentage 14

Total nimiber of cases well from within a few months of opera-
tion, and therefore promising cases, added to survivals two

years or more 241

Percentage of promising cases 58

There were 266 operations on the female, 128 on the male, and 22 'in
which the sex is not given. The greater proportion of females is explained
by the fact that in males some other portion of the genitourinary appa-
ratus is also involved, rendering them unfit for any operation. The
following table gives the ages at which the disease occurs :

1 to 10 years 9

10 to 20
20 to 30
30 to 40
40 to 50
50 to 60
60 to 70
Age not given 45

40
.135
,140
. 40
, 4
, 2

Total 415

DISEASES OF THE KIDNEYS AND URETERS. 295

The miliary form of tuberculosis is by far the commoner, and as a rule
never goes into the caseous form to any great extent, the patient dying
before this occurs from tuberculosis in other parts of the bo'dy. In the
415 cases tuberculosis of other organs was mentioned 54 times, the
lungs having been affected 37 times. Caseous disease of both kidneys
was mentioned 27 times (6.5 %) and immediate 'death ensued in 24 %
of these cases, the disease not having been recognized in the opposite
kidney before the performance of nephrectomy. Infection through the
urethra is not common. The bladder may be exposed for a long period
to the contact of tubercle bacilli without becoming affected. In none
of the cases was any reference made to the condition of the genital
apparatus in the female. In 16 cases of caseous tuberculosis in the male
the genitals were affected 8 times (50 %). Vesical tuberculosis as a
primary disease is commoner in males than in females. In the female
the kidney is the commoner seat of origin.

George M. Edebohls^ prefers renal decapsulation to nephrectomy,
resection of the kidney,' and nephrotomy whenever it will answer the
purpose equally well or better, because it is comparatively innocuous,
the danger of hemorrhage is less, the after-treatment is simpler, and
urinary fistula is avoided. He presents a preliminary report of 6 cases
in which decapsulation was performed for conditions other than
Bright's disease. They are as follows: (1) Acute pyelonephritis with
miliary abscesses; right nephrectomy and decapsulation of the left kid-
ney. (2) Acute right pyelonephritis with miliary abscesses; decapsula-
tion of the right kidney. (3) Acute hemorrhagic nephritis; decapsula-
tion of both kidneys. (4) Intermittent hydronephrosis of the right
kidney associated with chronic Bright's disease; decapsulation and fixa-
tion of the right kidney. (5) Intermittent right pyonephrosis and chronic
interstitial nephritis; decapsulation and fixation of the right kidney.
(6) Polycystic degeneration of the kidneys and chronic diffuse nephritis;
decapsulation of both kidneys. All of the patients recovered.

J. L. Thomas^ has performed nephropexy by the Vulliet method 10
times with satisfactory results. Vulliet's method consists in the fixation
of the kidney by means of a detached strip of the tendon of the erector
spinas passed through the parenchyma of the kidney. Thomas suggests
the use of a small swivel fixed to a long delicate handle for the purpose
of facilitating the separation of the fasciculus of tendon. He makes 2
longitudinal incisions in the fibrous capsule of the kidney, one near the
outer border of the organ, and one near the hilum; the capsule is then
freed from the parenchyma by blunt dissection and the split tendon
of the erector spinre is passed beneath the separated capsule from without
inward, the ends being secured in the wound near the spine. A few
sutures are passed through the capsule and the fascia luml:)orum.

A. H. Goelet^ emphasizes the importance of nephroptosis in pro-
ducing renal disease and disease of the female pelvic organs. Nephrop-
tosis causes disease of the female pelvic organs by compressing the ovarian

» Brit. Med. Jour., Nov. 8, 1902. ^ grit. Med. Jour., Nov. 8, 1902.

^Amer. Med., Oct. 3, 1902.

296

GENERAL SURGERY.

vein and interfering with the return circulation from the pelvis. In
prolapse of the third or fourth degree the kidney niaj' be affected by
nephritis, perinephritis, pyelonephritis, hydronephrosis, pyonephrosis,
and atrophy, or, in other words, such diseases as would result from
prolonged congestion of the organ or from obstruction to the ureter.
Operation is not advised for prolapse of the first or second degree, except
when the left kidney is found to be in the second degree of prolapse
at the time of an operation on the right kidney, the left kidney being
fixed at the same time to obviate the necessity for a second operation
later, prolapse of the second degree always being progressive. Operation
is always necessary for nephroptosis of the third degree. It is unnecessary
to decapsulate the kidney or to transfix the parenchyma with sutures.
Firm adhesion of the fibrous capsule to the muscles of the back may

Fig. 52. — Showing details of operation and method of insertion of the sustaining sutures : .1, Kid-
ney ; ^, fatty capsule ; CC, retractors separating maigins .,(' lumbar incision; DI), I'-forcops drawing
out fatty capsule; BE, the first or lower sustaining suture; FF, second or upper sustaining suture;
G, needle carrying end of suture from within out tlirough the structures of the back at upper angle
of the wound (Goelet, in Amer. Med., Oct. 4, 1902).

be secured if these two structures are held in contact for a sufficient
length of time. Goelet employs 2 sutures of silkworm-gut, one having 3
insertions under the fibrous capsule of half an inch in length each,
and the other, 2 insertions of the same length (see Fig. 52). They are
brought out through the structures of the back at the upper angle of
the wound, just below the last rib, and are tied over a small pad of
gauze to prevent cutting and loosening of the suture loop, which would
permit the kidney to sag and destroy the chance of adhesion. These
sutures are removed at the end of 3 weeks. Goelet has fixed 136 kidneys
by this method without a death or a relapse.

Max BrodeP suggests a more rational method of passing the

1 Amer. Med., Aug. 2, 1902.

DISEASES OF THE KIDNEYS AND URETERS. 297

suture in fixation of the kidney. The simple through-and-through
sutures tear out because they pass in the same plane with .the
framework of the cortex. The direction of the suture proposed by
Brodel is at right angles to the framework of the cortex. The fibrous
capsule, being the most resistant structure, is utilized instead of the
kidney-substance to form the main support for the suture. The suture
is passed in a triangular manner through the cortex so as to leave two
suture bridges on the surface of the kidney. These bridges bear the
brunt of the work, and traction on the suture is borne by them instead
of by the circulatory or secretory structures of the kidney. To make
this suture tear, the bridge must pull the fibrous capsule into the cortical
substance of the kidney, a procedure requiring considerable force. The
bridges should not be shorter than 7 mm. in length.

A. E. Gallant^ concludes a paper on the corset for movable kidney
as follows: "(1) The symptom-complex designated movable kidney,
Glenard's disease, etc., cannot be accounted for on the ground of simple
kidney mobility or prolapse. (2) Nephroptosis is nearly always asso-
ciated with ptosis of other abdominal and pelvic viscera, subnormal
nutrition and nervous instabiUty. (3) Treatment to be successful must
be directed toward the replacement and support of the prolapsed viscera,
the correction of functional derangements, and improvement of general
nutrition. (4) Nephropexy without replacement and support of the
abdominal viscera will fail to bring relief. (5) Nephropexy is indicated
only when operating upon a true 'surgical kidney.' (6) A corset meas-
ured, fitted, and put on while the woman is lying in the dorsal posture,
and worn continuously when ilot lying down, will elevate and support
the viscera and immobilize the ectopic kidney. (7) The corset affords
maximum pressure over the suprapubic area, minimum compression
above the waist-line, and ample space for heart, lungs, and intestines;
gives a refreshing sense of comfort as soon as put on ; Dietl's crises cease,
and as time goes by, gastrointestinal action improves, nervousness
diminishes, anemia is dissipated, and a well-marked increase in body-
weight ensues. (8) A corset made on this plan has been found of great
service to women with pendulous abdomen, adiposis; replaces the abdom-
inal binder after childbed and celiotomy; and for young girls when
first they adopt skirts suspended from the waist, the wearing of such
a corset is prophylactic to the production of Glenard's disease."

Ramon Guiteras^ outlines in detail the various types of operations
employed since Hahn first fixed the kidney and describes his own
method. He denudes one-half of the posterior surface of the kidney,
that nearest the convexity, and leaves the anterior surface intact. Two
retention sutures of chromicized catgut are passed through the peeled
back capsule at the point of reflection, the upper suture at the junction
of the middle and upper thirds of the kidney, the lower suture at the
junction of the lower and middle thirds of the organ. The needle is
inserted near the edge of the reflection, includes both layers of the
capsule, and passes under the layer still adhering to the parenchyma

'Intemat. Jour of Surg., Feb., 1903. ^ ]y[g^ Rg^^ ^pj-ji n^ 1903.

20 s

298

GENERAL SURGERY.

for f of an inch and emerges through the outer reflected layer. The 2
anterior retention sutures are inserted at levels corresponding to those
of the posterior set. The suture is passed under the edge of the cut
capsule to a point situated f of an inch from this edge on the anterior
surface, where it pierces the capsule, passes over the capsule for f of an
inch vertically, and again pierces the capsule from without inward,
running under it and emerging at the free end of the fibrous coat at
the convexity of the organ. These sutures are passed through and tied
over the muscles in such a way as to bring the kidney into close apposition
with the parietes as nearly as possible at the normal level.

Fig. 53. — Milbank Johnson's modification of Penrose's operation for nephropexy (Donaldson, in Amer.

Med., Feb. 28, 1903).

Frank Donaldson V describes a modification of technic in the Penrose
operation for nephropexy which he credits to Milbank Johnson. "He
makes 4 openings about 15 mm. on either side of the main incision, ABC
and D, Fig. 53. These incisions go through skin, fascia, and muscle.
The catheter is then passed through the opening A, on through the fatty
capsule a few millimeters to the side of the main incision in the same,
around the kidney proper about 1 cm. from and above the ureter and
renal vessels, and out through the fatty capsule and the opening B on
the opposite side. Similarly, a second catheter is introduced through
the opening C and brought around below the ureter and vessels of the
1 Amer. Med., Feb. 28, 1903.

DISEASES OF THE KIDNEYS AND URETERS.

299

kidney and out through the opening D. The incision is then closed."
After exerting the proper amount of tension on the kidney the catheters
are clamped together. The rubber tube does not prevent healing of the
original wound, as is the case in the Penrose operation.

F. P. Canac-Marquis^ describes his method of anchoring floating
kidney. After incising the capsule to the extent of 8 cm. on its dorsum,
the capsule is freed for 3 or 4 cm. in all directions and a double silkworm-
gut continuous suture is made on "each side of the incision, starting
at a (Fig. 54), passing through the skin, fat, muscle, and capsule proper;
taking about 1 cm. of the mus-
cles with the capsule proper
and passing out in the inverse
order, as shown in Fig. 54 at a.
The same procedure for the
opposite side is shown at h
and h'. By pulling these su-
tures taut, the capsule is
drawn to the side and ex-
poses a raw surface of kidney
parenchyma about 3 cm. wide
and 6 cm. long. A lead nickel-
plated shield is threaded and
shotted and the shot crushed
on these sutures, when mod-
erate tension has been accom-
plished. The next step in this
operation is to draw the mus-
cles over the raw surface of
the kidney, which is accom-
plished by passing double silk-
worm-gut sutures, starting at
c, going through skin and fat,
crossing over and taking in
all of the muscles of opposite
side, then recrossing over sur-
face of kidney to take the
muscles of the side whence
suture started ; to be recrossed
and take in fat and skin, as
shown in Fig. 54 at c'. The

same procedure is followed in lower angle of incision, as shown in Fig, 54,
e and c' ."

James Swain ^ says that in all cases of movable kidney associated
with nervous symptoms or with splanchnoptosis belts should be tried.
In younger women with strong abdominal muscles belts are more likely
to fail than in older women with lax abdominal walls. A pad under
the belt on the side affected is of service. The abandonment of the

* Jour. Am. Med. Assoc, April 4, 1903. ' Bristol Med. -Chi. Jour., Dec, 1902.

Fig. 54.— Canac-Miirquis's method of anchoring a floating
kidney (Jour. Am. .Med. Assoc., Ai>ril4, 1903).

300 GENERAL SURGERY.

pad is largely due to the mechanical difficulty of exercising sufficient
pressure on the pad without annoying the patient. This difficulty may"
be overcome by a device which consists of a "freely running adjustable
band passing obhquely round the outside of the belt, guided by loops.
This passes round the back, and both ends cross over the position of
the junction of the middle and lower thirds of the pad placed under
the belt, to be fastened by means of buckles securely fixed — one on
either side — to the bottom of the belt. By drawing on the ends of the
band when passed through the buckles, a direct pressure upward and
backward is exerted upon the pad beneath. When belts fail, operation
is indicated."

S. T. Brown^ reports 2 cases of diabetes associated with movable
kidney in which nephropexy was followed by a disappearance of the
sugar from the urine.

C. A. McWilliams^ gives the New York Presbyterian Hospital sta-
tistics of movable kidney: "Total, 61 cases: 2 occurred in men; 59, or

96.7 %, in women; 21, or 35.6 %, were single women. Of the married
women, 22, or 37.2 % of the whole 59, had borne children. Average
number of children to each, 2. Right kidney movable in 53 cases, or

86.8 %. Left kidney movable in 4 cases, or 6.6 %. Both kidneys
movable in four cases, or 6.6 %. Average age was 33^ years; youngest,
17; oldest, 65 years. Trauma antecedent in only seven cases, or 11.4 %.
Complications: Femoral hernia in 2. Gastrointestinal indigestion in 25.
Marked constipation in 28; diarrhea in 3. Jaundice in 1. Chronic
appendicitis in 9. Urinary symptoms in 18. Renal colic in 7. Renal
calculus in 1. Pyelitis in 1. Chronic nephritis in 2. Neurasthenia in

11. General enteroptosis in 3. Uterine abnormities in 5. Results of
operation: 42 cases followed after operation showed 22, or 52.3 %, cured
of subjective symptoms; 15, or 35.7 %, benefited; 5, or 10.9 %, no
benefit. Uncomplicated: 19 cases, or 31.1 % of the whole 61. Of these

12, or 63.1 %, were cured. Complicated: 23 cases, or 34.4 % of the
whole 61. Of these, 10 or 43.4 %, were cured. Recurrence occurred in
6 cases out of 36 examined, or 16.6 %. Mortality of operation: 2 cases
in 61 operations, or 3.2%."

R. E. Newton^ reports a case of profuse hematuria from a slightly
movable kidney which promptly ceased after nephropexy.

Byron Robinson* presents an exhaustive article entitled landmarks
in the ureter. His remarks were based on the investigation of over
100 ureters of man and animals. Numerous cuts form excellent illustra-
tions of the text. The conclusions are as follows : "(1) The ureter is not
a uniform calibered tube. (2) It consists in general of three isthmuses
or sphincters located at points in the ureter where projecting adjacent
structures compromise; kink its lumen. The ureteral lumen is comprom-
ised by: (a) the distal renal pole projecting the ureter medianward,
producing what I shall term the proximal isthmus, sphincter or neck of
the ureter; (6) the ureteral lumen is compromised at the point where

' Phila. Med. Jour., April 4, 1903. ' Med. News, Oct. 4 1902.

3 Australasian Med. Gaz., Dec. 20, 1902. * Ann. of Surg., Dec, 1902.

DISEASES OF THE KIDNEYS AND URETERS. 301

the vasa iliaca project the ureter ventralward, producing what the author
terms the middle isthmus or sphincter, the flexura iliaca ureteris. The
middle ureteral isthmus is due to the increased ventral projection of the
ureter by the vasa iliaca on assuming the erect attitude (man, erect
bimana). Quadrupeds do not possess the middle ureteral isthmus, and
consequently less lumbar ureteral spindle, (c) The lumen of the ureter
is compromised at the point where its distal end penetrates obliquely
the muscular wall of the urinary bladder. (3) Compromised lumen by
isthmuses or sphincters induce ureteral dilations — reservoirs or spindles.
There is a ureteral reservoir proximal to each ureteral isthmus, e. g.,
(a) ureteral pelvis proximal to the proximal isthmus or neck; (6) lumbar
spindle proximal to the middle ureteral isthmus; (c) pelvic spindle proxi-
mal to the distal ureteral isthmus in its vesical wall. (4) The ureteral
spindles are more pronounced in woman than in man on account of the
proximal and distal arteria ureterica having an excessive or periodic
hyperemia during reproductive life (puberty, menstruation, gestation,
puerperium, and climacterium). Consequently, in senescence, when its
proximal and distal arteria ureterica become affected with arterial
sclerosis or calcification, lack of nourishment will induce pathologic
dilations of the lumbar and pelvic spindles. (5) Calculi lodge at the
ureteral isthmuses. (6) Torsion of the ureter or kink may easily com-
promise the ureteral neck or proximal ureteral isthmus. (7) Surgical
interventions on the ureter should be performed at the ureteral reservoirs
or spindles on account of ample lumen and wall. (8) Pathologic condi-
tions of the ureter lie mainly in defects of the ureteral wall (inflammatory
products, paresis, tuberculosis, etc.) producing deficient peristalsis, or in
the mechanical obstruction to the ureteral stream (calculus, kink, torsion,
stricture). (9) So long as the ureteral peristalsis is not interfered mth,
and especially the ureteral stream is not obstructed, the ureters perform
their function. (10) However, as soon as any mechanical obstruction to
the ureteral stream arises (as kink, calculus, stricture), the nondrainage
induces residual deposits with resulting accumulations of bacteria,
whence the vicious circle occurs in the tractus urinarius exactly similar
to vicious circles arising from obstructions in the pylorus or the biliary
ducts, (11) The ureter is an independent organ conducting the urine
from the kidney to the bladder by rhythmic waves, regardless of altitude
or force of gravity. It is an elongated duct interpolated between kidney
and bladder with similar functions to the bladder — a reservoir. (12)
The ureter being located in a universally loose areolar bed, and being
longer than the distance between its proximal and distal ends, is capable
of an extensive range of motion in pathologic conditions or for surgical
intervention. (13) The irregular caliber of the ureter, dilations (reser-
voirs, spindles), and constrictions (isthmuses, sphincters) is an hereditary
heritage from the Wolffian body enhanced by environments."

Hugh Cabot^ reports a case of ureteral anastomosis following the
accidental excision of ^ inch of the right ureter in removing a cancerous
uterus. The patient recovered.

' Boston M. and S. Jour., Dec. II, 1902.

302 GENEKAL SURGERY.

A. H. Gould^ reports 2 cases of complete bilateral duplication of
the ureters. By complete duplication is meant that both kidneys have
each two ureters, and each ureter is separate throughout, having its own
orifice in the bladder.

H. A. Kelly ^ classifies strictures of the ureter according to their
location, extent, and cause. The location of a stricture may be at any
point in the ureteral tract, but is most frequent at the vesical end. The
extent varies from a few millimeters to several centimeters. Strictures
are caused by inflammation of the ureteral walls produced by the com-
moner pyogenic organisms, by the gonococcus and by the tubercle
bacillus. The commonest cause of inflammation is tuberculosis, the
rarest gonorrhea. The symptoms are those of the associated infection,
which is rarely localized in the ureter until the disease is well advanced
in the bladder or in the kidney. The diagnosis is made by palpation,
by inspection, and by ureteral catheterization. The pelvic portion of
the ureter is easily accessible to palpation either through the vagina
or through the air-distended rectum. On cystoscopic examination the
ureteral area is found sw^ollen, deeply injected or surrounded by areas
of ulceration; the opening is often obscured so that it appears like a
dimple in the midst of a large cushion of puffy mucosa. In these cases
it is often extremely difficult to catheterize the ureter. The most charac-
teristic sign of stricture is the strong bite felt upon mthdra\Adng the
catheter. The methods of treatment are as follows: "(1) Dilation of
the stricture by flexible or metal catheters in a graduated series, up to
4 or 5 mm. in diameter. This is the ideal method. (2) Freeing the
ureter from a bed of inflammatory tissue, by dissecting it out. This is
occasionally sufficient. (3) Resection of the ureter. This is rarely possi-
ble. (4) Extirpation of the entire supravesical urinary tract of the
affected side, by a nephroureterectomy or a ureteronephrectomy, or, as
I have done in one case, a nephroureterocystectomy. This is the only
reliable method in cases of tuberculosis, as well as of pyoureter and
pyelonephrosis of long standing. (5) Amputation and implantation of
the bladder. This is applicable when the stricture is low down, the
opposite side diseased and the diseased side still capable of doing some
work. (6) Complete division of the stricture. This plan may be of
service when the stricture is unusually tight. Important accessories to
the treatment, and preliminaries to any active operative interference are
the evacuation of the old urine or pus accumulated above the strictures,
and the steriHzation of the upper urinary tract by the injection of solu-
tions of boracic acid, mercuric chlorid, silver nitrate, or formalin."

F. Cathelin^ describes a new instrument for segregation of the
urine. The instrument consists of a No. 25 French catheter inside of
which runs a stylet which is graduated at the proximal end and has
attached to its vesical end a fine steel spring which may be folded flat
so as to pass through the catheter and which when extruded from the
vesical end of the instrument springs into an elliptic form dividing the

' Am. Jour, Med. Sci., March, 1903. ^ Jour. Am. Med. Assoc, Aug. 16, 1902.
' Ann. des Mai. des Organes Genito-Urinaires, No. 7, July, 1902.

DISEASES OF THE KIDNEYS AND URETERS. 303

bladder into two halves. Attached to the elliptic steel spring is a thin
rubber membrane which prevents the urine on one side of the bladder
mingling -with the urine on the other side of the bladder. Running
through the shaft of the instrument are 2 fine catheters, one of which
drains the right half and one of which drains the left half of the bladder.
The outer end of the shaft of the instrument is supported by an upright.
Each catheter drains into a small flask, so that the urine from each kidney
may be examined separately.

Martin B. Tinker^ believes that a sufficiently large number of cryo-
scopic examinations have been made by reliable observ^ers to prove
positively the value of the test. Casper and Richter place a higher value
on cryoscopic tests of the urine and blood than on the phloridzin test,
quantitative estimation of urea, or other usual methods, but lay special
stress on the agreement of all these methods when tried in a given case.
The methylene-blue test is not of sufficient value to be used as a routine.
Rumpel has tested the freezing-point of the blood and urine in a series
of cases of typhoid fever and other diseases, and finds no important
variation from the normal point of healthy individuals. Under normal
conditions the freezing-point of urine varies between — 0.9° C. and
— 2.0° C. A freezing-point above — 0.9° C. indicates fewer solids in the
urine, and therefore renal insufficiency. Normal blood has a freezing-
point of —0.56° C. with a variation between —0.55° C. and —0.57° C,
or only 0.02 degree. An increase of the freezing-point to over — 0.58° C.
indicates an increase of the solids in the blood and shows that renal
insufficiency is present. An advantage of this test over the ordinary
chemical tests is that the freezing-point is influenced by all the products
excreted in the urine, and there is little doubt that many of these waste
products are of as great importance in determining the functional activity
of the kidney as are urea and chlorids. This method seems to offer
the advantage of greater accuracy, and is simpler than the elaborate
methods of quantitative determination of specific gravity which must
be used when accurate results are desired. Tinker tested the blood of
25 patients with normal kidneys and found that in 23 it froze at exactly
— 0.56° C. In the two remaining cases there was a variation of 1.01° C.
"The modified Heidenhain apparatus was used in these tests. It con-
sists of a thermometer 45 cm. long mth a large bulb which is graduated
from 1° C. above freezing to 4 degrees below the freezing-point. The
degrees are subdivided into tenths and hundredths and the scale is
sufficiently large so that ^^^ of a degree can be easily read. To allow
for expansion of the mercury in warm weather and at ordinary room-
temperature a reservoir bulb is provided at the upper end of the tube.
For ordinary examinations about 20 cc. of blood or urine are taken.
The blood or urine to be examined is placed in a test-tube, which in turn
is inserted in a larger tube which makes an air-space about the fluid
to be frozen, insuring gradual cooling of the liquid to be examined. To
lower the temperature to the freezing-point a mixture of salt and ice
may be used, but an apparatus is also on the market in which the lowering
^ Johns Hopkins Hosp. Bull., June, 1903.

304 GENERAL SURGERY.

of temperature is brought about by evaporation of ether. The test-tube
containing the blood or urine may be placed directly in the salt and
ice mixture until the mercury comes down out of the reservoir bulb.
This vnW save a great deal of time in the freezing, and if the blood or
urine is warm it may be difficult to freeze it unless this is done. The
test-tube containing the solution is then placed within the second tube,
which acts as an air-chamber. While the solution is cooling, it is stirred
constantly by means of a wire loop so that the solution is thoroughly
mixed and kept everywhere at the same temperature. The mercury
sinks more or less rapidly, not to the point of freezing, but considerably
below it before freezing really takes place. As freezing occurs heat is
given off and the mercury again rises to the freezing-point, where it
remains for some time. If left in the freezing mixture, however, the
mercury again begins to fall and can be reduced if desired to the tem-
perature of the ice and salt mixture. Before the thermometer is used
it should be tested by trying the freezing-point of distilled water." The
necessary amount of blood may be obtained by a large aspirating syringe
in the same way as blood is taken for blood-cultures. It was found
necessary to expose the vein by dissection in about one-third of the
cases. It is not necessary to defibrinate the blood. Three cases of pus-
kidney which later came to necropsy were examined, and in each the
variation of the freezing-point from the normal was marked. The value
of cryoscopic examination of mixed specimens of urine is far less than
the cryoscopic examination of the blood. The chief value of the test
is for prognostic purposes. If renal insufficiency of a high degree is
found, operation may be contraindicated. Cryoscopic examination is
simple and may be made by those little experienced in its use; it does
not consume more time than many other methods in general use; the
results are more reliable than are obtained by those tests now in general
use. The field of cryoscopy is limited, but the method is of decided
value when indicated at all.

DISEASES OF THE PENIS, URETHRA, TESTICLE, ETC.

John B. Roberts^ advocates excision of the lumbar l3rmphatic
glands in malignant disease of the testicle. If it is true, as Leaf
believes, that the lymph-vessels and veins communicate, both veins and
nodes should be excised in all cases.

Paul Thorndike and W. T. Bailey^ analyze 75 cases of tuberculosis
of the testicle. "Cases, 20 to 30 years of age, 50 %; 20 to 40 years of
age, 67 %; family history, negative in 86 %; past history, negative in
53 %; gonorrhea, in 30 %; gonorrheal epididymitis, in only one case;
left side affected, in 60 %; right side affected, in 36 %; both affected,
in 18 % ; trauma assigned as cause, in 12 %; previous urinary symptoms,
absent in 59 cases; previous urinary symptoms, present in 9 cases;
symptoms indicating prostatic involvement, present in only 1 case;
examination of lungs not recorded in 39 cases; negative in 23 cases;

» Ann. of Surg., Oct., 1902. ^ Boston M. and S. Jour., July 3, 1902.

DISEASES OF THE PENIS, URETHRA, TESTICLE, ETC. 305

positive in 13 cases; epididymis alone involved, in 42 cases; epididymis
and testis involved, in 32 cases; vas deferens involved, in 12 cases; by
rectal examination, vesicles involved, in 16 cases; prostate involved, in
13 cases; prostate negative, in 13 cases; pathologic records, present in
36 cases." Thorndike has never operated early enough to make it
possible to leave the testicle. He emphasizes the importance of castra-
tion even when there are tuberculous lesions in other portions of the
body. [If the disease is limited to the epididymis, we believe epididy-
mectomy should be performed. If the testicle proper is at all involved,
the entire testicle should be removed. Until recently it was believed
that orchidectomy is useless if the prostate or vesicles are involved.
Koenig and others maintain that removal of a tuberculous testicle or
epididymis is followed by distinct improvement in a tuberculous prostate
or in tuberculous vesicles.]

A. A. Cabot^ reports a case of strangulation of the testicle due to
torsion of the cord. At operation the cord was found to be twisted
360 degrees. The mesorchium was short and the cord was wrapped
tightly around it. The testicle was gangrenous, hence it was removed.

W. W. WilHams^ reports a case of gangrene of the testicle due to
torsion of the cord. Recovery followed castration.

J. B. Christopherson^ reports a case of imperfect descent of the
testicles in which both testicles were found in the right inguinal canal.

S. F. Long"* describes a method of circumcision. The skin is re-
moved from the base instead of the end of the penis. A triangular
piece of skin is removed from the dorsum of the penis, the amount of
skin to be removed being determined by the length of the foreskin. If
the foreskin is 1 inch in length, the denudation should extend 2 inches
along the dorsum. "Having ascertained the amount to be removed
and marked the point on the dorsum and on each side at the base with
small forceps, we proceed with a sharp scalpel to outline the section
to be removed. Beginning at the juncture of the organ with the pubes
and extending around either side about two-thirds the circumference,
passing around the marking forceps and including them in the piece
to be removed, with a neat curve we proceed in a direct line to the dorsal
forceps, passing around them and thence down the other side encircling
the other lateral forceps, and up to the point of beginning. The sec-
tion of skin should be carefully dissected off, leaving the fascia and
blood-vessels undisturbed. The parts are now approximated and the
stitches put in, completing the operation." The advantages claimed
over the old operation are: "The delicate grading of skin with mucous
membrane has not been disturbed; sensitive nerves are not severed;
there is no hemorrhage except the very slight oozing from the capil-
laries of the severed skin ; circulation has not been interrupted and edema
has been avoided; the wound can be made aseptic and less painful; the
dressings do not become soiled or wet by the urine, and may remain
until union is complete; the slight line or scar is covered by the hair,

' Boston M. and S. Jour., June 25, 1903. * N. Y. Med. Jour., June 6, 1903.

' Brit. Med. Jour., Feb. 7, 1903. * Pacific Med. Jour., Oct., 1902.

306

GENERAL SURGERY.

as it is reproduced; the operation is more easily done, and the wound
is healed in half the time required by the old method."

L. J. Krause^ publishes a method of obviating the difficulty of sev-
ering the skin and mucous membrane exactly opposite each other in
circumcision. "A sharp-pointed bistoury is passed to the point at
which it is desired to make the section, and then pierces the skin from
within outward. This opening is made exactly in the dorsal middle line.
Through the opening is passed a grooved director. The bistoury is then
reintroduced and perforates the skin from within outward to^'one side of

Fig. 55. — Klotz's method of circumcision. The circular and longitudinal incisions (Medicine, Dec,

1902).

Fig. 56. — Klotz's method of circumcision. The cuft-shaped flap of skin is dissected off all around the

penis (Medicine, Dec, 1902).

Fig. 57. — Klotz's method of circumcision. The two edges are brought together and sutured (Medicine,

Dec, 1902).

the frenum. The grooved director which has been introduced through
the upper opening is then passed out through this lower opening, and a
pair of scissors severs the integument and mucous membrane in a clean
cut exactly opposite, and when the sutures are introduced there is no
puckering. The same procedure is then repeated upon the opposite side
of the frenum."

Walter C. Klotz^ describes a new method of circumcision. "The

* Cincinnati Lancet-Clinic, Nov. 29, 1902.

* N. Y. Med. Jour., Oct. 4, 1902.

DISEASES OF THE BLADDER AND PROSTATE. 307

prepuce is retracted toward the root of the penis, and held moderately
tense. A circular incision (Fig. 55, A) is made around the penis from 2 to
3 inches behind the coronal sulcus, according to the amount of skin it is
desirable to remove. This incision should divide only the skin as far as
areolar tissue. A second incision (Fig. 55, B) is made around the penis
about ^ inch behind the coronal sulcus. This should be like the first, but
in a plane placed more obliquely, so as to be parallel with the line of inser-
tion of the glans. The two circular incisions are then joined by a longi-
tudinal one (Fig. 55, C) along the dorsum of the penis, and, beginning along
the edges of the latter, the quff-shaped flap of skin outlined by the 3
incisions should now be dissected off all around the penis (Fig. 56). The
two edges are then brought together (Fig. 57)."

DISEASES OF THE BLADDER AND PROSTATE.

J. B. Bissell^ discusses the diagnosis and treatment of tubercluous
cystitis. It is shown that a slight traumatism is much more apt to be
the exciting cause of tubercular cystitis than a severe traumatism. The
condition is rarely primary, arising as a rule either from the prostate or
kidney. In spite of the fact that Koenig denies that the disease is ever
primary, the author believes that it sometimes though seldom is, and
reports a case. The normal mucous membrane strongly resists infection
from the tubercle bacillus and infection is rare except when the mucous
membrane has been injured. The disease is most usual in males between
the ages of 17 and 40. The most frequent symptom is hematuria, which
is often very slight and accompanied by little or no pain. Frequently
it is inconstant; it usually appears at the end of micturition, varying in
amount from a few drops to a teaspoonful. It is probably the earliest
symptom of the disease. The hematuria which comes on later in the
disease, indicating the ulcerating stages, is a different hemorrhage. It
lasts longer and comes earlier in the act of urination, and the pain which
accompanies it is often severe. As the disease develops, pain becomes
a more or less constant symptom, and sometimes becomes so severe as
to suggest calculus. Large quantities of bladder epithelium are fre-
quently found in the pus. The frequent voiding of clear urine without
pain and without apparent cause, with a few drops of bright-red blood at
the end of urination, or, less often preceding it, is almost pathognomonic
of beginning tuberculous cystitis. The urine is acid, although toward
the end it may become neutral or even ammoniacal. The ulceration
may be so extensive as to perforate the bladder-wall. Incontinence is
rare unless the process has reached the neck of the bladder and the latter
has become extensively involved. The cystoscope is of great value if
used carefully. Early in the disease the tuberculous process begins with
grayish-white nodules which when seen after coalescing and before break-
ing down may be mistaken for a neoplasm. Examination per rectum
often shows nodules in both lobes of the prostate and thickening of the
walls of the seminal vesicles, as well as tenderness to pressure in this
» Phila. Med. Jour., Sept. 6, 1902.

308 GENERAL SURGERY.

location. If the tubercle bacillus is certainly found, the discovery proves
the diagnosis, but it must be borne in mind that the smegma bacillus
resembles it so closely that at times it will deceive an expert observer.
The differentiation may be made by the inoculation of animals. The
personal and family history and the examination of all the organs of
the body are of great assistance in arriving at a proper diagnosis. The
history or trauma, however slight, whether of an external injury, a pre-
vious attack of acute or chronic urethritis, overdistention of the bladder,
instrumentation, irritant injection, or a common cold producing a con-
gestion of the bladder-w*all, may be of great help in determining the
diagnosis. Bissell considers the pulse in cases of tuberculous cystitis as
quite suggestive. It is almost always more rapid than normal, ranging
from 90 to 110. The temperature is slightly elevated. Exercise is apt to
produce a desire to urinate. The differential diagnosis between stone
and tuberculosis is often made with the greatest difficulty. It must be
borne in mind that the use of the sound is dangerous, and that it is an in-
strument which must be employed with the greatest care. The author
thinks that the treatment should consist largely in the adoption of general
and hygienic measures and is very much opposed to operation. When
drainage of the bladder is obtained, it should be by the suprapubic route,
as suprapubic cystostomy opens the bladder at a distance from the local
lesion.

In discussing the causes, symptoms, and treatment of cystalgia,
Lydston^ states that among the causes are: Lesions of the urinary tract,
lesions of the neighboring organs, such as the prostate, rectum, etc.;
locomotor ataxia and general paralysis, diathetic conditions, such as
gout and rheumatism; diseases of the testis and spermatic cord; lead
poisoning and malarial infection. Cystalgia may occur in hysteric and
chloranemic patients and sexual disturbances and abuses may produce it.
In treating this condition the physician should be careful not to treat
too radically some slight lesion of the urinary tract, which lesion Is in-
considerable in proportion to the pain suffered. The true cause should
be looked for and removed if possible. The immediate treatment con-
sists in the use of sedatives, such as opium, belladonna, etc., and the
employment of hot sitzbaths. Predisposing causes such as gout, malaria,
or general debility, require special attention.

In discussing the etiology and treatment of chronic cystitis,
Stokes^ refers to the various avenues by which microorganisms may gain
access to the bladder. The old idea that the urine in chronic cystitis is
always alkaline does not hold, since in at least one-half of the cases the
urine is acid. The treatment will be influenced by the cause of the con-
dition, and Stokes objects to the indiscriminate employment of urotropin
in cystitis. The drug should only be used in those cases in which there is
alkaline urine. In cystitis of gonorrheal or pyogenic origin, irrigation
with silver solution is favored. Mercuric chlorid solution should never
be used in cystitis of gonorrheal origin, nor should silver solution be used

1 Jour. Am. Med. Assoc, Aug. 23, 1902.
=> Jour. Am. Med. Assoc, Sept. 27, 1902.

DISEASES OF THE BLADDER AND PROSTATE. 309

in tuberculous cystitis. Perineal drainage is to be preferred to supra-
pubic drainage for chronic cystitis.

Valentine/ in discussing aids to cystoscopic practice, describes a
*'box phantom" which consists of a small box at the bottom of which is
a schematic circular device separated into 4 segments. A larger phantom
is also described which is a little more complicated, and its use should
follow that of the first. These mechanical devices are used in order to
perfect one's self in the use of the cystoscope.

Milton^ discusses bilharziosis from the surgical point of view,
relating his experience in the Kasr-el-Aini Hospital of Cairo. The only
places in which this disease offers opportunity for relief by surgical
means are in the bladder, the urethra, the rectum, and the female genital
organs. It presents itself in 3 forms — the atrophic, the hypertrophic,
and a combination of the two. It most frequently attacks the bladder,
its symptoms being hematuria occurring at the end of micturition, pain
and scalding during micturition, and frequent micturition. These symp-
toms occur in the early stages of the disease. Later there are presented
all the symptoms of an intractable septic cystitis. The patient is fre-
quently subject to stone. In cases in which the formation of the bilhar-
zial tissue is extreme, adhesions may form between the distended bladder
and the anterior abdominal wall, with the subsequent formation of urinary
fistulas. When the ureter becomes involved, obstruction to the passage
of urine is apt to occur. This obstruction may be the result of narro\\ing
in the atrophic form, and of polypi in the hypertrophic fonn of the dis-
ease. After discussing the various forms of the disease and their treat-
ments, Milton concludes his article with some interesting statistics. At
the Kasr-el-Aini Hospital, during the year 1901, 930 cases of this disease
were treated; 714 of these in the out-patient department alone. The
disease is most frequent between the ages of 15 and 45, although it may
occur at any age; 893 patients were males and only 37 were females.
The black races seem to enjoy a certain amount of immunity from the
disease, which is most prevalent among the peasants of lower Egypt.
It is shown that many more people suffer from the disease than are aware
of the fact, which is proved by the examination of the urine of a large
number of school-children, in which the bilharzia was frequently dis-
covered.

J. H. Jacobson^ (Toledo) reports a case of transplantation of the
ureters with a portion of the trigone into the rectum for the cure
of exstrophy of the bladder. The patient was a man of 29 years who
had had repeated operations done for the cure of the exstrophy. The
openings of the ureters were plainly seen, and into them could be passed
without difficulty the ureteral catheters. The urine from both kidneys
contained albumin and pus. The patient was put in the Trendelenburg
posture, and the ureters, together with a small portion of bladder-wall,
separated from the main portion of the bladder and carried into the
rectum through a slit on either side about the level of the promontory of

1 N. Y. Med. Jour., June 6, 1903. ^ Lancet, Marcli 28, 190.3.

3 Jour. Am. Med. Assoc., Jan. 3, 1903.

310 GENERAL SURGERY.

the sacnim. The remaining portion of the bladder was then removed.
Six months after the operation the patient was voiding urine through
the rectum about once every 3 hours, although he could retain it for 6
hours. The urine was voided independently of bowel evacuations.
Occasionally during the night the urine passed involuntarily.

Greene and Brooks^ present a contribution on the pathology and
prognosis of the diseases of the bladder. The conclusions drawn from
their discussion are as follows: "(1) The most frequent cause of diseases
of the bladder is: (a) Lesions of the central nervous system, causing
dilation, (6) septic processes of various varieties, (c) hypertrophy of the
prostate. (2) In all conditions in which the spinal cord or central ner-
vous system is involved, frequent and early catheterizations should be
resorted to, to prevent the bad effects of overdistention, or the possi-
bility of cystic rupture. (3) Conditions of the bladder must greatly
modify the prognosis in operative procedures for the relief of obstructions
of the urinary flow, therefore the importance of cystoscopic and other
examinations cannot be too strongly insisted upon. (4) Hypertrophy of
the bladder-wall is due to 4 different processes, separate or combined:
(a) Inflammatory infiltration, (6) increase of the fibrous connective tissue,
(c) smooth muscle hyperplasia, (d) infiltration by new-growth, (e) the
clinical symptoms in hypertrophy of the bladder depend on which of
these factors predominate."

D. F. Jones^ deals with intraperitoneal rupture of the bladder and
adds to the reported cases 2 of his own which recovered after suture. He
has been able to add to Alexander's table (see Year-Book of Surgery,
1903) 9 cases including his own collected from recent Hterature, making
a total of 54 cases of intraperitoneal rupture treated by suture. Thirty-
two of the cases were published prior to 1893, and gave a death-rate
of 63^ %, while 22 were reported since 1892 and show a mortality of
27^ %. There is an improvement therefore in the death-rate of 36 %,
and the average interval between the injury is increased 4 hours in the
second period over the first. This improvement must therefore be
attributed rather to technic than to earher recognition and earlier opera-
tion. Regarding the technic, Jones commends the suggestion of Alex-
ander that the prevesical space should first be opened, and beheves
that this will undoubtedly save opening the peritoneum in some cases.
"The ease with which the suture of the bladder wound is accomplished
depends largely upon the position of the patient. The incision should be
made with the patient flat, after which the Trendelenburg position should
be used and the intestines walled off with large gauzes." The difficulty
of suturing the lower end of the bladder wound can be obviated largely
by putting the patient in the Trendelenburg position, and by beginning
to suture at the upper end of the wound. By this means the wound
is pulled up within easy reach, and each suture below can be placed
without difficulty. Fine twisted silk is thought to be the most satis-
factory suture material. Testing the line of sutures by injecting the
bladder is thought to be unnecessary. It is far safer to drain the abdo-
» Med. News, June 20, 1903. ' Ann. of Surg., Feb., 1903.

DISEASES OF THE BLADDER AND PROSTATE. 311

men than not to drain, and gauze drainage is preferable to tubular
drainage. Authorities differ regarding the method of draining the blad-
der; the tendency has been, however, toward either frequent catheteriza-
tion or frequent urination. Perineal drainage has few advocates at the
present time. Symptoms present in both of Jones's cases were: (1) Sud-
den severe pain in the lower part of the abdomen, which remained as a
constant pain. (2) Constant desire to urinate, with inability to do so.
(3) Preference for an erect or partially erect position of the body rather
than the recumbent position. (4) General tenderness; little or no rigid-
ity. The abdominal wall was so lax in both cases that it bulged with
the pressure of the free fluid in the abdomen. (5) A small quantity of
bloody urine in the bladder. (6) Dulness in the flanks. The method of
injecting air in the bladder is not approved of, nor is that of injecting
boracic acid solution, though the latter is less dangerous and may be
occasionally necessary. It should never be used, however, unless the
patient is prepared for immediate operation. The first case reported is
that of a man, 27 years of age, who was operated upon 89 hours after
the rupture; the tear was 2h inches in length, was vertical, and was
situated in the posterior wall. It was repaired by two layers of Lembert
sutures of silk. The abdomen was flushed with a hot salt solution and
a gauze drain was inserted. Constant drainage of the bladder was em-
ployed for 6 hours, after which the bladder was kept empty by frequent
voluntary acts of micturition. No leakage occurred and the patient
recovered. The second patient was a man, 26 years of age. He was
operated upon 26 hours after the rupture. The laceration was 1^ inches
in length and was situated high on the posterior wall ; the technic of the
operation was the sa me as in the first case, with the exception of constant
drainage of the bladder kept up for 48 hours. On the second night
after the operation, when the patient was on the verge of delirium tre-
mens, he got out of bed and walked about, the wound became infected,
and on the seventh day some leakage occurred; this, however, later
ceased, and the patient left the hospital in 4 weeks perfectly well.

Daly and Harrison^ report an instructive case of intraperitoneal
rupture of the bladder upon which Harrison operated 64 hours after
the injury. The patient recovered. The patient was a man aged 36
who, after carrying a pail of water, experienced sudden severe pain in
the abdomen. The interesting points in this case are the entire absence
of symptoms indicating rupture at the time of the patient's admission
to the hospital or for some time afterward. At the time of his admission
10 ounces of clear urine were withdrawn by the catheter, nor was there
subsequently any bloody urine found in the bladder. On the third day
it was evident that the patient was suffering from a rupture of the blad-
der, as no urine could be withdrawn and there were other symptoms
indicating intraperitoneal rupture, but consent for operation was not
obtained until 64 hours after the onset of symptoms. The patient was
in a very bad condition at this time and was transfused during the opera-
tion. A large quantity of slightly turbid fluid of uriniferous odor was
» Brit. Med. Jour., Jan. 10, 1903.

312 GENERAL SURGERY.

found in the abdominal cavity. A rent in the posterior surface of the
bladder-wall sufficient in extent to admit the tip of the index-finger was
found and carefully sutured with two layers of Lembert sutures of silk,
the mucous membrane not being included. The abdominal cavity was
washed out and the wound closed. A retention catheter was placed in
the bladder, where it remained until the eighth day. Through it a
plentiful supply of urine escaped. The patient after the operation for
several days was in a bad condition and suffered from uremic delirium.
On the eighth day he was much improved, his temperature was normal,
and as the wound was healed the sutures were removed. On this day,
however, he contrived to tear open his wound and withdraw 2 feet of
small intestine. The wound was reopened, the abdominal cavity flushed,
and the intestine returned, the patient making a slow but uneventful
recovery. This case is interesting not alone on account of the length
of time elapsing between the reception of the injury and the operation,
but also because of the accident after the operation, the recovery in
spite of the accident, and also because there was no history of an injury
which would seem hkely to have caused a rupture of the bladder. The
patient emptied the bladder a short time before the onset of symptoms,
but it was learned that he had been drinking, and it is thought that
the bladder must have been partially distended at the time of rupture.
There have only been 5 cases recorded in which the time between the
injury and the operation has been longer or so long as in this case, and
of these 5 cases only one patient recovered.

F. Milnes Blumer^ reports a case of intraperitoneal rupture of the
bladder with operation 2 days later followed by recovery. The
patient was a man 35 years old who ruptured his bladder by falling
across a rail. The symptoms were not marked until after the first 24
hours. The rent in the bladder- wall was 2 inches long and was closed
with fine silk. The abdominal cavity was drained with a glass tube
which was left in for 2 days. A catheter could not be retained or even
passed. The lower portion of the wound became infected, which neces-
sitated the removal of some of the stitches. There was some leakage of
urine. A catheter at this time was inserted into the bladder and re-
tained. The patient's temperature fell and he made a good recovery.
The leakage and subsequent suppuration of the wound are attributed to
a small wound at the anterior part of the bladder-wall which was found
at the time of operation and closed. It was thought that this wound
had been caused by a silver catheter which was passed upon the patient's
admission to the hospital.

Ledderhose,^ in discussing the treatment of intraperitoneal rupture
of the bladder, states that so long as no symptoms of peritonitis are
present the abdomen should invariably be opened and the bladder
sutured, but when peritonitis develops before the patient comes under
surgical treatment an expectant plan of .treatment should be employed.
A retention catheter alone should be depended upon for a time. If a
large collection of fluid in the abdominal cavity persists, then it should

1 Brit. Med. Jour., April 4, 1903. ^ Centralbl. f. Chir., No. 26, 1902.

DISEASES OF THE BLADDER AND PROSTATE. 313

be evacuated by the simplest possible method and no attempt be made
to repair the rupture. The author presents a record of cases to show
the value of this treatment. He stated that if this method was followed
in the treatment of intraperitoneal ruptures of the bladder already com-
plicated with peritonitis the mortality of this condition would be much
reduced.

Primary suture of the bladder after suprapubic cystotomy is
considered by Hoffmann^ to be the ideal treatment. The results when
this procedure is followed are much better than when drainage has been
established, the recovery being much more rapid and complete. The
method is not to be used, however, if there are certain contraindications,
such as cystitis, thickened and bruised bladder- walls, etc. Hoffmann
closes the bladder with two rows of sutures, one of catgut and a second
of silk. He also advises fixing the bladder to the abdominal wall after
primary suture.

Hugo^ reports a case of a man 24 years of age who presented himself
at the hospital stating that 5 years before he had been shot through
the bladder. The bullet entered the left side of the abdomen and
passed out through the right buttock. For 2 years there was a discharge
of pus and some urine from the abdominal wound. For 2 years the
patient had passed a little blood in the urine, and at the time of ad-
mission presented evidences of stone. He would not permit a supra-
pubic section and therefore the bladder was opened through the perineum
and 3 stones extracted, one a small free one, another a partially encysted
one, hour-glass in shape, and a third small one, which was behind the
partially encysted stone. All of the stones were phosphatic. The
nucleus of the stone in the deep part of the cyst was a very small piece
of lead and a piece of black cloth, which had probably been carried in
by the bullet No nucleus was found in the other calculi. The patient
made an uneventful recovery.

A case of perforation of the bladder-wall by a calculus is reported
by Lowers.^ The patient was a boy aged 19. The stone was phosphatic
and weighed 40 grams. The ulceration of the anterior bladder-wall
produced suppuration in the prevesical space, as it always does in such
cases. In removing the stone by the suprapubic route the peritoneal
cavity was freely opened, but the patient made a complete recovery.
Out of 29 cases of perforation of the bladder by stone collected by Chap-
palin the perforation took place at the anterior wall in only 4 instances.
In the majority of cases ulceration occurred either in the posterior or
inferior part of the bladder. A condition such as was met with in this
case requires prompt drainage and removal of the stone. If it is a large
one and the urinary fistula be long and narrow, it will be best to perform
perineal or suprapubic lithotomy, rather than to extract the stone through
the fistula after previous .dilation. In doing the suprapubic operation
the danger of opening the peritoneal cavity is very great because of
the adhesions.

' Miinch. med. Woch., Oct. 28, 1902. ^ j^rit. Med. Jour., Nov. 22, 1902.
^ Jour, de Chir. et Ann. de la Soc. Beige de Chir., No. 5, 1902.
21 S

314 GENERAL SURGERY.

A case of complete removal of the urinary bladder is reported by
A. W. Mayo Robson/ The patient was a woman whose bladder was
extremely involved in a malignant growth. A 4-inch median vertical
incision was made and also a 3-inch transverse incision just above the
pubes. The recti muscles were divided at their insertion and the peri-
toneal cavity was opened. The viscus was freely movable and its sepa-
ration from the peritoneum, the uterus, the vagina, and the pubic arch
was accomplished by gradual dissection without producing marked
hemorrhage or any other difficulty. The ureters when exposed were
divided near their attachment to the bladder. When the bladder had
been entirely freed from all its attachments except the urethra, the latter
was grasped with forceps and divided. Ureteral catheters were inserted
into the divided ureters and held in position by means of catgut sutures.
Each ureter with its catheter was then carried through a small incision
in the anterior vaginal wall and fixed in this position with sutures. The
peritoneal cavity was closed by a continuous catgut suture. The urine
passing through the right ureter was normal, but that from the left was
small in amount and bloody, indicating probable disease of the left kidney.
The patient died on the thirteenth day from uremia. No abdominal
symptoms developed at any time after the operation. If the patient
had recovered Robson intended to convert the vagina into a bladder and
make use of the urethra which had been preserved.

Herbert Lund^ reports a case of complete excision of the male
urinary bladder with implantation of the ureters into the rectimi
for a papillomatous growth. The patient was a man of 57. The papil-
lomatous growth involved chiefly the trigone and lower half of the bladder,
the fundus being fairly free. To the right of the fundus there was a
pouch. Although the bladder had been opened for the purpose of drain-
age to relieve hemorrhage, it was determined to remove the bladder,
and this was done, the ureters being divided just proximal to their en-
trance into the bladder and the ends being carried into the rectum
through a small wound. They were not sutured to the rectal wall, but
the ligatures attached to them were carried out through the anus and
fixed to a piece of drainage-tube. No urine escaped from the rectum,
however, until the tube was inserted, when a quantity of urine containing
pus and fluid escaped. The patient died on the third day from septic
infection of the ureters and kidneys. Both ureters were found dilated
with pus and urine and the pelvis of each kidney was filled with these
materials. There was a quantity of pus in the urine prior to the opera-
tion, and it was undoubtedly the infection of the kidneys and ureters
prior to the operation which caused the death of the patient.

In a clinical lecture upon tumors of the bladder, Freyer^ first con-
siders epithelial tumors, of which the most common and the most amen-
able to treatment are the papillomas, which ^re analogous to cutaneous
warts. The tj^pe most frequently seen is the pedunculated villous papil-
loma, varying in size from that of a cherry to that of a walnut. After

1 Brit. Med. Jour., Nov. 8, 1902. ^ Lancet, Dec. 13, 1902.

^ Lancet, Jan. 24, 1903.

DISEASES OF THE BLADDER AND PROSTATE. 315

removal these are seen to best advantage when placed in water. Freyer
has removed a papilloma as large as an orange, attached to the bladder-
wall by a pedicle an inch long and as thick as a goose-quill. The growth
of a papilloma may be extremely slow, but those of small size may give
rise to very grave symptoms. In the vast majority of cases papilloma-
tous tumors occur singly. Instances are on record of spontaneous de-
tachment of a pedunculated papilloma due probably to the spasmodic
contraction of the bladder on the tumor. These tumors are most fre-
quently found between the ages of 25 and 50 years. When a growth is
seen through the cystoscope to be covered by villi, it is not proper at once
to conclude that it is of a benign type, for malignant tumors are some-
times clothed with villi and may even be more or less pedunculated.
Benign growths may be recognized by the absence of any hardness about
their pedicles or bases and by the fact that the mucous meni])rane in the
vicinity is soft and devoid of infiltration. Adenomas rarely or never
occur in the bladder, and Freyer expresses the belief that many such cases
reported have been adenomas of the prostate gland. Epithelioma ranks
next in frequency to papilloma. It is extremely rare before the age of
40. In the later stages it may ulcerate into the bowel, may extend to
the groin, giving rise to pain and edema in the corresponding lower
extremity, or it may make its way through the sacrosciatic foramen.
Tumors of the connective-tissue type occur but rarely in the bladder,
though fibroma, myxoma, and myoma are sometimes encountered. Sar-
coma is the most common tumor of this type found in the bladder, but is
much rarer than the epithelial growths. Sarcoma occurs as a smooth,
dense, rapidly growing tumor involving the entire thickness of the
bladder-wall. In referring to the symptoms and diagnosis of bladder
tumor, hematuria is first described. It is the most important and usually
the earliest symptom in all forms of bladder tumor. The urine is not
uniformly mixed with blood as in hemorrhage from the kidneys. The
attacks of hematuria are intermittent, lasting from one to several days,
and completely ceasing in the intervals. Finally the urine may never
be quite free from blood, though at times the bleeding will be more severe
than at others. The earlier portions of the urine may be clear and free
from blood, the stream gradually growing deeper in color until eventually
pure, bright blood is passed. Clots are frequently present, are dark and
irregular and unlike the worm-clots occurring in renal hemorrhage. The
bleeding is usually independent of position and motion, in these respects
differing from hemorrhage due to stone. Profuse bleeding is rare in
connection with stone, and is the rule with tumor. The extent and fre-
quency of the bleeding do not bear any proportion to the size of the
tumor. Increased frequency of micturition occurs sooner or later with
all vesical growths and never disappears until the tumor is removed. It
is most marked when the tumor is situated near the neck of the bladder.
Occasionally it is the initial symptom, preceding hematuria. Pain is
nearly always present in the later stages of all tumors. Retention of
urine may occur from various causes. Occasionally shreds of tumor
tissue may be found in the urine. Pus appears in the urine if cystitis

316 GENERAL SURGERY.

exists; this is rare in benign growths, particularly in the early stages,
unless the bladder has been infected by instruments. The ureter may
become blocked by the tumor, and hydronephrosis result. Rectal or
vaginal examination will aid in forming a diagnosis. Freyer describes
minutely the Leiter cystoscope and refers to its great value in diagnosti-
cating bladder tumors. In washing out a bladder preparatory to the
use of a cystoscope, care should be taken to irrigate the bladder slowly
and gently so as not to excite fresh bleeding. The bladder should be
examined methodically. In the vast majority of instances when a tumor
exists it will be found in the vicinity of one of the ureteral openings.
Care should be taken that the light is turned off for at least half a minute
before withdrawing the cystoscope in order to avoid burning the urethra.
That no mishap may take place, Freyer always detaches the connecting
cords from the instrument before its withdrawal. The only treatment
of bladder tumors which offers the prospect of permanent relief consists
in the removal of the growth, and this can best be done through the
opening obtained by suprapubic cystotomy. The Trendelenburg posi-
tion is considered quite unnecessary in the performance of this operation.
Freyer has also given up the use of the Petersen bag, which he believes
does more harm than good. Having located the tumor with the finger,
its pedicle is grasped with a pair of forceps and the tumor is removed by
torsion. If the growth is sessile, it will be necessary to use forceps with
broad serrated jaws. If the sessile growth is a large one, it should be
removed piecemeal, and this can be best accomplished by keeping the
bladder well distended with fluid, otherwise there will be danger of the
healthy portions of the bladder-wall being nipped. The seat of the
tumor can be best examined through an ordinary Ferguson's vaginal
speculum; light can be thrown through the speculum by means of an
electric forehead lamp. Through the speculum, any remaining portions
of the growth may be removed and the base treated as seems necessary.
If the growth is mahgnant, it should be grasped by the forceps and
brought well into the wound; this will be facilitated by an assistant's
finger in the rectum. The mucous membrane should be incised all
around the base of the growth and a free removal accomplished by broad
serrated forceps. It is unnecessary and inadvisable to attempt to suture
the edges of the mucous membrane over the former site of the tumor.
Catgut sutures are absorbed too rapidly to be of any use, and silk sutures
might form the nuclei of calculi. Suprapubic drainage is always em-
ployed after these operations.

Crandon^ discusses at length the pathogenesis and pathologic
anatomy of enlarged prostate. The work here represented was done
largely with a view of investigating the conclusion of the monumental
work of Ciechanowski. The article is an extensive one and terminates
with the following conclusion: (1) The underlying cause of the usual
form of prostatic enlargement and of certain forms of prostatic atrophy
is a slow formation of new connective tissue due to infection or to infec-
tion aggravating a senile degenerative process. (2) The gonococcus is-
lAnn. of Surg., Dec, 1902.

DISEASES OF THE BLADDER AND PROSTATE. 317

probably most often the specific infection because (a) of_ its great fre-
quency; (6) other inflammatory causes are not common in the parts in
question ; (c) a great similarity exists between the histology of gonorrheal
processes and those seen in these senile prostates. (-3) Neoplasms, fibro-
myomas, and adenomas occur, but may be called rare.

Ransohoff' advocates strongly the prerectal curvilinear incision
for prostatic abscess, and reports 3 cases upon which he has operated
by this method. If the acute follicular suppurations of the prostate
which attend gonorrhea are excluded, suppuration within the parenchyma
is relatively rare. The report of the Massachusetts General Hospital for
8 years shows only 13 cases of acute prostatitis in a total of 25,000 sur-
gical patients. Several of these acute cases were not designated as pros-
tatic abscess. Although the symptoms, local and general, indicate both
the nature and seat of the trouble in most instances, nevertheless ab-
scesses within the prostate are sometimes overlooked. This is largely
due to the fact that the physician fails to make a digital examination of
the rectum. Occasionally the abscess assumes a latent form without
functional disturbance of either urethra or bladder and yet periprostatic
phlegmons of the gravest character are developed. Ransohoff refers to
a case of this kind which was admitted to his wards in a moribund condi-
tion. The autopsy revealed an enormous phlegmon of both ischiorectal
fossas, gangrene of the anterior rectal wall, and sloughing of the prostate
gland. Running free through the large cavity were 2 inches of the intact
urethra. The vital resisting power of the urethral wall under stress of
sloughing processes around and about it is often observed in extravasa-
tion of urine. A large proportion of prostatic abscesses, if untreated,
open into both the rectum and urethra. This was the result in 21 out of
67 recorded cases. Such cases are either rapidly fatal or, if recovery
ensues, leave urethrorectal fistulas which are often beyond relief. "In
55 out of 115 cases, the abscess opened spontaneously into the urethra
or was opened by the beak of a passing instrument. It is self-evident
that in this category would be found a large number of follicular abscesses,
or such at any rate as would not be deeply placed within the parenchyma.
How frequently the urethral drainage of even these superficial abscesses
is insufficient is manifested by the chronicity of the discharge and the
recurrence of retention symptoms." Whatever their source, deep-seated
prostatic abscesses develop without entangling alliances with either the
urethra or rectum, although with increase in size they tend to open in
one or the other of these channels. Therefore, to drain the abscess
between the urethra and rectum is the natural procedure. After referring
to the methods of draining the abscess through the urethra and through
the rectum the author describes 3 cases in which he established very
satisfactory drainage through the perineum without injury to either the
rectum or the urethra and in which prompt healing of the abscess took
place. He employed a prerectal curvilinear incision, beginning near the
tub(>r ischii of the right side, curving around and within an inch of the
anal orifice to the same point on the left side. No staff was used. " After
1 Ann. of Surg., Nov., 1902.

318 GENERAL SURGERY.

the division of the superficial fascia with a few fibers from the external
sphincter to the bulbocavernosiis, the bulb of the corpus spongiosum and
the transverse perineal muscles were readily exposed and drawn forward
with a blunt retractor. The rectum was then drawn backward, and in
the depth of the wound the fibers of the levator ani and the compressor
urethras were held aside after blunt dissection. By this blunt and almost
bloodless dissection the rectum was easily separated from the posterior
surface of the prostate gland. The urethra was not opened. With an
aspirating needle the abscess within the gland was easily located. It was
opened through a median posterior incision." In one of the cases there
was an escape of gas from the fourth to the eighth day after the operation
which was probably due to a slight sloughing of the anterior wall of the
rectum. This is the only valid objection which can be urged against the
prerectal incision. By adhering closely to the prostatic capsule and
guiding the cleavage away from the rectum this danger is but slight. It
is maintained that the advantages of this incision greatly outweigh this
unlikely wound complication.

Bouffleur^ recommends the transvesical cauterization as a sub-
stitute for the Bottini operation for the treatment of some forms
of prostatic hypertrophy, and after a study of the two methods he
claims the following advantages for the suprapubic or transvesical route :
"(1) It admits of an accurate anatomicopathologic diagnosis which is
fundamentally essential to intelligent treatment. (2) The cauterization
can be made with the galvanocautery or the more commonly possessed
Paquelin cautery with ease, rapidity, and safety. A curved cautery-
blade would greatly facilitate the procedure. (3) The incision can be
accurately placed. (4) We can see the field of operation and the struc-
tures being cauterized. (5) The length and depth of the incision can be
regulated to meet the requirements in the particular condition found.
(6) The temperature of the blade is under direct ocular observation. (7)
The time of application can be regulated so as to insure destruction of
the tissue, and if the Paquelin is used it can be applied with sufficient
force and time to make the incision, regardless of the density of the tissue.
(8) There is no danger from bending of the cautery. (9) If hemorrhage
does occur, its location can be definitely determined, and measures for
its control intelligently and effectively employed, as has been demon-
strated by Eisendrath. (10) It is applicable to all forms of enlargement
projecting into the bladder, and particularly so in the removal of pedun-
culated lobes or valve formations. A partial prostatectomy followed by
cauterization would be an ideal procedure for such conditions. (11) It
is applicable in all cases regardless of urethral obstruction. Such ob-
structions can frequently be readily removed from within. (12) It
admits of the removal of a calculus or the direct treatment of an ulcer.
It also admits of suprapubic drainage if the cystitis seems to require it,
or if the urethra is impermeable from within. (13) It is not as likely to
be followed by infection, phlebitis, sepsis, etc., as the uncertain urethral
operation."

• Ann. of Surg., July, 1902.

DISEASES OF THE BLADDER AND PROSTATE. 319

Negretto^ describes a method of cauterization of the prostate
through the rectum for the relief of obstruction due to hypertrophy.

The patient is carefully prepared by thoroughly emptying the rectum
the day before the operation. The procedure is described as follows:
" The patient is placed in the perineal-lithotomy position with the pelvis
well raised ; rectum dilated with the speculum and packed with sterilized
gauze above the prostate. The speculum is then \vithdrawn, the left
index-finger introduced into the rectum, and the center of the gland is
sought. Following the index as a guide, the tenaculum is inserted at this
point, slight traction upon it being exerted by an assistant. The specu-
lum is replaced and, if necessary, gauze packing introduced to hold back
any folds of the rectal mucosa. Cauterization with the Paquelin or
galvanocautery is then practised all around the point where the tenaculum
is inserted, the cautery being laid flat. The extent and depth of cauteri-
zation are regulated according to the size of the gland ; but usually it is
superficial, as this is generally sufficient to induce involution. However,
in the case of a very large gland it has been found advisable to supple-
ment flat cauterization by deep insertion of the cautery immediately
around the tenaculum and about to the depth of its point. The opera-
tion is said to last only about 2 minutes. After the operation the dose
of bismuth and opium is repeated, that the site of operation may be kept
clean for several days, and a permanent Nelaton catheter is left in posi-
tion for a few days, its removal being followed by thorough disinfec-
tion of the bladder and urinary passages. The advantage claimed for
such use of the catheter is reduction of congestion through mechanical
distention of the urethra, and consequent facilitation of the discharge of
urine from the bladder. This decrease of congestion plays no small part
in the reduction in the size of the gland. On the sixth or seventh day a
purge of oil is given, the resulting stool causing the discharge of the gauze
packing, which has been left in situ. Usually after 10 or 12 days the
catheter is permanently removed, and urine is thereafter voided natu-
rally. In the 12 cases so treated Negretto has had marked improvement
or permanent cure, with no vmfavorable effects save in a few instances in
which there was bloody urine for a day or two after operation. An
important factor in the reduction of the size of the prostate by this
method is believed to be its power to overcome congestion. The opera-
tion is also said to be devoid of danger and to have the inestimable advan-
tage of being mthout effect upon the genital organs."

E. Wyllys Andrews^ describes a method of performing infrapubic
section in prostatectomy. The infrapubic route is preferred because
of the great advantage to be obtained if the surgeon will divide all
attachments of the prostate to the pubic arch. The following are the
author's conclusions: "(1) The narrowness of the male pelvic outlet
becomes surgically important with the overgrown prostate. (2) Over-
growth of the prostate does not cause obstruction unless there is also
outside pressure. (3) This may come from the ligaments and muscles
without the organ actually pressing upon the ischia or from bony pros-

' Gaz. degli Osped., Aug. 10, 1902. ^ Jour. Am. Med. Assoc, Oct. 19, 1902.

320 GENERAL SURGERY.

sure. (4) Relieving the prostate from the fixed space behind the pubis
allows it to expand and cures the obstruction, (5) This can be done
best by an anterior incision and should be accompanied by a cutting of
the prostatic ring and removing a segment extra-urethrally. (6) Inci-
dentally the change of position, lowering the bladder outlet, does away
with the retroprostatic pouch, and greatly assists natural drainage. (7)
The separation of the prostatic and urethral ligaments from the pubis
and the weakening of the urogenital diaphragm are not to be avoided,
but sought."

Paul Thorndike^ reports 9 cases of prostatectomy with 1 death, and
reaches the following conclusions regarding the condition : " (1) That
great relief can be given to all patients suffering from symptoms due to
obstructing enlargement of the prostate, either by palliative or by opera-
tive means. (2) That the time to resort to operative measures is just
as soon as palliative treatment, carefully executed by competent hands,
has failed to give relief. (3) That complete prostatectomy is always the
operation of choice, because it is the only operative procedure which
cures or gives uniformly good results, when successfully performed in
proper cases. (4) That the best time for its performance is just as soon
as palliative efforts have failed, or are manifestly impossible of execution,
and before secondary changes in the bladder and kidneys, due to long-
continued obstruction, have taken place. (5) That in those cases which
come for surgical relief so late in the development of the pathologic
conditions that the bladders and kidneys are extensively diseased, and
the patient is manifestly exhausted by long-continued suffering, other
less certain and perhaps less severe measures may be advised, instead
of a complete prostatectomy; but that such a decision can only be and
must always be made by the surgeon for the individual case, and cannot
be made the subject of a generalization. A consideration of these other
methods of treatment cannot be entered upon in this paper."

Sir William Thompson^ reports 5 cases of suprapubic prostatectomy
and discusses the various operative measures for the relief of prostatic
hypertrophy. While he thinks the method followed in these cases is
preferable to others, yet he states that there are cases in which the
operation through the perineum may be more easy, such as in a man
with a large pendulous abdomen. Small prostates may be more easily
removed through the perineum, but that route is certainly unfitted for
the enucleation of some of the large masses frequently met with. Par-
ticular attention is called to the following points: " (1) So far as I have
seen, the lateral lobes are most frequently the cause of obstruction, I
have not myself seen a true pedunculated mass producing a block at
the internal orifice, although we have been in the habit of laying stress
upon this as the usual cause of the urinary distress. (2) The bulk of
the prostate as felt in the rectum gives us no indication as to its intra-
vesical contour. It may present two smooth lateral masses in the bladder,
\^4th the urethral opening forming a dimple between, or it may have
a somewhat undulating surface, due to the projection of adenomatous

1 Boston M. and S. Jour., Aug. 28, 1902. ^ grit. Med. Jour., April 18, 1903.

DISEASES OF THE BLADDER AND PROSTATE. 321

tumors in the substance of the gland itself. No extravesical examination
will determine the difference, although in cases in which the prostate is
very large its general outline may be determined by a bimanual examina-
tion— -two fingers of the left hand being in the rectum, and the right
fingers over the bladder. (3) The size of the prostate has no necessary
relation to tiie severity of the urinar}^ distress. (4) The smaller the
tumor, the more difficult relatively is its enucleation. Freyer has also
observed this fact, and he accounts for it by the suggestion that the
large tumor shakes itself free, as it were, from its natural attachments.
The prostate which I exhibit, which was removed mth its urethra, only
took 10 minutes to enucleate. The single lobe took 25 minutes of hard
work. I think the removal of the larger tumors is more facile, because
they are more bulky, looser in their attachments, and therefore more
easily dealt with by the forefinger when they are pressed upward from
the rectum. The smaller ones are not so stable; they are apt to move
much during the enucleating process. Added to all this there is no
doubt that the attachments of the mucous membrane are more intimate
and require a good deal of cautious force to free them." The hemorrhage
which sometimes is severe from the veins of the prostate is usually easily
controlled by flushing with hot boric acid solution. When this is not
sufficient, Thompson employs a tampon made of a piece of smooth red
rubber, which is attached at its center by means of a silk ligature to a
catheter and is then drawn into the urethra. The pressure of the rubber
is sufficient to arrest the hemorrhage, and it can be easily withdrawn
through the suprapubic wound by a hgature which is passed through its
edge. This tampon closely resembles that which is used for plugging
the posterior nares.

Thorkild Rovsing^ (Copenhagen) presents his own experience in the
various methods of operating for hypertrophy of the prostate and
strongly recommends the more conservative methods of treatment.
Freudenberg, one of the strongest advocates of the Bottini operation,
found that the mortality-rate in 318 cases in which the Bottini operation
was done was 8.5 %. The mortality of the operation of prostatectomy
is even higher. Only a small percentage of the cases treated by castra-
tion and vasectomy are permanently benefited. " Rovsing, in concluding
his article, advocates that patients who are not in specially bad condi-
tion, who have only a moderate amount of residual urine, and who have
intelligence and facilities for catheterization, be treated by systematic
catheterization in preference to any of the operative methods. Those
cases in which there is total retention or in case of severe cystitis and
other complications he believes are preferably treated by suprapubic
cystotomy. He performs the operation under local anesthesia with cocain
solution, inserting a drainage catheter which can be left for an indefinite
time, and by the apparatus which he employs soiling of the patient's
clothing is avoided. Out of a considerable number of cases in which he
has employed this method of treatment none of the patients have died
as result of the operation, and in many cases in which the patients were
' Archiv. f. klin. Chir., 1902, Ixviii, 934.

322 GENERAL SURGERY.

in an apparently desperate condition so complete a recovery resulted
that they were able to get about and resume their employment."

In a discussion on the treatment of chronic enlargement of the
prostate at the British Medical Association, P. J. Freyer^ reported 7
additional cases of enlarged prostate removed by the suprapubic route.
These, together with cases previously operated upon, make a total of 21.
[For a description of the suprapubic operation performed by Freyer see
Year-Book for 1903.] Each of the additional 7 cases was described
briefly and the specimens were shown. These specimens are classified
in 3 groups, as follows: ''(1) Those in which the lateral lobes have
separated along their superior commissures only, the prostates coming
away as a whole, leaving the urethra, and probably the ejaculatory ducts
in most instances, uninjured. (2) Those in which the lateral lobes have
separated along both commissures and have been removed separately,
leaving the urethra and ejaculatory ducts intact. (3) Those in which
the lobes have not separated along either commissure, the prostate being
removed as a whole, after the urethra and ejaculatory ducts had been
torn across, and in some instances the prostatic urethra either partially
or entirely removed. In most of the cases of this type it will be observed
that the prostate is encircled by a thin girdle of fibrous and muscular
tissue, part of the prostatic sheath, so that in these instances not only
has the prostate in its true capsule been removed, but in addition a
thin layer of the sheath outside this has also come away." Freyer has
abandoned the use of any cutting instrument for dividing the mucous
membrane over the prominent portions of the prostate in the bladder
preparatory to the enucleation of the gland in its capsule, using instead
the sharp edge of the finger-nail. He states that in the gradual enlarge-
ment of the prostate the sheath becomes thinned in the direction of
the bladder till eventually the prostate bursts through its sheath in
this direction and is merely covered by mucous membrane. Great care
should be taken to avoid opening the true capsule of the gland, and
therefore the use of scissors or the scalpel should not be recommended.
If the capsule is opened, the surgeon will find himself enucleating isolated
adenomatous tumors instead of the whole organ. Freyer has now per-
formed this operation "on 21 patients, varying in age from 58 to 79
years, the prostates removed weighing from H to 10^ ounces. All had
entered on catheter life, and, save two or three, complete catheter life
from a few months to 14 years. All were in broken health, some of
them being almost moribund before operation. Many suffered from
cystitis, pyelitis, kidney or heart disease, or some other complication. In
19 of these patients an absolute and complete cure has ensued. In one
instance the patient had recovered from the operation, and was passing
his urine naturally, when acute mania set in, from which he died on
the twenty-fourth day. The remaining case, after progressing satisfac-
torily in all respects, suddenly, on the ninth day, succumbed to heat-
stroke."

Alexander (New York) was the first to discuss this paper, and con-
1 Brit. Med. Jour., Nov. 8, 1902.

DISEASES OF THE BLADDER AND PROSTATE. 323

fined his remarks largely to the surgical anatomy of the p'rostate. "He
demonstrated the fact that the true capsule of the prostate was derived
from the pelvic fascia, and that within this and independent of it was
the secondary capsule or sheath, the so-called prostatic sheath of Thomp-
son. He pointed out, secondly, that enlargement of the gland partic-
ularly affected the lateral lobes in front of and behind the seminal ducts,
and agreed with Freyer that the so-called third lobe was always of the
nature of an outgrowth from one or other lateral lobe. Thirdly, he
directed attention to the important distinction from a pathologic point
of view between the portion of the gland represented by the lateral
lobes and that part which lies behind the urethra in front of the seminal
ducts. The first was responsible for obstruction in enlargement of the
gland, while it was in the latter that cancerous and other pathologic
conditions most frequently originated. When the whole prostate was
removed the capsule which belonged to the pelvic fascia was not taken
away with it; the sheath was, however, removed. By a study of the
surgical anatomy he had been convinced that for removal of the gland
the perineal route was the best. He operated through a median jDerineal
section and preserved the prostatic urethra."

Sir WiUiam Macewen inclines to the view that the perineal route in
operating upon the prostate is the route of choice. He agrees that the
cause of obstruction is in the overgrowth of the lateral lobes in most
instances, and he has, by removing the lateral lobes through the perineum
without opening the urethra, obtained very satisfactory results.

Jordan Lloyd stated that he thought it was clear that Freyer had
performed two different operations; in some cases he had enucleated the
lateral lobes; in others he had taken away the whole gland along ^nth
the prostatic urethra.

Parker Syms (New York) took a strong stand in favor of the perineal
operation in preference to the suprapubic route for removing the prostate.
The suprapubic method not only makes two wounds in the bladder- wall,
but leaves a pouch from which the prostate has been removed, which
pouch is drained in a most unsatisfactory manner. Syms described his
own method of performing perineal prostatectomy and showed liis
inflatable rubber prostatic retractor [see Year-Book for 1903], which
greatly facilitates the enucleation of the prostate through the perineal
wound. The rubber retractor also has the advantage of preventing
bleeding. Usually, but not always, the floor of the prostatic urethra is
divided when the middle portion of the gland is taken out, and Syms
has had all of his specimens examined microscopically and it has been
shown that the mucous membrane had not been taken away except in one
case, and in that but a small portion was found on the middle lobe.
After the enucleation has been completed an ordinary perineal drainage-
tube, No. 35 or 36 French, is employed, the wound and the space behind
the bladder from which the prostate was removed being firmly packed
with iodoform gauze. The tube is removed on the fifth, sixth, or seventli
day, when the patient is allowed to sit up and walk about. "He has
operated upon 21 patients, and has had no death immediate nor remote.

324 GENERAL SURGERY.

His second case was incomplete for reasons elsewhere stated. All of
his other cases have resulted in practical cure, that is to say, they have
been able to hold their urine, not having incontinence; and they have
been able to empty their bladders, being cured of residual urine: They
have been able to hold their urine from 2 to 4 hours during the day.
Most of them have been able to go the night without rising; some of
them have been obliged to rise once. These 21 patients have been a
fair representation of the various types of this affection. They have
ranged from 50 to 78 years of age. All had cystitis except one. He was
operated upon during his initial attack of retention. Two of the patients
had bladder stones. Some of them were very feeble old men; some of
them were men in good health. One case only suffered from shock
omng to a postoperative bleeding which required repacking of the wound.
This is the only complication which occurred in any of these cases."

Reginald Harrison did not think that the operation as described by
Freyer is entirely free from criticism in its general application to the
advanced forms of prostatic obstruction. He believes that the removal
of a portion of the urethra which the prostate contains is open to the
objection that there is a great likelihood that cicatricial contraction mil
later produce stenosis of the canal, giving rise to great difficulty and
the necessity of the use of the bougie. In fact, he reports a case of
his own operated upon after the method of Freyer in which this did
take place. It is thought that frequently it is unnecessary to remove
the entire prostate, but that the offending portion can be removed by
the perineal route with comparative safety and without danger to the
urethra.

In closing the discussion Freyer stated that he wished to emphasize
the difference between the operation which he performed and the old
operation of McGill, which was but a partial prostatectomy, whereas
his operation consists in the removal of the entire organ.

Ochsner^ deals vnth the indications for operation in hypertrophy
of the prostate and reports 22 cases with operation. From a study of
these cases and the literature on the subject, the following conclusions
are drawn: " (1) Perineal prostatectomy is indicated in all cases of ob-
struction due to hypertrophy which cannot be relieved for any consider-
able period of time by hygienic measures and medical treatment. (2)
This is especially true in old men past the period of virility, because
in these cases it is not necessary to preserve the seminal vesicles. (3)
In younger patients more persistent efforts should be employed to obtain
relief with nonoperative treatment, and in case of operation the seminal
vesicles should be preserved. (4) In the presence of stone of the bladder
complicating or resulting from the obstruction due to enlargement of
the prostate gland, the latter should be removed and the stone extracted
through the perineal wound. (5) The contraindications to the operation
are (a) acute infection, (h) advanced nephritis with or without pyelitis,
(c) other coexisting conditions of sufficient importance to make any major
operation very unsafe. (6) If possible thorough preparatory treatment
^ Chicago Med. Recorder, May, 1903.

PLASTIC SURGERY, BURNS, ULCERS, GUNSHOT WOUNDS. 325

should precede the operation. This should consist in hygienic measures,
rest in bed, drinking distilled water, irrigation of the bladder, and the
administration of nonirritating remedies which have a tendency to render
the urine sterile. (7) In case the obstruction is complete and catheteriza-
tion impossible because of the obstruction or on account of the resulting
hemorrhage, an immediate operation is indicated. (8) The operation
should be performed before patients have advanced to this condition."

N. P. Dandridge^ discusses the present status of treatment of
hypertrophy of the prostate, describing a number of cases operated
upon. The author takes the stand that although, of course, there are
many cases in which prostatectomy is indicated and should be performed,
especially those complicated by stone, yet it is thought that the tendency
to operate is too prevalent. He is convinced that in the largest propor-
tion of cases of hypertrophy the proper and judicious use of the catheter
is to be preferred to operative measures. Perineal drainage for some
weeks wdll often yield favorable results. Perineal prostatectomy is the
preferable method of removing an enlarged prostate, but should not be
postponed too late. The operation should be considered a grave surgical
procedure and not recommended hastily.

After the discussion of the symptoms of prostatic hypertrophy,
their cause and relief, Edward L. Keyes, Jr.,^ presents the following
conclusions: "(1) Chronic obstruction to urination Ls the underlying
cause of almost all the symptoms attributable to hypertrophy of the
prostate gland. (2) This obstruction may be regarded as an elevation
of the internal orifice of the urethra. (3) Yet obstruction may exist
without symptoms, and symptoms without obstruction. (4) For the
immediate cause of all the symptoms is congestion. (5) Hence to the
patient the disease represents only a congestion. (6) While to the sur-
geon it represents, for the most part, an obstruction, an elevation of
the urethral orifice. (7) The symptoms may often be relieved by relief
of the congestion without regard to the obstruction. (8) Yet such treat-
ment is purely palliative and is not the function of an operation. (9)
Radical treatment consists in permanent relief of the obstruction in the
floor of the urethra with little regard to congestion. (10) This may be
accomplished by cauterization or extirpation of the offending mass
through a perineal or a suprapubic incision. (11) The operation to be
preferred must attack the obstacle most directly, and remove it most
rapidly, while preventing hemorrhage and providing perfect drainage.
(12) Of the operations employed at the present day, the one which
most often fulfils these conditions is perineal galvanoprostatotomy."

PLASTIC SURGERY, BURNS, ULCERS, AND GUNSHOT

WOUNDS.

BardeUini^ presents an interesting report of gunshot wound of the
cervical portion of the vertebral column. The patient was a boy,

' N. Y. Med. Jour., Jan. 3, 1903. ^ Phila. Med. Jour., Dec. 6, 1902.

3 Riforma Medica, May 6, 1903.

326 GENERAL SURGERY.

aged 16 years. The bullet entered the mouth, injuring the teeth and
tongue, and lodged between the fourth and fifth cervical vertebras. At
first the patient presented the symptoms of cerebral concussion, but later
developed an inability to move the head because of pain and rigidity
in the neck. When the head was bent forward, the patient complained
of a sensation like an electric current passing through the entire body,
especially marked in the lower limbs. There was tenderness on pressure
of the right side of the neck in the region of the thyroid cartilage. A
skiagraph was made, which showed the bullet lodged in the space between
the fourth and fifth vertebras. As no improvement had taken place after
the twenty-third day, it was decided to remove the bullet. The pharynx
was exposed through an incision extending along the right sternocleido-
mastoid muscle. When the pharynx was opened, the course taken by
the bullet could be easily determined. It was found in the position
indicated by the skiagraph and was removed. The pharynx was closed
with a catgut suture and the wound in the neck was closed with sutures
of silk. Infection took place, having its origin in the pharyngeal wound,
and allowed the escape of food into the wound. After drainage, how-
ever, the wound closed and the patient recovered. Bardellini thinks that
the sensation complained of by the patient and produced by flexion of
the head was due to the laceration of the intervertebral ligaments and
a resulting displacement of the vertebras in such a manner as to com-
press the special nerve-roots. Another case operated upon by the author
is referred to, in which esophagotomy was done for the removal of a
foreign body and the esophageal wound closed. In this case also infec-
tion took place. These two cases confirm the advice of those authorities
who recommend tamponage of esophageal wounds.

A discussion of gunshot injuries of the skull and brain based upon
the study of 30 cases occurring during the South African war is presented
by Irving.^ It is stated that the majority of the deaths occurring on
the battle-field were results of wounds of the skull and brain. Those of
the thorax rank next as a cause of immediate death. It is said that
7 out of 10 penetrating gunshot wounds of the skull are immediately
or rapidly fatal. Notwithstanding these statements, the percentage of
recoveries in this class of injuries has been surprisingly large when com-
pared with former wars. This is not only due to the systematic use of
antiseptics, but also, and in a niuch greater degree, to the properties of
the small-bore bullet, its high penetrating power, its slighter liability to
distortion, and its general initial asepticity. Irving states that he has
observed 12 cases in which recovery took place after complete perforation
of the cranial cavity. Solid small-bore bullets are capable, if at close
range, of producing considerable explosive action. These effects are
more marked when the bullet comes in contact with the shafts of the
long bones and are less marked in the skull. All gunshot fractures of
the base involving the middle or posterior fossa, or both, with penetra-
tion of the cranial cavity and base of the brain, are at all ranges either
immediately or ultimately fatal. As the range at which the wound is

» Lancet, Oct. 25, 1902.

PLASTIC SURGERY, BURNS, ULCERS, GUNSHOT WOUNDS. 327

inflicted increases, the character of the injury becomes progressively less
severe. A description is given of gutter fractures and of superficial and
deep perforating fractures. Seven out of the 9 cases of deep perforating
fractures reported by Irving recovered. Six of these patients were fol-
lowed up for at least a month after operation; at this time they could
talk quite intelligently about their wounds and their experiences, but
the power of continued mental exertion was soon exhausted. One
interesting case is recorded in which a soft-nosed Mauser bullet entered
the skull through the malar and sphenoid bones, struck the petrous
portion of the temporal, glanced and struck the vertex of the skull,
was again deflected, and lodged in the motor area. The interesting point
in this case is that, although the bullet was a so-called expanding bullet,
it did not expand. This patient died.

G. R. Fowler^ presents the notes of a case of gunshot wound of
the neck. The buflet entered the mouth and lodged beneath the skin
at the posterior border of the sternomastoid muscle. In its transit the
bullet tore away a portion of the left side of the tongue. The tongue was
sutured and the track of the buUet was packed. On the sixth day after
the injury there was a profuse hemorrhage which caused the tampon in
the track of the bullet to be forced into the mouth. About an hour
after the onset of hemorrhage, and when it had been partially controlled
by packing, Fowler exposed the common carotid artery and passed under
it two ligatures, one of which was twisted just sufficiently to control
the blood-current without undue pressure of the arterial coats. The
weight of the forceps was suflficient to prevent the untwisting of the
ligature. An incision was then made in the neck, the bullet removed,
a quantity of blood-clot cleaned out, and the bleeding point readily
discovered when the pressure upon the carotid was slightly relieved. The
bleeding vessel was the facial, which was ligated. The ligatures were
removed from the carotid, and, no bleeding occurring, the lower wound
was closed and the upper wound drained. Six days later and 12 days
after the receipt of the injury, another profuse hemorrhage took place,
and again the common carotid was exposed and the blood-current con-
trolled in the same way as on the first occasion. The bleeding at this
time apparently came from the ascending pharyngeal, which, however,
could not be ligated because of the distortion of the parts due to inflam-
matory exudate. Because of the septic conditions overlying and sur-
rounding the bifurcations of the common carotid, figation of the external
carotid was out of the question; therefore a ligature was placed about
the common carotid. The bleeding ceased at once, but, owing to the
freedom of anastomosis between the external carotids, it was thought
wise to ligate the external carotid of the opposite side, which was done
at once. The patient made a slow but uninterrupted recovery.

W. L. Rodman^ discusses gunshot wounds of the thorax and abdo-
men from the standpoint of the civil surgeon. The diagnosis of pene-
trating wounds of the thorax is not difficult, as a rule, and should always
be made without the use of the probe. The amount of external hemor-

* Brooklyn Med, Jour., Feb., 1903, ^ Jour. Am, Med, Assoc, Feb, 14, 1903.

328 GENERAL SURGERY.

rhage in such cases is usually small. Hemothorax is apt sooner or later
to develop, and is usually due to an injury of the intercostal vessel,
Rodman states that unless the patient succumbs within a short time to
hemorrhage the prognosis is good, provided the wound has not been
interfered wdth. Numerous instances are reported of recovery from
penetrating wounds of the chest, and in fact recovery is the rule if patients
do not die immediately from shock or hemorrhage. The treatment in
such injuries should be confined to cleansing the skin about the wounds
and thoroughly immobilizing the chest and keeping the patient quiet
with opium. Suppuration as a subsequent complication is not likely to
occur unless some portion of the clothing has been carried into the lung.
It is shown that the bullet itself is not likely to set up suppurative in-
flammation. Any attempt to remove the ball from the lung is accom-
panied by great danger and is rarely justifiable.

Attention is called to the fact that pistol-shot wounds of the abdomen
may occur without perforation of a viscus, a number of such cases having
been reported. Penetration without perforation is extremely rare in civil
practice. Contrary to what has usually been taught, extraperitoneal
wounds of either the intestines or bladder are more fatal than intra-
peritoneal wounds. Attention is called to the improvement recently
made in the recovery-rate after operation for penetrating gunshot wounds
of the abdomen. Rodman insists on as early a laparotomy as is con-
sistent vnth the environment and conditions of each case. Frequently
there is little extravasation of intestinal contents until the abdomen has
been opened and the intestine handled; hence it is recommended that
when operating upon these cases each aperture should be protected with
gauze as soon as it is encountered, and the openings as quickly closed
as possible. It ls the author's belief that drainage should very generally
be employed in shot wounds of the abdomen. It is a mistake to wait
for the subsidence of shock or its amelioration before opening the abdo-
men in these cases. Rodman protests against the idea that celiotomy
should be performed regardless of environment and the ability of the
operator. Inexperienced and timid men may, from a false sense of duty,
operate on such cases when their lack of training, want of assistants,
and inadequate facilities foretells disaster to their patients. Abstention
from all food and drink, with opium to check peristalsis early in the
case, will save more cases than reckless operating.

LaGarde^ discusses gunshot wounds of the chest and abdomen
from the military standpoint. The treatment of such wounds is not
the same in military practice as in civil practice. This is largely due
to the difference in size, composition, and velocity of the projectiles and
to environment, transport, and morale. The greatest resistance in tissue
wounds comes from compact bone, like that encountered in the shaft
of the long bones, and from water. The remarkable escape from injury of
the heart, the great vessels, and the esophagus in penetrating wounds
of the chest is due to the loose cellular tissue which permits displacement
at the moment of impact. This change in position is more apt to occur
1 :\Ied. News, Nov. 15, 1902.

PLASTIC SURGERY, BURNS, ULCERS, GUNSHOT WOUNDS. 329

when the remainmg velocity of the bullet is low. Referencer is made to
two cases occurring in the Philippine Islands in which the bullet passed
through the chest and in which the escape of the heart and large blood-
vessels was remarkable. Wounds of the lung made by the modern bullet
almost invariably recover, except in those instances in which the missile
cuts one of the large vessels. The mortality from penetrating gunshot
wounds of the chest during the Civil War was 62.5 %, whereas during
the recent war with Spain and in the Philippines they presented a mor-
tality of 27 %. In the Surgeon-General's Report for 1900 there are
recorded 116 cases of penetrating gunshot wounds of the abdomen which
were submitted to operation, with a mortality of 70 %, and the large
majority of the 30 % that recovered sustained no injury of the intestine.
The success of celiotomy for gunshot wounds during war -\Aill largely
depend upon the confidence and skill of the operator and the nature
of the environment. In order to accomplish successful abdominal work
in war it Avill be necessary to use a great deal of forethought so that
the operators may not be hampered by the endless difficulties which are
apt to occur in active campaign.

A lengthy discussion is presented by Louis A. LaGarde* on poisoned
wounds in warfare, with the following conclusions: The custom of poi-
soning implements of warfare is shown to have been practised from the
most ancient times to the present day, by the employment of not only
vegetable but also of bacterial poisons. By experiments LaGarde has
shown that the explosive and the ball are contaminated, the first in
12 % and the latter in 47 % of instances." The wad- and wadding mate-
rials are always contaminated. It is also shown that the bacteria existing
in the powder, the wad, on the ball or in the barrel of the gun are not
destroyed either from the heat generated by the firing or from the
friction. LaGarde also believes that there is nothing in the act of
firing to destroy the lethal properties of vegetable poisons, and that
these are readily conveyed into wounds when they are placed in the
powder, on the ball, or in the barrel. Animal poisons, such as snake-
venom, can be conveyed in the same manner. The above facts can be
so easily proved that it becomes the duty of the surgeon in all criminal
attempts to make a thorough investigation of the weapon, and the fol-
lowing rules are suggested : (1) If powder grains are found in the clothing
or wound, they should be carefully collected for examination. (2) The
projectile inflicting the wound when recovered should be at once dropped
into mediums with sterile forceps. (3) If the wound has been the result
of a ricochet shot, the point of impact before penetrating the skin
should be examined for the presence of poison. (4) The inside of the
barrel of the weapon should be examined for specific microorganisms.
(5) The examination should also include a thorough study of all the
ammunition remaining in the weapon. (6) The same steps should be
observed in examinations for the presence of toxins, animal and vegetable
poisons.

Charles Roberts^ discusses the treatment for abdominal wounds in

' Jour. Am. Med. Assoc, April 18, 190.3. ^ jj^it. Med. .Jour., Oct. 4, 1902.

22 S

330

GENERAL SURGERY.

war and reaches the following conclusions : " (1) That as a rule the condi-
tions in a field hospital are not suitable for performing laparotomy.
Moreover, many patients with penetrating abdominal wounds recover
without operation, and in the majority of those who die the nature of
the injury is such that death must result whatever be the conditions of
operation, and an exploratory laparotomy may add a fresh danger to
the patient. (2) When occasions arise in which the conditions of opera-
tion approximate to those in civil practice laparotomy should be under-
taken for increasing intraperitoneal hemorrhage endangering life, and
when there is evidence that perforation of the stomach or bowel probably
exists, provided that the patient is seen early enough."

Amyx^ reports a case of gunshot wound of the abdomen in which
there were 19 perforations of the intestine and 4 lacerations of the mesen-
tery. A number of these perforations were closed and 11 inches of
bowel, which contained 12 perforations, resected, and an anastomosis

Fig. 58. — Richards's case of accidental giin.shot-wound of chest: .1, Wound of entrance; S, wound
of exit (Anier. Med., Feb. 21, 1903).

done -with a Murphy button. Besides perforations of the small intestine,
the cecum, ascending colon, and sigmoid were also perforated. The
operation was performed 2 hours after the receipt of the injury. After
the repair of the wounds and resection of the bowel the abdominal cavity
was thoroughly irrigated with salt solution and a number of gauze drains
introduced. The time of the operation was 3 hours. Except for the
development of a gluteal abscess, the patient's convalescence was satis-
factory. The abscess resulted from the bullet, which was removed when
the abscess was opened.

Richards^ reports a case of an American soldier who accidentally shot
himself through the left chest. The points of entrance and of exit
of the bullet are indicated in the accompanying illustration (Fig. 58).
The patient bled profusely from the wounds at first and also expectorated
considerable blood. The area of skin about the wounds was thoroughly

1 Med. Rec, Sept. 20, 1902. ^ Amer. Med., Feb. 21, 1903.

PLASTIC SURGERY, BURNS, ULCERS, GUNSHOT-WOUNDS. 331

cleansed and an antiseptic dressing applied. The patient later devel-
oped traumatic pneumonia, which gradually subsided, and he recovered.
In less than two months he returned to duty. During his convalescence
gymnastic lung exercises were employed to reestablish expansion.

Collier^ discusses the relationship between nasal obstruction and
deformities of the upper jaw, teeth, and palate, and presents a number
of casts illustrating his views. In the first place, the author's communi-
cation tends to show that in impeded nasal respiration there is a difference
in the pressure on the outside of the young and growing skull, altering
and affecting the curve of the upper jaw and the shape of the face and
palate. It is shown that in young animals the nasal cavities of which
have been obstructed for the purpose of scientific observation, a profound
alteration takes place in the development of the upper jaw, and a marked
alteration in the curves of the alveolar arch, and in the position and
height of the palate. Collier believes that heredity has nothing to do
Avith these changes, as is shown by the fact that they are not present in
infancy, but take place later in youth. The effect upon the bone is pro-
duced by the passage of air through the mouth, which abstracts the
contents of the nasal chambers and so produces an increased pressure of
the nasal box. This increased pressure not only pushes up and elevates
the hard and soft palate, but it squeezes and approximates the halves
of the upper jaw, thus impeding its development. Professor Ziem, in
his experiments upon animals, has shown the truth of this explanation.
If a manometer be connected with the nose and fitted accurately during
each oral inspiration, the mercury -will ascend in the proximal limb; this
is considered by the author as an absolute proof of his theory.

The use of paraffin in plastic surgery is dealt with by Paget,^ who
devotes particular attention to the technic and to the improvement of
deformed noses and prolapse of the rectum. But one serious disaster
has been traced to the use of paraffin, a case of pulmonary embolism.
The greatest care should be practised in the preparation of the paraffin
and in the selection of the syringe. A leak or a crack in the syringe or
the setting of the paraffin before the injection is completed ruins the
whole operation. Paget believes that the best paraffin is that which has
a melting-point somewhere between 108° and 115° F. When the paraffin
must stand heavy and immediate pressure, the higher melting-point is
preferable. In the injection into the loose submucous tissue an ordinary
antitoxin syringe is satisfactory, but in the nose cases an especially
well-made and tight syringe with its needle attached by a screw is to be
preferred. It is also well to have two syringes in case an accident hap-
pens. Paget has operated upon 43 cases of deformed noses, and in no
case has there been a death, embolism, sloughing of the skin, or wander-
ing of the paraffin. The results have varied from very good to indif-
ferent, but the large majority has been satisfactory. It must be remem-
bered in these cases that only when the skin over that portion of the nose
which is to be raised is fairly movable is the paraffin injection possible.
This bars, of course, those cases in which depression is covered by cica-

' Lancet, Oct. 18, 1902. ^ Lancet, May 16, 1903.

332 GEXERAL SURGERY.

tricial skin which is tightly bound dowTi. Just before injecting the
paraffin the needle should be dipped for 6 or 8 seconds in water that is
boiling or just off the boil, in order to prevent the setting of the paraffin
in the needle. The greatest care should be exercised by the assistant to
prevent the paraffin settling in the forehead, the eyebrows, the inner
angles of the orbits, and the side of the nose. Paget makes the injection
at the lowest point of the depression. The molding should be vigorous,
and while it is being done cold water should be allowed to trickle over
the nose. The patient is, of course, etherized. Paget has had 3 cases
of prolapse of the rectum in old people in whom he has obtained good
results from paraffin injection.

Walsham^ discusses some operations for rectifying crooked and
depressed noses. He states that crooked noses often are not the result
of fracture of the nasal bones, but their bodily displacement at the fronto-
nasal suture. This, however, does not appear to be true when the patient
is looked at from the front, as the anterior or cartilaginous portion of the
nose is generally at the same time deflected in the opposite direction. For
these cases forcible straightening ls generally insufficient, and for cor-
recting the deformity Walsham recommends a subcutaneous osteotomy
of both bones along the nasomaxillary suture. This can be done through
a small skin incision and with a mastoid chisel. If thoroughly replaced,
the tendency to recurrence of the deformity after one or two days is not
great. Subcutaneous suture of the lateral nasal cartilages is then spoken
of, the author stating that he has had good results from wiring the car-
tilage to the nasal bone when it has been displaced. Occasionally it is
necessary to remove the ends of the overlapping nasal bones. His results
from the use of paraffin have been very satisfactory and permanent.
Walsham also recommends shifting the septum bodily at its juncture
with the "floor of the nose in cases of harelip, where it is found fixed out
of the median line. This operation he believes to be original with him-
self. Another operation is referred to, that of forming a septum by
elevating the maxillary crests in depression of the bridge due to necrosis.

Moszkowicz,^ who is a colleague of Gersuny, discusses the injection
of paraffin for the correction of deformities and compares the use of
hard and soft paraffin. Gersuny and the author have employed paraffin
injections in 28 cases of deficient nasal bridge and for numerous other
conditions. They always employ the soft paraffin, the melting-point
being from 36° C. to 40° C, which at ordinary temperatures is of the con-
sistence of lard, and after heating can be expressed through the finest
hypodermatic needle. Eckstein has presented 3 objections to the use
of this soft paraffin: he states that it may be absorbed; that it may
migrate from the point of injection; and that it may produce embolism.
Stein supposes that the paraffin is slowly absorbed and replaced by con-
nective tissue. The author, however, proves that this is not the case,
but that the paraffin becomes encapsulated. About 10 weeks after in-
jection there is a small-celled infiltration around the mass, and if the
injection is made into cicatricial tissue numerous giant-cells are found.

' Lancet, April 4, 1903. ' Wien. klin. Woch., Jan. 8, 1903.

PLASTIC SURGERY, BURNS, ULCERS, GUNSHOT-WOUNDS. 333

The second objection of Eckstein is true, but Moszkowicz sfates that it
has not been proved that the same objection cannot be made to the harder
paraffin. He does not think that the soft paraffin is more Hkely to pro-
duce embohsm than the harder variety. Reference is made to a case
reported by Pfannenstiel in which paraffin with a melting-point of 45° C.
was injected for the cure of incontinence of urine in a woman, and in
which pulmonar}'- embohsm followed. The author has seen 2 cases of
pulmonary embolism occur from the injection of Gersuny's soft paraffin
when the injection was made A\ithout special precautions into the peri-
vaginal tissue and the parametria for prolapse of the uterus. Both of
these patients, however, recovered. The danger of embolism can be
eliminated by first injecting Schleich's solution and then redrawing a
portion of the fluid into the syringe. If blood is withdrawn, the needle
is in a vein and the paraffin should not be injected; if, however, no blood
is withdrawn a second syringe containing the paraffin may be attached
to the needle and the injection proceeded Anth. The white German
paraffin may be sterilized by boiling and drawn into the syringe while
liquid; when it has cooled it is injected. Moszkowicz has in 2 cases of
progressive facial hemiatrophy injected a mixture of 1 part of soft paraffin
and 4 parts of olive oil with advantage. When this method is employed,
a number of injections are required. In two cases in which the synovial
membrane had been removed because of tuberculous disease a quantity
of melted paraffin was poured between the articular surfaces to prevent
ankylosis, and in each case a movable joint was obtained.

Francis Alter^ suggests a modification in tlie technic of injecting
paraffin for saddle-nose. He reports a case of bis own in which the
muscular action of the alae of the nose was interfered with to such an
extent that the patient instead of breathing naturally through the nose
was obliged to breathe entirely through the mouth. The condition,
however, was remedied by removing the inner posterior lateral portions
of the alsp. In order to prevent the iiffiltration of the paraffin far enough
down to interfere with the action of the alse, it is suggested that these
portions of the nose should be compressed between the thumV) and fore-
finger of an assistant on each side at the time the injection is made.

F. B. Lund^ reports numerous cases of congenital abnormalities of
the phalanges, presenting photographs and skiagraphs. An interesting
point in the cases reported is the tendency of these deformities to be
transmitted from parent to child.

Keetley' makes a second report of a patient. on whom he performed
what he calls *' transplantation by exchange." The operation was one
for a large hairy mole on the cheek of an infant 2 or 3 weeks old. The
operation consisted in strapping the arm to the side of the face, dissecting
the mole from the cheek, except at one point, in taking a flap from the
arm corresponding to the area exposed on the cheek, and in fixing the
mole to the arm and the flap to the cheek. Later, the bases of the mole
and of the flap were divided, and a very excellent result was obtained.

• Amer. Med., Nov. 22, 1902.

' Ro;5ton M. and S. Jour., Dec. 11 and 18, 1902. ' Lancet, Nov. 22, 1902.

334 GENERAL SURGERY.

Flegenheimer^ reports a successful case of pig-skin grafting. The

patient had suffered the loss of about one-third of the skin and subcu-
taneous fat of the arm and forearm. Numerous grafts consisting of the
full thickness of the skin taken from the belly of a healthy young pig
were placed upon the granulating area, and nearly all of them lived.
The entire wound was soon covered with healthy skin which presented
a growth of fine hair.

X-RAYS.

For a;-ray in treatment of tumors, see section on cysts and tumors.

William Rollins^ contributes some notes on x-light. "The a;-light
tube must be in a nonradiable box from which no a;-light can escape
except the smallest beam that will cover the area to be examined, treated,
or photographed. The box must have a nonradiable diaphragm plate,
the opening in which can easily be adjusted, while looking in the fluoro-
scope, until the beam of light is the smallest that will cover the area under
examination. The crjrptoscope must have a plate of heavy lead glass to
absorb the a;-light which has passed unchanged through the fluorescent
screen, to prevent injury to the observer's eyes. The walls of the crypto-
scope must be made of nonradiable material. The patient should be
covered during photographic exposures with a nonradiable sheet, exposing
only the necessary area. An experimenter who works much with a;-light
should use a nonradiable face mask, the eyeholes of which are glazed with
thick plates of heavy lead glass. In using the cryptoscope, while testing
the tube during pumping and tuning, he should not use his hand for
examination, but should attach to the cryptoscope a Rontgen gauge and
a Williams fluorometer for determining the penetrating power of the
x-light and its brightness. The hand that holds the cryptoscope should
be protected with a nonradiable covering. During the pumping and
tuning of x-light tubes, they should be kept in an oven with nonradiable
walls." Experiments on animals prove that not only may the x-rays
bum or blind, but they may also kill. All apparatus used about patients
during applications should be of material which will allow sterilization.

Edward A. Tracy^ reports 3 cases in which he utilized actinic rays
for anesthetic purposes during minor operations.

G. C. Burdick* read a paper on radiotherapy in tuberculosis before
the American Rontgen Society, December 10 and 11, 1902. Much of his
work was based on a series of experiments conducted on guineapigs
inoculated with the tubercle bacillus. He found that when a culture of
the bacillus is exposed to the Rontgen ray its development is checked
considerably, although in every case it failed to kill the germ. Pigs
exposed to the ray lived much longer than pigs not so exposed. When
the ray was used in cases of tuberculosis in man, a slow but certain
improvement took place, and eventually a good recovery. Cases of
fibroid tuberculosis yielded very slowly. Abdominal tuberculosis re-
quires longer treatment than the pulmonary form. In a few cases a

' Virginia Med. Semi-Monthly, June 26, 1903.

2 Boston M. and S. Jour., April 2, 1903.

* Boston M. and S. Jour., Nov. 6, 1902. " Jour. Am. Med. Assoc, Jan. 17, 1903.

X-RAYS. - ' • 335

tendency to relapse has been noted. In the cases of mixed infection
improvement is delayed and there is a very marked tendency to the
sudden development of toxemia. Joint tuberculosis, in which only the
bones are involved, offers the best results, but permanent relief cannot
be obtained until complete ankylosis has occurred, and the author advises
that nothing should be done with the x-ray until this ankylosis has
occurred. He used the ray in a total of 43 cases of tuberculosis in all
parts of the body with uniformly good,results, except in one case, in which
death occurred. This was a case of advanced general tuberculosis, and
even here the improvement was at first marked.

Milton Franklin^ concludes that a phototherapeutic apparatus
should fulfil the following conditions: "(1) It should be supplied with
light by artificial means. (2) The lamp should be as powerful as the
circumstances will permit, as no arrangement of lenses or reflectors will
coax power out of a feeble lamp. (3) The lamp should be an electric
arc using chemically prepared electrodes calculated to produce a spectrum
powerful in the ultra-violet. (4) All lamps of the incandescent principle,
of whatever design, should be avoided. (5) Condensing and collecting
lenses should be as large as the nature of things will permit, and should
be made of rock-crystal or of some medium equally diaphanous to the
chemical rays. (6) The cooling apparatus should consist of a layer of
water containing no other substance and sufficiently thick to absorb the
greater proportion of heat-rays. It should be inclosed in some kind
of a vessel which will not interfere with the passage of the chemical
rays. (7) The machine should be mounted to enable the operator to ad-
just and turn it in any direction with the utmost degree of precision."

Sir WiUiam Crookes^ says: "The emanations from radium are of
three kinds, one set is the same as the cathode stream now identified
with free electrons — atoms of electricity projected into space apart from
gross matter — identical with matter in the fourth or ultragaseous state,
Kelvin's satellites, Thomson's corpuscles or particles, disembodied ionic
charges retaining individuality and identity. Electrons are deviable in
a magnetic field and are shot from radium with a velocity of about two-
thirds that of light, but are gradually obstructed by collisions with air
atoms. Another set of emanations from radium are not affected by an
ordinarily powerful magnetic field, and are incapable of passing through
very thin material obstructions. They have about 1000 times the energy
radiated by the deflectable emanations. They render air a conductor
and act strongly on a photographic plate. These are the positively
electrified atoms. Their mass is enormous in comparison with that of
the electrons. A third kind of emanation is also produced by radium
besides the highly penetrating rays which are deflected by a magnet:
there are other very penetrating rays which are not at all affected by
magnetism. These always accompany the other emanations and are
Rontgen rays — ether vibrations — ^produced as secondary phenomena by
the sudden arrest of velocity of the electrons by solid matter, producing
a series of Stokesian 'pulses' or explosive ether waves shot into space.
'Med. News, Sept. 20, 1902, ^ Lancet, May 23, 1903.

336 GENERAL SURGERY,

These rays chiefly affect a barium platinocyanid screen and only in a
much feebler degree zinc sulfid. Both Rontgen rays and electrons act
on a photographic i^late and produce images of metal and other sub-
stances inclosed in wood and leather and shadows of bodies on a barium
platinocyanid screen. Electrons are much less penetrating than Rontgen
rays and will not, for instance, show easily the bones of the hand. A
photograph of a closed case of instruments is taken by the radium emana-
tions in 3 days and one of the same case by Rontgen rays in 3 minutes.
The resemblance between the two pictures is slight and the difference
great. The action of these emanatons on phosphorescent screens is
different. The deflectable emanations affect a screen of barium platino-
cyanid strongly, but one of Sidot's zinc sulfid only slightly. On the
other hand, the heavy, massive, nondefiectable positive atoms affect the
zinc sulfid screen strongly and the barium platinocyanid screen in a
much less degree. If a solid piece of radium nitrate is brought near the
screen and the surface is examined with a pocket lens magnifying about
20 diameters scintillating spots are seen to be sparsely scattered over
the surface. On bringing the radium nearer the screen the scintillations
become more numerous and bright, until when close together the flashes
follow each other so quickly that the surface looks like a turbulent
luminous sea. It seems probable that in these phenomena we are actually
witnessing the bombardment of the screen by the positive atoms hurled
off by radium with a velocity of the order of that of light; each scintilla-
tion rendering visible an impact on the screen and becoming apparent
only by the enormous extent of lateral disturbance produced by its
impact. In the same way, individual drops of rain falling on a still
pool are not seen as such, except by reason of the splash they make
on impact, producing ripples and waves in ever-widening circles. A con-
venient way to show these scintillations is to fit the blende screen at
the end of a brass tube with a speck of radium salt in front of it and
about a millimeter off and to have a lens at the other end. Focusing,
which must be accurately done to see the best effects, is accomplished
by drawing the lens tube in or out." Sir William Crookes proposes to
call the little instrument designed for this purpose the "spinthariscope"
from the Greek word T-'.vOajii'i, a scintillation.

M. A. Cleaves^ describes a portable and easily adjusted lamp for
producing actinic rays. It is modeled after the one devised by Bang,
and consists of water-cooled iron electrodes inclosed in a metal chamber
which has two openings, into one of which is fitted a water-cooled chamber
with quartz lenses, and into the other a sliding colored window which
allows the operator to govern the intensity of light and to treat such
conditions as require a direct exposure to the light. The conducting
wires and the tubes for water pass through a hard-rubber handle. The
electrodes may be arranged for any intensity of light.

T. W. Brockbank^ reports 2 cases in which he used ultra-violet ray
anesthesia successfully for minor operations. The area to be operated
upon was exposed for 15 minutes to the rays of a No. 4 Munnin lamp.

» Med. Rec, March 28, 1903. " Amer. Med., April 25, 1903.

X-RAYS. ^ 337

C. 0. Files^ describes a new high-frequency apparatus. It consists
of a mica tube about 10 inches long into which are screwed 20 brass
knobs at intervals of half an inch, the screws projecting into the hollow
part of the tube. The wire from the positive pole of a static machine
is fastened to the knob at one end of the tube and a wire from the negative
pole is fastened to the knob at the other end. A brass sliding rod with
a depression in the upper side for contact with the screws fits into the
mica tube. The static spark leaps from one knob to the next until
it reaches the end of the rod; making a strong current with a great
number of interruptions. When the rod is pushed into the tube, the
spark-gap is lessened and the number of interruptions is decreased.

G. W. Crile^ reports a case in which an x-ray picture of a calcified
aorta was mistaken for a foreign body. The patient thought he had
swallowed a set of false teeth and made numerous attempts to dislodge
them, lacerating the lower pharynx. A skiagram showing a dark shadow
at the lower end of the esophagus, an operation was performed and the
esophagus found to be empty. A postmortem examination revealed the
cause of the shadow in an extensive calcification of the aorta.

Rutherford^ announces important discoveries relating to "thorium
emanations." "Thorium is one of the rare metals which has a power
of emitting rays similar to those which come from radiiun. They are
invisible, but will reduce the silver salts of a photographic plate. These
rays when passed over red-hot lead chromate and through boiling nitric
acid are unaffected, there being no chemical reaction. This led to the
view that the emanations might be of the nature of gases similar to
those which have been recently discovered in the atmosphere, and which
it is almost impossible to combine chemicalh'. Upon cooling the tulie,
through which these rays passed, with liquid air it was found that the
emanations were condensed in the tube. This was determined by a gal-
vanometer. The emanations were discharged in such a way that the}''
made a circuit between two electrically charged plates, the current being
registered by a delicate galvanometer. As soon as the tulie was cooled
by liquid air the current ceased, showing that whatever had been passing
through the tube was condensed. Afterward the tube was removed from
the liquid air and allowed to get warm. When the temperature had
risen to a certain point the galvanometer suddenly registered a stronger
discharge than any previously obtained. The emanations were condensed
inside the sealed tube and kept for almost a week. These experiments
seem to prove that these emanations or corpuscles have some of the
characteristics of ordinary gases. Thomson calls these emanations of
radioactive substances electrons. An electron is about the 7 go part of
the hydrogen atom, and these masses start from the negative })ole in a
vaccum tube with a velocity half that of light. Electrons emanating
from radioactive bodies behave like particles of matter partaking of the
properties of a fog or mist, and are capable of ])eing diffused away in
the free air like odoriferous substances."

1 Med. Rec, April 18, 1903. ' Cleveland Med. .Jour., Dec, 1902.

^ Montreal Pharni. Jour., Dec, 1902.

OBSTETRICS.

By barton COOKE HIRST, M.D., and W. A. NEWMAN
DORLAND, M.D.,

OF PHILADELPHIA.

PRELIMINARY AND GENERAL CONSIDERATIONS.

The Midwives Act and the Teaching of Obstetrics. — In his intro-
ductory address to a course of lectures on Obstetrics at the Owens College,
Manchester, W. Japp Sinclair^ made several references to the Midwives
Act, recently adopted in England, and to the work which lies before
the Central Midwives Board, of which he is a member. The Act, it will
be remembered, only came into force on April 1, and the board has
consequently not yet had time to complete the large body of rules, the
making of which may be said to form its first duty, and these, when
framed by the board, must be approved by the Privy Council, which
is to consider any representations made with regard to them by the
General Medical Council. Sinclair was therefore precluded frohi speak-
ing in detail of the work done and to be done by the board, but he was
able to forecast in general terms the changes which the Act might be
expected to bring about. With regard to the midwives themselves, he
looked to the Act as destined ultimately to abolish the "Gamp" through-
out the country, removing the practice of midwifery from the hands "of
the iUiterate widow, the elderly housemaid, the innominate drudge of
country districts," and placing it, so far as it is to be practised by persons
not members of the medical profession, in the hands of those who, he
submitted, should not be altogether illiterate. For example, he sug-
gested that the certified midwife should be able to read a manual, to
write a report of a case, and to have such acquaintance with the rule
of three as to enable her to prepare an antiseptic solution or to dilute
a baby's milk in the same degree on two successive occasions. The Act
itself Sinclair evidently looked upon as far from perfect, although^'capable
of amendment and improvement, but he expressed the belief that the
changes brought about by it might in the future be found to exercise
considerable influence upon the teaching of obstetrics in medical schools.
In considering the course of training generally adopted in England
for this branch of medical study, he drew unfavorable comparisons
between English practices and the superior efficiency which he claimed
for German methods. The Midwives Act is beyond question a measure

* Lancet, May 16, 1903.

PRELIMINARY AND GENERAL CONSIDERATIONS. 339

which leaves to the board which it has brought into being a very wide
discretion in the framing of the regulations by which alone the Act will
become effective, and many will study these with interest besides the
class directly concerned in them, [Although we have referred to the
Act as having come into force on April 1, that date only marked the
commencement of the powers of the board, the most immediate duty
of which consists in the framing of rules. It is not until April 1, 1905,
that a midA\'ife not certified under the Act is precluded from taking or
using the title of midwife or any name implying that she is certified
under the Act, and consequently there is no immediate urgency for the
certification and registration of those who are permitted by the Act to
be certified without being examined under the regulations of the Central
Midwives Board. They have to comply with the necessary formalities
in the course of two years from the date of the Act coming into operation,
but ar6 not obliged to do so before. It is not until April 1, 1910, that
every woman practising as a midwife will have to be certified. As,
however, the women who may desire admission to the roll of midwives
by means of the training and examinations to be imposed by the board
will require time in which to prepare themselves, that body is no doubt
proceeding as rapidly as circumstances will permit with the framing of
the necessary regulations,]

The Lessened Birth-rate. — [In view of the alarmist tendency of one
or two recently published papers on the falling birth-rate, it is perhaps
worth while to look at another aspect of the question. To some extent
this has already been done in the editorial columns of the "Journal of
the American Medical Association,"^ Attention has been called to the
unreliability of the data on which much of the pessimistic deduction has
been made, and to the fact that a falling birth-rate and death-rate were
both accompaniments of thrift and easy circumstances in a popula-
tion,] A, L. Benedict^ handles the subject elaborately. He shows that
a diminished birth-rate depends on many factors, and not aU of them,
or those most efficient, are necessarily immoral or objectionable. The
advance in the age of matrimony during the past century is alone effective,
he holds, in reducing the birth-rate nearly 50 %, and he quotes genealogic
records to show that the high birth-rate of earlier generations was asso-
ciated with an equally high death-rate, and possibly with a degeneracj-
that tells on the prolificity at the present. If our grandparents, he
suggests, had not overtaxed their reproductive powers their descendants
might perhaps have been more numerous. Moreover, the extinction of
well-known families cannot be credited altogether to lowered fecundity;
in many cases the descendants are still numerous under other surnames.
Sociologically, the fact that the well-to-do multiply scantily has a com-
parative tendency; it affords a chance of social circulation from below
upward. Society dies at the top, but grows upward from the roots.
[Some of his arguments may not be as valid as others, but there is no
doubt that there is something to be said on the side opposed to the
alarmists of the present day. Their charge, sometimes openly made, and

* July 5, 1902, 2 Med. Times, May, 1902.

340 OBSTETRICS.

more often implied, that the reduced fecundity in this or other countries
is the result of criminal or quasi-criminal practices is not proA^able, and,
we believe, is mainly if not altogether unjust. The proletarian who
brings children into the world to an inevitable inheritance of disease
and misery, if not to actual crime, may also be regarded as criminal,
far more so, indeed, than those who by self-restraint or by any legitimate
means refrain on pnidential grounds from having children. We may
regret that this is sometimes done from mistaken and sordid motives,
but we must recognize that there is more than one way to view the
matter, and that it is probable, indeed, almost certain, that there has
been a vast amount of pessimistic deduction from extremely imperfect
data. The American race is neither decadent nor d3dng out, and in
many sections of the country is probably nearly or quite as prolific as
ever. In the New England States the American population of the post-
reproductive ages is much greater than in other sections, and we doubt
very much if the birth-statistics are reliable in some others where they
are reported as indicating a decidedly decadent tendency. Deductions
from statistics of the private practice of specialists are especially liable
to be misleading unless the greatest care is taken to allow for possible
errors, and records of the remote past are obviously too imperfect for
reliable comparison. Families died out then as they do now, and any
extensive and elaborate genealogic tree would show a proportion of
unfertile marriages and minimal families that might perhaps seriously
reduce the average. The "died in infancy" list would be found vastly
larger than ls the rule to-day in the native population and the surviving
families not always by any means excessively numerous. Taking into
account the later marriages of to-day and the lessened infantile death-
rate, the difference may not be so serious a one as regards the maintenance
of the race as at first sight appears. It is a misfortune when any country-
suffers in its birth-rate to such an extent as appears to be the case in
France, and possibly in certain portions of this country and Canada.
That these conditions are as general as has been recently claimed is
not proved, and there is not enough reliable data to assume that they
can be. Moreover, there are certain facts, those of emigration of the
young, and the return of the old to their birth-places, for example, that
may markedly affect the significance of the data we have. While it is
advisable to be warned of possible evils, it is also well to be prepared
to make due allowances for possible exaggerations and illegitimate de-
ductions. The facts are yet wanting to justify the conclusion that there
is any very pronounced decadent tendency as shown by a decreasing birth-
rate in the native stock of this country except in certain limited regions,
and even there there may exist conditions that are not fully allowed for
by the alarmists.]

THE PHYSIOLOGY OF PREGNANCY.

The Determination of Sex. — [The problem of the determination of
sex has always been one of great interest to the general public as well

THE PHYSIOLOGY OF PREGNANCY, 341

as to the medical man and to the pure scientist. The interest is excited,
however, more by the practical than by the scientific aspect of the
subject; nevertheless, during the past 200 years, no fewer than 500
theories have been propounded with regard to the determination of sex,
and the majority of these, if not the whole, are in all probability entirely
without any foundation in fact. The practical interest raised by the
problem leads an enthusiast to assert, every now and then, that he
has at last discovered a method whereby the sex of the unborn child
may be made to be what its parents desire. Many will doubt whether
such a discovery, could it have been made, would not in the end have
brought about disastrous results, and they will at least rejoice that
the observations of recent years, and more especially those of Beard,
Bessels, Boveri, Farmer, Guignari, O. Hertwig, Hacker, jNIoore, Meves,
von Rath, Riickert, Strasburger, Weismann, and others, all tend to the
conclusion that sex is predetermined before the embryo begins to exist,
and, to quote Beard's words, ''any interference with or alteration of
the determination of sex is absolutely beyond the human power." Dur-
ing the search for the point at which sex is determined new facts have
been brought to light and some old beliefs have been disproved, and,
among others, destruction has fallen upon tiie almost imiversally accepted
opinion that the organisms produce the germ-cells, and that by the
union of germ-cells of different sexes a new organism is produced. The
latter part of this belief is no doubt correct, but as regards the first
part the fact seems to be that the organism is only a nidus in which
the germ-cells rest before they proceed to the production of the elements
of new germ-cells; an important nidus it may be, and all-necessary for
the continuance of the germ-cells, but without any direct influence upon
the characters or capabilities of the cells. This being the case, the
practical interest ceases, but the scientific interest is undiminished, for
the exact period at which sex is determined is as yet not discovered,
though it is surmised. So far as the evidence at present available goes,
it appears from the results of the researches of Beard and others that
of the 32 cells produced by the first 5 divisions of the fertilized ovmn,
one becomes a primitive germ-cell and the others are utilized for the
formation of the membranes and appendages by means of which the
embryo about to be formed is nourished and protected. The primitive
germ-cell divides simultaneously with the further divisions of the non-
germinal cells, and in^this way the number of the products of the primitive
germ-cell, which are known as primary germ-cells, become 2, 4, 8, 16,
32, 64, 128, 256, etc. One of the primary germ-cells continues to divide
and its descendants form the embryo. The remaining primary germ-cells
become the germ-cells of the embryo. As a rule, they accumulate near
the root of the mesentery in the germinal ridge, and ultimately they are
inclosed in the ovary or testicle. The sex of the ovum is, therefore, fixed
before the spermatozoon fertilizes it.] In this respect M. von Lenhossek^
takes a very different position from that assumed by Van Lint, whose
work was recently reviewed in the "British Medical Journal,"^ who holds

* Das Problem der geschlechtsbestimmencjen Ursachen, Jena, 1903.
^ April 11, 1903, p. 857.

342 OBSTETRICS.

that the sex of the embryo is determined by the relative strength of
the spermatozoon and the ovum, a female embryo being produced by
the union of a strong spermatozoon vnih. a weak ovum. In order to
maintain von Lenhossek's position it must be proved that after impreg-
nation the ovum, and later on the embryo, has a sex, although it shows
apparently no signs of it. The young embryo is neither to be regarded
as neuter nor as hermaphroditic, but it is to be looked upon as already
male or female, while as yet it shows no indications of sex. As early
as the fifth week it is believed by Nagel that the cells of the future testicle
can be distinguished from those of the future ovary, and it is maintained
that it is not improbable that still earlier signs of sex may exist, if only
we were able to recognize them. This, of course, is for the human
subject; in some of the lower animals — as in Dinophilus apatris, one of
the worms — there are ova which are quite recognizably different, the
female eggs being large, oval, and granular, the males being small, round,
and clear. The ova in the human subject, and in many of the animals,
do not indeed show any sexual dissimilarity, either in their histologic
or in their chemical characters; but similarity in these details may be
only apparent, not real. Nature is constantly teaching us that dis-
similarity may exist when we cannot perceive it; she also occasionally
astonishes us into recognizing similarity between apparently very dis-
similar states. He is a bold histologist who will nowadays maintain
that no difference exists between two masses of protoplasm simply be-
cause his microscope reveals to his eye no difference between them.
Another problem arises if we admit that sex is determined in the ovum
before impregnation — namely, how long before impregnation is it fixed?
Nothing very definite can be asserted upon this matter; but it may be
asked whether, having carried the determination of sex so far back,
there is any need to stop at, say, the maturation of the ovum. Is it
not likely that the female infant comes into this world with the ova
in her ovaries already male and female? This is undoubtedly a ver}^
important question, for if we admit the latter supposition, all our hopes
of modifjTJig the sex of offspring vanish into thin air. If, on the other
hand, the sex of ova is not settled till maturation, then there may be
some chance of altering their destiny. So it will be seen that the prac-
tical side of the problem has been gradually narrowed down. No treat-
ment of the mother after her pregnancy has begun can be efficacious,
for the sex of the ovum is fixed before there is yet an embryo. It is
possible that treatment just before pregnancy may be of some effect,
but only if the sex of the ovum is determined at or about the time of
maturation. But if we admit this possibility of a therapeutic determina-
tion of sex, what is the treatment to be? Von Lenhossek shows fallacies
in the well-known methods of Schenk, of which so much has been heard
in recent years, and it must be admitted that the reasoning upon which
they are founded is not in accord with biologic discoveries. The ten-
dency of recent research has been to show that the better nourished the
ova are, the more likely %vill they prove to be female, while the poorly
nourished ones A^ill give origin to male embryos. This conclusion has

THE PHYSIOLOGY OF PREGNANCY. 343

not, however, been established, and, even if it be proved for the human
subject as well as for the lower animals, it does not follow that it can
be put to practical use. How can we, so to say, starve the ova in a
woman's ovaries before the beginning of pregnancy? To starve the
woman may or may not be effectual, for it would seem that under such
circumstances the reproductive function may, as it were, take precedence
over the others; the ovary ^vith its ova may become, from the stand-
point of nutrition, the preferred part.

Many valuable statistical studies have been made to determine the
influence of parental age upon the sex of the offspring. According to
Sadler and Hofacker, if the husband be younger than the wife, there
are as many boys as girls; if both are of the same age, there are 1029
boys to 1000 girls; if the husband be older, 1057 boys to 1000 girls.
These laws are not to be accepted as conclusive. The normal proportion
between female and male births is 100 to 105 or 106. In the case of
illegitimate births the proportion is reversed, at least for the children
first born. Kaltenback calls attention to the fact established by Hecker-
Ahlfeld that there is a great excess of male births in old primiparas,
this being 124 and 140 to 100. According to a contribution of Janke
published in 1891, if a boy be desired the sexual sphere of the wife and
her sexual appetite must be strengthened to the utmost by generous,
even luxurious, diet while the husband lives more as a vegetarian. This
reminds one of the suggestion of Debay, that in order that a boy shall
be produced the \vife must for 20 to 25 days before the impregnating
coition live chiefly on nitrogenous foods.

The Origin of the Liquor Amnii. — An editorial in the "British
Medical Journal"^ remarks that the leading article on the origin of the
liquor amnii, published shortly before^ has been the occasion of eliciting
from Henry Morris a letter' recalling to the memory of the profession
his researches on this interesting subject, which were carried out in 1876.
[We are perhaps too prone in these days to go to foreign sources for
our information on the scientific and experimental aspects of medicine,
and to neglect researches carried out within our own realms.] Morris's
case of congenital h3'dro nephrosis* was a very interesting one, and from
it the author drew this conclusion, inter alia, that the liquor amnii is
in part composed of fetal urine. There is no information whether the
liquor amnii was diminished or increased in amount in this instance,
and unfortunately in most of the reported cases of hydronephrosis no
mention is made of this important fact. At the same time, Morris's
conclusion does not depend for its proof upon the coexistence of oligo-
hydramnion and hydronephrosis, for it is possible that before the devel-
opment of the hydronephrotic condition urine may have passed in suffi-
cient quantity into the cavity of the amnion to prevent any noticeable
scarcity of the liquor amnii, or the hydronephrosis may have been
intermitting. It is true that Ballantyne^ describes a case of bilateral

> February 7, 1903. ^ Brit. Med. Jour., Jan. 24, 1903.

^ Brit. Med. Jour., Jan. 31, 1903.

■• Obst. Jour, of Great Britain, vol. iv, p. 267, 1876-77.
* Manual of Antenatal Pathology, p. 381.

344 OBSTETRICS.

hydronephrosis with hypertrophic dilation of the bladder in a fetus in
which the liquor amnii was estimated at not more than 1 fluid ounce;
but he also refers to an observation made by F. Fabris^ in which the
bladder had no communication with the exterior, and contained 2.^
liters of fluid, and yet there was marked hydramnios. A. R. Simpson,^
also, some years ago, showed an anencephalic fetus with functionally
useless kidneys, whose birth had been accompanied with a great flow
of liquor amnii. It cannot, therefore, be maintained that the reported
cases of fetal hydronephrosis have demonstrated the renal origin of the
liquor amnii, but the occurrence of a considerable number of instances
of this antenatal malady, in all of which there was scarcity of the am-
niotic fluid, would go far to prove the participation of the fetal kidneys
in its production. Chemical analyses of the liquor amnii, and of the
fetal urine, such as were made for Morris by WilHam Foster, ^ have shown
the marked resemblance which exists between the composition of these
two fluids ; but it must be remembered that urea may be met in transu-
dates, and does not of necessity indicate a renal origin. All such investi-
gations, as well as the information derivable from the morbid fetuses
referred to in a previous article,* support the view that the liquor
amnii is of fetal origin, but they do not absolutely prove it, neither do
they certainly point to the fetal kidneys as the only or constant source
of the fluid. The complexity of the problem of the metabolism of the
unborn infant is very great.

Comparative Investigations of the Blood and Amniotic Fluid of
the Mother and Fetus. — The physiologic processes which take place
between mother and child during pregnancy are still in a large part
unexplained. Some of 'these problems are considered in a series of
investigations lately made by W. Zangemeister and T. Meissl,^ and in-
clude the determination of the red blood-cells in both mother and child,
the lowering of the freezing-point of both serums and the amniotic fluid,
and finally the specific gravity, the chlorin-content, and the total quan-
tity of albumin. The followng facts were determined: The number of
red cells is relatively greater in the child than in the mother; the blood
of the child does not coagulate so readily as that of the mother, nor
as' completely, so that it was often difficult after 24 hours to obtain
enough serum for the tests; the serum of the mother contained, as a
general thing, a larger amount of albumin than that of the child, but
the specific gravity and the total oxygen-content of the serum of the
mother was always greater than that of the child ; the quantity of chlorids
is about the same in both individuals ; the average freezing-point of both
senmis is approximately the same, which means that the blood of infant
and mother is under the same conditions of osmotic pressure. As regards
the liquor amnii, it was fovmd that the specific gravity and amount of
albumin varied, under normal conditions,\\dthin very small limits. The

» Annali di Ostet., xvii, p. 329, 1895.

2 Trans. Edin. Obstet. Soc, vii, p. 122, 1882.

^ Morris's Surgical Diseases of the Kidneys, p. 334, 1885.

* Brit. Med. Jour., Jan. 24, 1903. = Miinch. med. Woch., April 21, 1903.

THE PHYSIOLOGY OF PREGXANCY. 345

quantities seemed to be less in the amniotic fluid than in the blood.
The lowering of the freezing-point is ahvays less in the liquor anjnii
than in the blood, and this is probably one of the most marked differ-
ences between the two. Halban and Landsteiner^ have made a series
of experiments upon the serum of maternal and fetal blood in the Ana-
tomical Institute at Vienna. Their conclusions are as follows: There is
a marked difference in the reaction of maternal and fetal blood in several
respects. The serum of the mother's blood requires a larger number of
corpuscles to undergo solution than does that of the fetus. The senmi
of the mother's blood agglutinates blood-corpuscles much more actively
than does that of the fetus. It has also a stronger action against bacteria
and against the process of fermentation. It Ls also more potent as an
antitoxin, and is a more potent agent as an immunizing senuu. The
active principles of blood-serum seem to be present in the blood of the
fetus, but not to be well developed nor to be active. The deficient
development of blood-serum in the newborn explains the susceptibility
of infants to infection. [It would be of interest and practical importance
to ascertain at what period of extrauterine life infantile senmi becomes
active, and how such a result could be brought about.]

The Isolation of the Living Uterus. — E. M. Kourdinsky^ has
attempted to study the physiologic processes of the uterus l)y isolating
this organ and keeping it alive for a sufficient length of time to make
the needed observations. The first attempt of this kind was made by
Rein, who used defibrinated blood for the process of keeping the uterus
alive. The author used the more modern methods of physiology and
employed Locke's fluid'' for this purpose. He performed laparotomies on
female rabbits under chloroform. A cannula was then introduced into
the abdominal aorta and its lower end was injected with Locke's fluid,
thus flushing the vessels of the utenis. The fluid returned through the
veins, and when the womb had been well washed, it was excised under
great precautions, with its appendages, the broad ligaments and the
vessels belonging to it, and then the whole preparation was placed in
a special apparatus in which the fluid was kept circulating through the
uterine arteries and veins. The apparatus consisted of a metallic box
lined vnih cotton and provided with double walls, between which warm
water circulated. The fluid to be injected into the organ was kept warm
by passing it through a coiled tube in warm water. The work of the uterus
was recorded by means of a catheter supplied with a rul)ber bulb which
transmitted the contractions pneumatically to a recording tambor. The
results of this study are as follows : A varying length of time is required
to revive the isolated rabbit's uterus— usually about an hour. The reflex
excitabilit}^ of various uteruses differs considerably, but as a rule preg-
nant uteruses are more excitable than nonpregnant ones. Young non-
pregnant uteruses, however, often work very vigorously. The uterus
was also observed in this manner during labor, and it was found that
the contractions of the cornua and those of the uterine os did not depend

' Am. Jour. Med. Sci., May, 1903. ^ Roiisskv Vratch, Dec. 21, 1902.

' Centralbl. f. Phv.siologie, 1900,'vol. iv. ^

23 S "

346 OBSTETRICS.

upon each other, and did not occur simultaneously. The waves of con-
tractions recur at more or less regular intervals after each other. After
about an hour the uterus begins to get tired, the waves are more distant
from each other, become longer and less regular, and finally the curve
becomes a straight Une. After a period of rest the uterus begins to
work again with the same regularity, and again there comes a period
of rest. In a word, the rhythmic arrangement of the work of the uterus
in labor is well regulated. The contractions of the cornua are peristaltic
in character, resembling very much those of peristalsis in the intestines,
and the movements of the rain-wonn. They usually start at the ab-
dominal end of the comua. The contractions of the os and vagina are
more like constrictions, which disappear after having been drawn for a
few seconds. The influence of oxygenation on the work of the uterus
was also shown. If the oxygen supply is gradually withdrawn, the con-
tractions soon weaken and stop; if the oxygen supply is suddenly with-
drawn at the acme of a series of waves, the uterus continues to work
for a time as though nothing had happened, but soon loses its tone
and stops contracting. The author also observed the act of birth itself,
and believes that he was the first to see the actual process of expulsion
from an isolated uterus.

The Relation of Meconium to the Fetal Appendix. — A. Low,^ in
the course of a systematic examination of fetal abdominal viscera, has
observed that the disposition of the meconium with regard to the different
portions of the fetal intestinal canal is as follows: (1) Small intestine:
Meconium begins to distend the lower half about the middle of the
fourth month, and continues to do so to a variable extent until the end
of fetal life. (2) Large intestine: Meconium begins to distend the rectum
about the beginning of the fifth month, thereafter tending to accumulate
in the cecum, and then gradually distending the whole of the large intes-
tine, so that after the seventh month dark green meconium distends the
large intestine in its whole length. (3) Appendix vermiformis: Meconium
was noted to be present in the appendix as early as the middle of the
fourth month, and thereafter in nearly every case it was present in the
appendix until the end of fetal life. The amount of meconium in the
appendix varies; it seems to depend somewhat on the condition of the
cecum — if the cecum is distended, then the appendix is always distended,
but there may be meconium in the appendix while the cecum is prac-
tically empty.

THE DIAGNOSIS OF PREGNANCY.

The Rectal Approach in Obstetrics. — W. G. Briggs^ describes 4
cases in which dilation of the cervix was accomplished by digital manipu-
lations through the rectum. In this and a former communication atten-
tion is called to the value of this procedure, as it avoids any possibility
of infecting the genital tract, and by it a more exact and earlier diagnosis
can be made. In delayed rotation the right index-finger in the rectum

» Lancet, May 2, 1903 ' Amer. Med., Oct. 4, 1902.

THE HYGIENE OF PREGNANCY. 347

can often crowd the sinciput backward or draw the occiput forward,
while the left hand crowds the shoulder, or possibly the face, toward
the median line. This is a procedure which markedly facilitates rotation.
The case of a primipara is described in which the cervix dilated nor-
mally, but the second stage was slow on account of delayed rotation.
Pressure by the right index-finger through the rectum against the right
temporal region, with traction toward the median line on the shoulder,
continued intermittently during and between several pains, rotated the
head, and labor was terminated normally. This manipulation must be
continued for some time, and perhaps be repeated, before the head will
retain its new position. In rotating, the head drags with it the uterine
tissues, and their elasticity tends to return the head to its former position.
When the labor is delayed by imperfect flexion or delayed extension, the
position may be altered by combined rectal and abdominal manipula-
tions. In delayed or imperfect flexion, place the index-finger as far back
on the occiput as possible and crowd the head forward (in relation to the
fetus) while the other hand on the buttocks forces the body of the fetus'
downward, thus approximating the chin to the breast. This pressure
should be applied and continued during the pain, and is generally re-
peated. In delayed extension traction should be made well forward on
the sinciput, either with the finger in the rectum or with the palm of
the hand applied to the perineum. In the application of forceps, the
index-finger in the rectum is often of great assistance in guiding the
blades and in adjusting them to the parietal surface of the fetal head.

THE HYGIENE OF PREGNANCY.

[Perhaps in no other single instance is the value of prophylaxis so
marked, in the face of continuing conditions, as in the toxemia of preg-
nancy. Under evidences of infection a woman may, by a watchful course
of attention, be carried along, oftentimes, to full term and deUvered of
a normal child. But constant prophylactic measures, consisting of the
very free ingestion of pure water, the use of frequent hot baths and
the hot pack, milk-diet, and the frequent administration of cathartics,
are required. These measures may so modify and hold back the effects
of toxic material generated within the body as a result of the pregnancy
as to enable a safe continuance thereof, but at no time should vigilance
be relaxed. If in spite of these preventing means signs of peril still are
observed, the recourse to premature delivery is always at hand, the
attending physician protecting himself — and his patient as well — by due
counsel.] F. W. Smith^ urges that the hygiene of pregnancy must begin
in the childhood of the woman. As soon as pregnancy begins the woman
should consult her physician for thorough general physical examination.
> Med. Rec, July 19, 1902.

348 OBSTETRICS.

PATHOLOGY OF THE FETUS AND OF THE FETAL
APPENDAGES.

Deciduoma Malignum. — [Deciduoma is iindoiibtecUy a disease which
is growing more frequent, or is more frequently diagnosed. It is astonish-
ing that so grave a malady was overlooked until Professor Sanger turned
attention to it in 1888. The development of a deadly complication a
short time after delivery might naturally cause the patient to attach
some blame to the obstetrician.] James F. Baldwin/ at a recent meeting
of the American Association of Obstetricians and Gynecologists, related
the case of a woman who was normally delivered ; the ])lacenta was sup-
posed to have been expelled entire. Two weeks later another physician
was sent for, and he found a piece of after-birth which he removed,
making use of the curet. "Criticism was indulged in, and a suit for
malpraxis was in the air," said Baldwin. Two or three weeks later the
second physician examined the patient and found what appeared to be
more after-birth. Baldwin carefully explored the uterus, and discovered
all the signs of malignant disease. The uterus was removed through
the vagina, which was free from deposit; on pulling down the omen-
tum a large secondary nodule was detected and removed. A few weeks-
after convalescence cachexia set in, followed by death. Baldwin be-
lieves that he has met quite half a dozen genuine cases of deciduoma
in his practice, while McMurtry related in full before the Association
the history of a patient in whom the malignant change came on within
a month after delivery. [All good teachers warn the student and the
midwife of the inunediate dangers of sepsis if the placenta and mem-
branes are not removed entire. The frequency of malignant deciduoma
teaches that placental relics may be sources of yet more deadly compli-
cation. On account of the rapid growth and early metastases of de-
ciduoma malignum the mortality is necessarily high. In 124 recently
reported cases, the mortality has been 59 %. This is to be contrasted
with 52 cases occurring previous to 1897, as reported by Borland, in
which the mortality was 78 %, the better showing in the later series^
being due to early recognition and prompt operation.] J. H. Teacher^
concludes that: (1) The so-called deciduoma malignum is a tumor
arising in connection with a pregnancy, and originating from the chori-
onic epithelium (or its forerunner, the trophoblast), which is of fetal
epiblastic origin (the view of Marchand). (2) That these tumors form
a quite characteristic group clinically, pathologically, and development-
ally, and that they should be classified neither as sarcomas nor as car-
cinomas, but as a distinct group sui genfris. The most appropriate name
is chorion-epithelioma. Malignant hydatidiform mole may be treated
as a variety of this disease. (3) That in addition to the common tumors
developing from a pregnancy there are tumors containing precisely
similar structures which are not connected with a pregnancy, and may
occur in other parts of the bodj^ than the uterus, and in either sex. The

' Am. Jour. Obstet., No. 5, 1902, p. 716. ^ Brit. Med. Jour., .June 20, 1903.

PATHOLOGY OF THE FETUS AND OF FETAL APPENDAGES. 349

most probable explanation of them is that they are teratomas, originating
from some structure which has the morphologic value of an included
ovum, and the chorion-epitheliomatous tissues represent the actual tro-
phoblast (chorionic epithelium) of the included ovum. The following
conclusions as to the nature of the growth are offered by D. KreAver.*
This epithelioma of the chorion belongs directly to the malignant t}npe
of tumors, and is composed of the overgrowth of epithelium from the
chorionic tufts. It is composed of two varieties of cells which are physio-
logically connected with these villi and gather in the tumor around
the walls of bloodvessels, which appears to be an explanation for the
enormous bleeding which is present in this disease. The relation of the
two varieties of cells in the tumor is analogous to that which is found
in the normal chorionic villi. Metastases appear to occur by wa}' of
the blood-current. Oncologically, the tumor belongs to the class of
carcinoma. Busse^ reports a very unusual case of a woman who died 6
months after an abortion, multiple emboli being detected in the pia
mater, brain, lungs, kidneys, and spleen, traceable to a large parietal
thrombus in the left ventricle, itself clearly secondary-. The thrombus,
as well as the emboli, exhibited the characters of deciduoma malignum.
When the uterus was examined no trace of deciduoma could be found.
Busse believes that some chorionic villi were detached and got into the
circulation during the abortion. Hiibl"' publishes full notes of a some-
what important case of a form of deciduoma malignum. His patient,
under treatment in February last, was then 36 years old. She had been
through 3 complete pregnancies followed by an abortion at the third
month, then another pregnancy to term, August, 1899. In June, 19C0,
a vesicular mole was removed by operation. In December, 1901, she
was delivered of a macerated child over 4| pounds in weight; 7 weeks
later hemorrhage set in, and at the end of 3 weeks was so severe that
the parts were examined. The patient was anemic and distinctly
cachectic. A tumor as big as a walmit was detected in the vagina pos-
teriorly and inferiorly, the mucous m(>mbrane was perforated and bled,
and there was also a bleeding ulcerated point on the tumor. The uterine
mucosa and the rest of the uterus and appendages were normal. The
vaginal tumor was freely excised and sutures applied to the seat of
excision. The tumor was made uj) of syncytium and cells of Langerhans's
layer in the midst of a hematoma. Ten days after the operation the
wound had healed well, but bleeding soon set in, and on the twentieth
day several deposits had appeared; they were spreading all over the
vagina. At this stage Hi'ibl's report was published. The case agrees
with another described by Peters, in which a primary deciduoma of the
vagina proved as malignant as is a uterine growth of the same kind.
Schauta has implied that vaginal decitluoma is not essentially malignant.
Hiibl remarks that Schauta's ojnnion was based on 3 cases recorded by
Schmit and Schlang^nhauser, but in all ()})eration was very early; and in
one which Hiibl examined there was a hematoma entirely surrounding

»Zeit. f. Geb. u. Gyn., 1902. Bd. xlviii, Heft 1.

' Monats. f. Geb. u. Gyn., Nov., 1902. '' Cent. f. Ciyniik., No. 48, 1902. ■

350 OBSTETRICS.

the newgrowth, while in his own case the newgrowth had spread beyond
the hematoma. F. J. McCann^ reports a' case of deciduoma mahgnum
occurring after the menopause. The patient was 53 years of age and
had borne 10 children. Menstruation ceased 18 months before her ad-
mission into the hospital on March 21, 1902, and during 12 months
there was no loss of blood. In October, 1901, a sudden gush of blood
came from the vagina, and the flow continued for one day. The hemor-
rhage recurred every 4 or 5 days until 3 weeks before admission, its
severity being such that the patient was confined to bed during the
flow. On examination the uterus was found enlarged to about the size
of a 3-months pregnancy, was uniform and soft in consistence, and freely
movable. On passing a sound into the uteiiis under chloroform, blood
literally poured out, and a gauze plug was employed to check the hemor-
rhage. Two days later vaginal hysterectomy was perforaied, and though
the patient rallied from the operation her subsequent course was un-
satisfactor}', and death occurred on the sixth day from suppression of
urine. On cutting into the uterus the whole cavity was found to be
filled with clot, some recent and some of old standing, while the uterine
wall was intensely vascular; there was no evidence of newgrowth in the
clot. Sections cut at different levels demonstrated the existence of
newgrowth between the clot and the uterine wall, and some cells pene-
trated the wall. The gro^vth was composed of multinucleated masses of
protoplasm, and of a loosely reticulated tissue containing in its meshwork
rounded cells with deeply staining nuclei. The remainder of the section
was composed of fibrin and blood-clot. The Pathologic Committee of
the Obstetrical Society of London reported that the specimen was un-
doubtedly an example of deciduoma malignum.

The Transmission of Chorionic Villi. — [These have frequently been
observ'ed in metastatic deposits following a cystic mole or carcinoma at
the placental site in pregnant women. A satisfactory explanation of
their occurrence in such cases has heretofore never been presented, and
in investigating this subject the question would naturally arise whether
analogous conditions may not be found in other pregnant states.] W.
Poten^ has recently published the results of his investigations in this
field. He has carefully studied a series of sections of gravid uteruses,
7 in number and varying in period from 2 to 9 months. His observations
are worthy of note. In all cases, even with a normal placental attach-
ment, it was possible to demonstrate the presence of detached chorionic
villi in the maternal bloodvessels in numbers varying greatly in different
cases. No evidences were found which would warrant the belief that
in normal cases these migrating villi had any effect on the fluid character
of the blood. No changes in the vessel-walls in the neighborhood of the
particle and no clotting could be detected. True emboli, however, could
be formed after passing the heart, in the pulmonary arterioles and capil-
laries, as the greater number are undoubtedly carried to this locality.
During the act of coughing or during a bearing-down pain the A'enous

^ Jour, of Obstet. and Gyn., March, 1903.
^ Arch. f. Gynak., vol. Ixvi, No. 3, 1902.

PATHOLOGY OF THE FETUS AND OF FETAL APPENDAGES. 351

stream may be halted or momentarily reversed, and at this time a few
particles may get into the peripheral veins, which would account- for
their occasional presence in vaginal nodules. The etiologic factors which
induce these conditions remain as yet a matter of doubt. The villi in
certain cases may be more brittle or the placental attachment insecure,
but the author inclines to the theory that changes m the blood-pressure
constitute the principal cause. This is manifested by stasis and eddies
in the blood of the maternal sinuses by which the floating vilH may be
torn away. Eclamptic conditions would appear as most likely factors
in causing this phenomenon, but in two specimens derived from such
cases only a moderate number of migrating viUi were found. Strange
to say, the largest number were seen in sections of a uterus from a patient
who had died from hemorrhage resulting from placenta prsevia, that is
to say, with a diminished blood-pressure. These contradictory results
do not permit at present a definite knowledge of the true etiology of
this condition. It appears, however, that the transmission of these
separated masses of villi in the maternal blood-stream is liable to occur
in the course of any pregnancy, but must not be considered of physiologic
or even of pathologic significance. The disintegration in the blood-
stream without any resulting symptoms is probably the ultimate fate of
these minute tissue particles. The author believes, however, that syphil-
itic infection of either mother or child may be induced by this means.
The villi have been observed to contain fetal blood, which would naturally
be set free in the maternal circulation when the former are disintegrated.
If the fetus is syphilitic, the virus could thus be readily transmitted.
In the same way the blood of the mother who has become syphilitic
during her pregnancy could infect the fetus by contact at the points
where the vilH have been torn away. The observations also explain how
in cases of malignant degeneration of the chorion, such as cystic moles
and syncytial cancer, these migrating villi may cause metastatic deposits
in other parts of the maternal organism.

Hydatidiform Mole. — Findley* reports 2 cases and summarizes his
study of the subject as follows: The causation of hydatidifonn mole is
unknown. It is most frequently found between the ages of 20 and 30
years; more often in multiparas. It probably results from degeneration
of the villi of the chorion through some disturbance of the maternal
circulation. The connective-tissue stroma of the villi degenerate, ^^'ith
serous infiltration or edema. The syncytium and Langerhans's cells pene-
trate more deeply when the maternal nutrition is defective. In 16 %
of the cases malignant degeneration occurs. It is very difficult to draw
the line between benign and malignant cases. The examination of a
specimen gives but little information regarding it. Retention of a mole
within the uterus does not influence its disposition to become malignant.
Diagnosis can only be positively made from seeing the vesicles. The
most constant clinical point lies in the rapid development of the uterus,
with irregular shape and consistency and hemorrhage. The treatment
of the condition consists in emptying the uterus at once. Because the
1 Med. News, Dec. 6, 1902.

352 OBSTETRICS.

womb is thin and weak it is l3est to avoid the use of the curet and to
employ ergot and vaginal packs to control the hemorrhage and stimulate
expulsion. After the mole Ls expelled, the uterus should be explored
with the finger, irrigated, and packed with iodoform gauze. Two weeks
after the birth of the mole the uterus should be curetted, the scrapings
examined, and if malignant disease is beginning, hysterectomy should
be performed. The patient should be kept under observation for 3 years
afterward, and should hemorrhage occur the uterus should be again
curetted and the scrapings examined microscopically. Statistics shoAv
the average age of these patients to be 27 years, the extremes being 13 and
58 years. In one patient 11 moles developed. In 8 cases there was
cystic degeneration of the ovaries. In 1 case the mole developed in
the fallopian tube. The longest period at which malignant disease
occurred after the development of the mole was 4^ years. The mortality
of this condition is 25 %. The causes of death are: syncytioma malig-
num, 16 %; hemorrhage, 4 %; septic peritonitis, 2 %; other causes
making up the remainder. According to D. Berry Hart,^ it has long
since been known that deciduoma mialignum follows hydatid mole in
about 50 % of all cases. What is the nature of hydatid mole? Is there
a malignant and a simple form of the mole? Can we tell histologically
what form will develop malignant disease? The questions must be con-
sidered from the following standpoints: (1) The structure of the early
normal vDlus ; (2) the naked eye and microscopic structure of the hydatid
mole; (3) the clinical features of liydatid mole; (4) its relation to de-
ciduoma malignum; (5) the possible nature of hydatid mole and its
relation to deciduoma malignum; (6) can we ascertain by microscopic
examination of the mole, or of its curettage-fragments after abortion,
whether deciduoma \\-ill develop ultimately? Normally the early villus
has a double epithelial covering — Langerhans's layer and the syncytium.
These can absorb decidual tissue penetrating into it, and can pass into
bloodvessels ^nthout coagulating the blood ; while normally their progress
is always marked by the condensed layer (Nitabuch's fibrin-layer).
Finally, both epithelial mantel and connective-tissue core, which approxi-
mate the Whartonian jelly in structure, differentiate in the normal
placenta, the synctytium gradually thinning, the cells of Langerhans
becoming more flattened, while the connective tissue loses its myxomatous
state and becomes more fibrous. With hydatid mole there is no fetus
present. The membranes alone may be degenerated, the placenta
healthy. Wlien we have a fetus, a placenta, and a hydatid mole to-
gether, the case has been probably a twin where one of the ova has
been fertilized and the other become a mole. The absence of a fetus
LS a great fact, not hitherto appreciated. Hydatid mole is rare, estimates
var\'ing from 14 in 10,200 cases to 1 in 728 (Konig, quoted by Gebhard)
and 1 in 2400 (St. Bartholomew's statistics, quoted by Williamson).
Hydatid mole has been found in the tube, and also in the paravaginal
tissue; the latter is a metastasis, but such rare conditions are only diag-
nosible by operation. Deciduoma in about half the reported cases is
1 Brit. Jour, of Obstet. and Gvn., Nov., 1902.

PATHOLOGY OF THE FETUS AND OF FETAL APPENDAGES. 353

preceded by hydatid mole. Virchow termed the mole "myxoma chorii."
The author believes that the temi deciduoma should be changed to
metastatic mole. The proportion of cases of deciduoma malignum fol-
lowing a mole is very low, hence it would be wrong to extirpate the
uterus in every case of mole. There is nothing in the microscopic exam-
ination of a mole to determine that it vdW become a case of deciduoma
malignum.

Hydrorrhoea Gravidarum. — [A sudden discharge of watery fluid
from the vagina during pregnancy naturally suggests the commencement
of labor, and it is of practical importance in a given case to determine
the source of the flow.] W. Sinclair Bo wen ^ points out that the fluid
may not have come from the amniotic sac, but from some portion of
the decidua, due to the fact that there is an existing "deciduitis." De-
ciduitis is a characteristic endometritis modified by the changes in the
uterine mucosa peculiar to pregnancy. The disease may be acute or
chronic. The acute form may be divided into: (1) the infectious or
exanthematous, (2) the hemorrhagic, and (3) the purulent. Chronic
deciduitis is a much more common complication of pregnancy and is a
predisposing cause in a majority of earlier abortions. There are 4 varie-
ties of the chronic form, differing in clinical history, severity, and in the
constituent element of tissue involved: (1) the diffuse hyperplastic; (2)
the polypoid; (3) the cystic; and (4) the chronic catarrhal. There is an
uncertainty as to the exact etiology and pathology of hydrorrhoea gra\'i-
darum. The exact source of the fluid Is as uncertain as its pathology,
and it is more than likely that all the constituent elements of the decidua
contribute to the formation of the fluid. The discharge may take place
suddenly A\ithout any warning, or there may be some discomfort due
to uterine contraction. The fluid is clear, thin, pale yellow, and con-
tains albumin. The flow occurs several or more times. The os is closed.
In rupture of the amniotic sac the occurrence ls usually at the end of
the pregnancy and immediately precedes delivery. Labor-pains have
usually been going on for some time. The discharge is but once. The
liquor amnii contains but a trace of albumin, and an abundance of urea.

The Recognition of Fetal Syphilis. — Hecker^ has made a thorough
examination of 62 stillborn children, and has found 33 (53 %) syphil-
itic and 6 (9.7 %) doubtful. Many of the cases (15 out of 33) could not
be definitely considered syphilitic innnediately at autopsy, but had to
be examined histologically before the diagnosis could be made certain.
A macroscopic diagnosis was made only when at least two organs showed
undoubted signs of syphilis. The spleen was the organ oftenest affected;
then the bones, liver, kidney, etc. For histologic examination the
kidneys are the most suitable organs, as they are the last to show signs
of maceration, and are found more frequently diseased microscopically
than any other organ. They were found involved in 90 % of cases:
spleen, 61 % ; thynuis, 50 % ; pancreas, 46 ^c ', bones, 43 % ; liver, 23% ;
lung, 17 %; navel, 16. %. The so-called macroscopic syphilitic bone-

* Am. Jo\ir. of Obstet. and Dis. of Women and Cliildren, Oct., 1902.
2 Deut med. Woch., Nov. G and 1.3, 1902.

354 OBSTETRICS.

lesions were often found microscopically to be only irregularities due to
maceration. Hecker discusses at length the macroscopic and the micro-
scopic S}T)hilitic lesions, dividing the former into pathognomonic, prob-
able, and uncertain signs, and considering the latter from the standpoint
of the bloodvessels, the connective tissue, the epithelium, and the dis-
turbances of development. He concludes his valuable article with the
dictum: If the autops}'" of a mature or immature fetus leave the presence
or absence of syphilis in doubt, a microscopic examination should be
resorted to. If frozen sections cannot be stained, small pieces of kidney,
spleen, thymus, pancreas, lung, and liver should be hardened. The
kidneys should be examined first, and in case of negative results, the other
organs in the order named. The round-cell infiltration about the renal
bloodvessels will usually make the latter superfluous. Congenital
syphilis may with certainty be said to be absent only when microscopic
examination of all the organs mentioned has shown that none of the
pathologic lesions of sj-philis was present.

Rigor Mortis in the Fetus. — Ludwig Seitz^ gives an exhaustive
critique of this subject, supporting his conclusions with abundant evi-
dence. In the adult rigor mortis bears the closest relation to normal
muscle-activity. The results of the latter are the production of lactic
and carbonic acids. Probably the only difference between the two con-
ditions lies in the nonremoval, in the dead body, of the acids from the
muscles. At any rate, their accumulation is the cause of rigor mortis
by the production of coagulation of the myosin. This involves short-
ening, and the stiffness is due to simultaneous contraction of opposed
groups. Rigor mortis is hastened by previous muscular exertion, and
it can be produced by the injection of acids and chloroform. It has two
stages, a preliminary waxy rigidity, and the well-established stiffness.
Turning to fetal life, the best-known text-books of the day, physiologic
and medicolegal, state that rigor mortis does not occur before the seventh
month, which is, beyond question, erroneous. Seitz gives 11 cases ob-
served by him of fetuses in more or less general rigor mortis, the length
ranging from 18 to 36 cm., the weights from 130 to 1800 grams; the tem-
peratures from 1° to 8° C; and the time of examination (when known)
from 7 to 48 hours after 'death. The rigidity was true rigor mortis and
not a desiccation effect, as it occurred equally when the fetuses were
wrapped in wet cloths, and was present in one fetus still in the amnion.
As regards fetal rigor mortis in utcro (or at the moment of delivery),
since 1894, 20 cases have been reported by 3 observers. The author
adds 4 of his own, making 24 in all. But why do we know only these few
cases? The chief reason is that rigor mortis is passed through, to the
subsequent relaxation, in utero. It could occur there, inasmuch as,
though the subsequent relaxation is generally regarded as a decomposition
effect, L. Herrmann has shown that it can occur when decomposition
is excluded, the continued action of the acids present leading to the for-
mation of acid albumin. That it actually is passed through there, is,
moreover, indicated by those cases in which the recently dead fetus (in
» Sammlung. klin. Vortrage, No. 343, 1902.

PATHOLOGY OF THE FETUS AND OF FETAL APPENDAGES. 355

which no maceration is visible) is born relaxed, and is incapable of pass-
ing into rigor mortis. Of this the author gives a case in which during
48 hours no rigor mortis set in, and the injections of acids and chloroform
failed to bring it about. Further, when the child dies during birth, the
length of time after death is, in an average parturition, not sufficient
for rigor mortis to develop, and after extracting a dead child, the ac-
coucheur, having much else to engross his mind, usually gives no
further attention to it. Besides rigor mortis, especially in the first stage,
can be broken up by the movements impressed upon the child during
parturition, especially if manipulative assistance is given. And actual
cases are cited in which unusual difficulties in operative procedures have
been reported as due to abnormal stiffness of the fetus ; in which at birth
rigor mortis was present everywhere except just in the parts manipulated,
and in which no one of a number of physicians had noticed anything
peculiar in a child in which, when extracted, the arms were stiff, and 5
minutes later rigor mortis was thoroughly established. The second
case shows that, as might be expected, in its second stage, also, rigor
mortis in the fetus can be broken up during parturition.

Fetal Monstrosities. — According to Thompson,^ there arc 3 types
of congenital malformation of hollow viscera in which the main anatomic
abnormality that is present consists in very great muscular hypertrophy,
for which no permanent organic cause is discoverable. These are hy-
pertrophy of the bladder with dilation of the ureters, of the colon with
no organic stricture, and of the pylorus and stomach- wall. In all these
the chief abnormality is enormous h\^3ertrophy of a muscular coat of a
hollow organ known to be active in utcro; and the amount found in some
cases soon after birth shows that it must have been present during in-
trauterine life, and in none, is there any evidence of such permanent
organic obstruction as would give rise to overgrowth of muscle. There
are two chief hypotheses as to the cause of this hypertrophy: (1) That
it is a primary developmental h^qjerplasia ; and (2) that it results from
overexertion. Thompson accepts the second theory as the true one, and
since there is no obstruction to cause overexertion, he endeavors to show
that it is the result of lack of coordination in the action of the organ during
intrauterine life, and suggests that this lack of coordination may be a
kind of intrauterine developmental neurosis.

Antenatal pathology presents no monster which, while preserving
some semblance to human form, deviates therefrom in stranger and more
striking manner than the condition known as elephantiasis congenita
cystica, remarks J. B. Hellier.^ The malformation depends u])on 3
conditions: (1) Certain defects of the skeleton. These, however, are
not the essential thing. It is not as in spina bifida, in which the osseous
defect causes the meningomyelocele. The distorted contours depend
upon disease of the soft parts; (2) the general anasarca of the body; (3)
the characteristic lesions consist of the formation of extensive, irregular
cystic cavities in the subcutaneous tissue. After reporting in detail
2 such cases, the author summarizes as follows : The first monster may

1 Brit. Med. Jour., Sept. 6, 1902. ^ Brit. .Tour, of Obstet., Feb., 1903.

356

OBSTETRICS.

be described as an acardiac fetus — a parasitic twin. It was affected
with hydrocephalus and cystic elephantiasis and general dropsy. It had
developmental defects in the anterior thoracic wall and in the extremi-
ties, with great defects in the internal organs, the heart, lung, liver, and
spleen being absent ; the kidneys were rudimentary and the alimentary
canal was imperfectly developed. The second had also cystic elephant-
iasis, absent upper extremities, and a rudimentary development of the
face and skull.

Complete ectromelus is a somewhat rare condition; partial ectrom-
elus affecting one extremity is much more common. John McGibbon^
reports a case of a female child in whom both the upper and lower ex-
tremities were absent (Fig. 59). The stumps of the lower extremities
ended in fleshy nodules, and those of the upper extremities were rounded,
as after an ordinary amputation. Bones could be felt in all the 4 stumps.

The child was the fourth of the
family. There was no history of
shock or maternal impression, and
no trace of any deformity in the
other children of the family or
their relatives. During the last
stages of pregnancy the mother
suffered much from pain in the
abdomen. False labor came on,
and persisted for 48 hours before
the OS relaxed. On account of
this, he was called to see the case
by the midwife in charge. The
child was otherwise healthy and
vigorous. On the nose was a
large red birth-mark.

In all cases of double mon-
strosity there is, to begin with, one
ovum, the varieties in form and
degree being determined by the extent and situation of the fission
of the embryonal anlage, says Kedarnath Das.^ When the splitting
is complete and the two portions of the embrj^o go on to perfect
development, there are born the so-called homologous or uniovular
twins. Up to the twelfth day the two develop evenly. At that time
the allantois buds out from the hind-gut of each individual, and its
vessels reach the placental portion of the chorion. According to the
degree of the development of the allantois and the placenta of
the second embryo, one gets several varieties in acardiac fetuses: (1)
A. anceps, characterized by nondevelopment of the face and anterior
part of the body. This species is rare. (2) A. acephalus, which is the
most common species; head wanting or rudimentary. Intestines and
abdominal organs rudimentary and merest trace of the organs above
the diaphragm. (3) A. amorphus. Least developed. Little more than
1 Lancet, Sept. 20, 1902. ^ grit. Jonr. Obstot. and Gyn., Oct., 1902.

Fig. 59.— McGibbon's case of ectroiuelus (Lancet,
Sept. 20, 1902).

THE PATHOLOGY OF PREGNANCY. 357

a lump of connective tissue covered with an edematous skin. (4) A.
acarnus. This is the rarest. The head alone is present, but is never fully
developed. The author has collected 45 cases from the literature. Acar-
diacs are said to be rarely born in first labors (Geoffroy St. Hilaire), but
5 of these 45 occurred in primiparas. In 6 cases gestation went on to
full term. The perfect twin is said to be born first. The sexes of the
twins are said to be identical. Hydramnion is usually present. [The
theory that these monstrosities are due to maternal impressions is un-
tenable. Almost all varieties of monstrosities have been produced ex-
perimentally upon the eggs of birds and upon lower animals b}' the action
of physical forces external to the embryo. Anmiotic l:)ands or adhesions
frequently arrest development, causing anomalies. A. Keith suggests
that inquiry into the condition of the mother dudng the weeks follow-
ing conception might throw some light ujDon the cause.]

Marcel Baudouin^ reports having found in the Museum of Patho-
logic Anatomy of the Faculty of Medicine of Paris a specimen of terato-
pagus which constitutes a new genus. It is essentially characterized by
the peculiarity that the union, instead of taking place between the um-
bilicus and xiphoid, — in other words, at the level of the epigastrium, —
extends from the umbilicus to the prepubic region, or to that corre-
sponding to the hypogastrium; wherefore he proposes for this monster
the name of hypogastropagus. This type of teratopagus is viable.
An hypogastropagus is evidently intermediary between a xiphopagus and
an ischiopagus, which is a new proof of the fact that in the teratology
of double monsters it is possible to find all transitions between the most
widely separated types,

THE PATHOLOGY OF PREGNANCY.

Hyperemesis Gravidarum. — [Since the introduction of anesthesia
and antiseptics th(>re has been no more valuable addition to practical
therapeutics than normal saline solution. The surgeon, physician, and
obstetrician alike appreciate the great value of this agent, and many lives
have been saved by its timely employment either by hypodermoclysis,
venous transfusion, or large rectal injections. For the relief of the shock
due to hemorrhage, either during operation or postpartiun, and for the
dilution of toxic material in the system, whether associated with sepsis
or eclampsia, salt solution is unexcelled, and transfusion, in which the
blood from another person is introduced into the venous circulation, has
been practically superseded by this more satisfactory and scientific
method. Columns might be written upon the particular value of this
therapeutic agent to the obstetrician alone.] It is interesting to note
that Condamin^ has secured splendid results in the treatment of per-
sistent vomiting of pregnancy by the systematic injection, preferentially
by the rectum, of from 3 to 4 liters of artificial serum or saline solution,
daily, in divided doses of 300 grams each. The injection is made so
slowly as to occupy from 10 to 15 minutes, and is arrested if it induces
^ La Sem. M6cl., Nov. 19, 1902. ^ Lyon M^d., vol. xcviii, No. 5, 1902.

358 OBSTETRICS.

peristalsis, to be recommenced when the movements have ceased. Should
there be intolerance, a few drops of laudanum may be added, or if neces-
sary the serum may be introduced hypodermatically. During the first
10 days or so that the treatment is continued the patient takes neither
liquids nor solids by the mouth, and then while the injections are con-
tinued for several days, oral nourishment is gradually increased from a
few mouthfuls to the ordinary quantity. This treatment is based on
the idea that the persistent vomiting of pregnancy is due to general in-
toxication, and it averted the necessity of inducing abortion in any of the
8 cases in which Condamin adopted it. According to Weil,^ vomiting
in pregnancy can be controlled with 10 drops of a 20 % solution of
menthol, administered on sugar whenever the nausea appears.

Valvular Cardiac Disease in Pregnancy.— {The question of the
effects of pregnancy in the case of a woman mth valvular heart-disease
is one that not infrequently confronts the physician. The family physi-
cian may be consulted early in a gestation, or not until marked symp-
toms arise, or he may be called upon to advise as to the marriage of a
woman with cardiac disease. In either event the prospects must be
carefully weighed and the patient should be made to feel the dangers
surrounding her. Much will, of course, depend upon the location and de-
gree of the cardiopathy, and the existing compensatory circumstances and
the compensatory possibilities, and the occupation of the patient, together
with, her general health and habits, having in mind that the common
danger in such cases rests with the increased amount of work thrown
upon the heart from the large volume of circulating blood. And then it
must be remembered that this danger becomes greater Avith the pro-
gressing pregnancy. As a general conclusion it may be stated that a
woman Avith heart-disease, especially a valvular lesion, has a shorter
life-expectancy if she becomes pregnant, and that her danger sharply
increases with succeeding gestations.] An analysis of 6 cases of preg-
nancy occurring in patients Avith heart-disease is presented by G.
Morelli.^ Of the number, there were 1 death occurring 2 months after
parturition, 1 abortion, 2 premature births, and 2 which went to full term
and passed safely through the puerperium. All suffered serious dis-
turbances, and the condition of all, with one exception, was aggravated
during the puerperal period. From all of which the author concludes
that cardiopathies unfavorably influence the course of pregnancy and
frequently lead to its spontaneous interruption; which latter may be
looked upon as the maternal organism's natural measure of defense.
Pregnancy, parturition, and the puerperium in many instances aggra-
vate cardiac disease and bring about a disturbance of compensation which
may prove fatal. No one line of treatment can be applied in all cases;
hygienic, medical, or obstetric treatment being required in individual
cases. Jardine^ calls attention to the low death-rate in these cases —
1 to 13. He <^\\s attention to pure mitral stenosis as being the most
deadly form of heart-disease complicating labor. When labor ends in

1 Clin. Rev., June, 1903. ^ q^^ ^^^i^ Osped., Dec. 14, 1902.

8 Jour, of Obstet. of Brit. Emp., April, 1902.

THE PATHOLOGY OF PREGNANCY. 359

these cases, the uterine vessels are cut out of the circulation, and if there
has not been a free hemorrhage during the third stage of labor, blood is
returned to the right side of the heart, which may become engorged and
paralyzed. Hence, bleeding should be encouraged during the third .
stage of labor, and if it does not occur from the uterus, and the patient's
condition is threatening, blood must be taken from a vein. Attention
is called to Hart's illustration of a case of this sort, showing the dis-
tention of the right auricle. Aortic incompetence is next in gravity,
and mitral incompetence if the heart-muscle is in-good condition is less
dangerous. Cardiac lesions do not show themselves during pregnancy
until after the middle of this time. Then breathlessness, palpitation,
cough, and edema appear, with albumin in the urine. The patient may
not be able to lie dow^n. The woman who has heart-disease and w^ho has
suffered from failure of compensation at any time should be strongly
advised not to marry. So far as treatment is concerned during preg-
nancy, the patient must be kept at rest, the bowels moved freely, the
kidneys stimulated, the lungs relieved, and cardiac tonics freely given.
Strophanthus is a better drug than digitalis in these cases. While the
patient will probably improve, the cardiac tonic must be continued.
In a bad case the induction of abortion before the fourth month is per-
missible. In the later months labor should not be induced. When labor
begins, large doses of strophanthus or digitalis should be given. As
soon as the os is fully dilated labor should be terminated. The patient
should never be allowed to bear down. If the heart begins to be em-
barrassed before the os is dilated, the os must be stretched open or in-
cised, chloroform given, and delivery at once effected. The uterus should
be allowed to relax and bleeding encouraged after the birth of the child.
Ergot is contraindicated unless in exceptional cases. If the patient did
not bleed from the uterus and showed embarrassment, blood should be
taken from the arm. During the puerperal period free stimulation and
cardiac tonics should be used. When patients die after labor, it is
from acute edema of the lungs and cardiac failure. Nursing should be
prohibited, as it influences the heart badly.

Necrosis of the Intestinal Mucosa. — [Although it has been known
that pronounced lesions may occur in the mucosa of the gastrointestinal
tract due to pathogenic organisms of the pyogenic type, yet no clear
knowledge of the cause and course of such conditions has been available.
An attempt has been made to classify these cases according to whether
the bacteria remained upon the surface of the intestine, giving rise to
symptoms by the formation of absorbable ptomaihs, or passed into the
tissues of the gut and were carried by the lymph and blood to other
organs of the body.] H. F. Harris^ reports the case of a woman about 7
months pregnant who developed the symptoms of uremia, and as she did
not respond to treatment and had a very contracted pelvis, cesarean
section was done. She recovered from the operation, but in a few days
showed signs of a severe toxemia and had numerous liquid stools of a
peculiar dark and offensive nature. Autopsy showed a chronic nephritis
1 N. Y. Med. Jour., Nov. 1, 1902.

360 OBSTETRICS.

with undoubtedly an acute exacerbation. The mucosa of the large in-
testine showed marked necrotic changes, and in the ascending colon there
were intensely ecchymotic areas. In the necrotic masses enormous
numbers of bacteria were found, principally diplococci, which corresponded
in every way with those described by Escherich as enterococci; although
the kidney lesion was pronounced, it is believed that the intestinal lesions
were the immediate cause of death.

Pregnancy and Tuberculosis. — [Eighteenth century writers re-
garded pregnancy as an advantage to phthisical women ; it was supposed
that if two women were suffering from pulmonary tuberculosis, the one
of them who became pregnant was likely to live longest. Modern writers
have wholly abandoned this view.] C. Hamburger^ declares that it is
now universally conceded that pregnancy and labor influence imfavorably
the course of phthisis, because of their excessive demands upon the
vitality of the woman, in virtue of which her susceptibility to tuber-
culosis is increased. The logical inference is plain: tuberculous women
must not have children ; if pregnane}^ occur, it must be interrupted in the
interest of the woman. This inferelice, says Hamburger, is not frankly
made as often as it should be. Only recently Kossmann has declared
that "pregnancy is only to be interrupted when failure to interfere would
inevitably result in the death of the mother diunng gestation and so cause
the death of the fetus as well." Hamburger remarks that the problem
must be approached according to the social class of the individual, be-
cause the demands during pregnancy upon the strength and vitality
of women belonging to the working-class are far greater than upon those
of the more fortunate classes. The mortality from tuberculosis increases
as the family income decreases. Hamburger therefore undertakes to
support his position by giving a series of pictures of the actual life of
pregnant working-women, showing how many children they have, what
their incomes are, how many persons live in one room or sleep in one bed,
and hence what the probable outcome of tuberculosis in such circumstances
is likely to be. Von Leyden and others emphasize the especial danger
of repeated pregnancies occurring at brief intervals in phthisical sub-
jects, and it is precisely among women of the working-classes that rapidly
repeated pregnancies occur. The treatment of tuberculosis in poor
women is at best a difficult task. Its difficulties become overwhelming
when pregnancy occurs. Good nourishment is indispensable; but during
pregnancy there occur vomiting and stubborn anorexia. Working-
women are denied good air, bodily rest, concentrated foods, careful
nursing in confinement, and rest after confinement. Hamburger considers
the dangers of abortion, but does not regard them as serious in com-
parison with the greater risk of prolongation of pregnancy. It is argued
that the probability of renewed conception and the necessity for renewed
interference make any interference inadvisable. He replies that it is
the duty of the physician to instruct phthisical patients as to the dangers
of renewed conception. To those who hestitate to destroy the fetus be-
cause of the possibility of its developing into a healthy human beings
1 Berl. klin. Worh., Nov. 24, 1902.

THE PATHOLOGY OF PREGNANCY. 361

the writer points out that so far as the children of the poor are concerned
such hopes are almost idle, because in this class of society isolation from
the mother is an impossibility and hygienic surroundings cannot be
provided. For all these reasons he believes that pregnancy occurring
in phthisical working- wo rhen should be interrupted; its interruption is
demanded iu the interest of the mother, of the family, and of the com-
munity. Lohnberg^ reports several cases of laryngeal tuberculosis in
pregnancy. Interruption of the pregnancy, in one case, at least, had
no beneficial effect upon the tuberculous process. This is a problem which
must be settled by the elements presenting themselves in each case.
The main postulates 'which the author lays down are the prevention, as
far as possible, of marriage of tuberculous persons ; and in those that are
married, to prevent conception. The slightest complaint of laryngeal
disturbance on the part of a pregnant woman should be followed by the
most scrupulous examination. If a tuberculous process is discovered,
the patient must be placed at once in the most favorable hygienic sur-
roundings; if the disease is quite advanced, the well-known methods of
treatment must be instituted.

Diphtheria and Pregnancy. — Chambrelent and Micheleau^ de-
scribed the following case : A woman, aged 44 years, 8 months pregnant,
was admitted to the hospital on March 1 . Eight days previously her throat
became sore, and hoarseness, aphonia, and difficulty in breathing soon
followed. On admission there were all the signs of laryngeal obstruc-
tion, stridor, retraction of the supraclavicular and suprasternal fossas,
and turgescent cervical veins. The throat was red, but no false mem-
branes were seen. The temperature was 101.4° F. and the pulse was
120. Antitoxin was injected. Two hours after admission the dysj^nea
had so increased that tracheotomy was necessary and membrane was
expelled through the tracheotomy woimd. A second injection of anti-
toxin was given and the respiration became almost normal. On the
following day the temperature had fallen to 97.7° and the pulse to 100.
The fetal heart was heard. On the next morning the dyspnea recurred.
On the left side of the chest no respiratory spimds could be heard and
on the right the respiratory murmur was weak. Aspiration through the
tracheal wound failed to remove any membrane. The fetal heart was
distinctly heard. After consultation it was decided to induce labor and
to make arrangements for cesarean section should death supervene. A
long esophageal bougie was introduced into the uterus. The bougie fell
out after 2^ hours and no uterine contractions were a])paront. Death
occurred at 3 a.m. on the following day. An attempt to introduce
the hand into the uterus in order to perfonn' version and to extract the
fetus failed, since the os was not dilatable. Cesarean section was at
once performed. The fetus showed no signs of life and all means of
resuscitation failed. The necropsy showed that the larynx was covered
with false membrane, but that the trachea was free from it. The bronchi
as far as the branches of medium caliber were lined with membrane.

1 Munch, med. Woch., Feb. 24, 1903.

2 Gaz. Hebd. des Sci. M6d. de Bord., Mav 17, 1903.
24 .S

362 OBSTETRICS.

The lungs were emphysematous and there was emphysema of the medias-
tinal tissue. In the small bronchi was a seropurulent exudation. The
false membranes yielded on cultivation the long diphtheria bacillus and
diplococci. [Very few cases of diphtheria in pregnancy have, been re-
corded. All writers regard the condition as grave. Of 12 published cases
in which antitoxin was not used, 6 were fatal; but in 12 cases in which
it was used all were successful. An interesting point is the great ten-
dency of the diphtheric process to extend to the larynx, as in children,
and contrary to what is usual in adults. Thus, in 12 cases published
before the introduction of antitoxin tracheotomy had to be performed 7
times. It is noteworthy that in the case now recorded there were no
signs of uterine contraction, although the asphyxia of pulmonary dis-
ease is regarded as one of the most important causes of abortion. The
diphtheria bacillus was not found in the fetus, but its toxins appeared
tolhave produced profound alterations in the fetal organs. The myo-
cardium showed signs of degeneration. The spleen was congested and
the seat of interstitial hemorrhages. The liver also showed interstitial
hemorrhages, accumulations of leukocytes in the portal spaces, and de-
generation of the hepatic cells. The kidneys showed similar but less
marked changes. In the lungs there were interstitial hemorrhages.]

The Kidney of Pregnancy. — In a woman who had remained per-
fectly healthy J. Veit^ found that the veins of one of the tubes, which
contained a perfectly normal ovum, contained chorionic villi and cells
of liangerhans's layer (syncytium) of the ovum. On looking up the
literature of the subject he found that this condition has been met fre-
quently, and is regarded by some observers as a normal one. He believes
that the syncytium is carried into the maternal blood directly from the
placental vessels, but puts aside a discussion of this question as com-
paratively unimportant as compared with that of the fact that fetal
elements can penetrate into the maternal circulation. This fact led
him to investigate the subject minutely, and he now publishes the re-
sults of his studies. As Veit was struck by the similarity of the conditions
in this case and in Ehrlich's experiments with the introduction of foreign
blood-cells into an animal, he proceeded to test the result of introducing
placental tissue artificially into the body. In order to exclude the action
of hemolysin he rendered the placentas as bloodless as possible, and
introduced finely divided or pulverized placentas (human and rabbit's)
into the peritoneal cavities of rabbits; on a few occasions he injected sus-
pensions subcutaneously and intravenously. Rabbits which received
6 placentas taken from full-time rabbit's uterus always died in 12 hours.
When he used 3 rabbits' placentas or 10 grams of human placenta the
urine which was secreted was found to contain albumin. He has not
yet been able to determine the minimal lethal dose, but found that 7
grams of human placenta were not always sufficient to kill. The albu-
min appeared in from 40 to 48 hours, and' disappeared in a short time
afterward. The actual cause of the albuminuria must be toxic,
and he regards it as a " lysin," just as red blood-cells when intro-
1 Berl. klin. Woch., Nos. 22 and 23, 1902.

THE PATHOLOGY OF PREGNANCY. 363

duced into a strange host produce a body which is capable of dis-
solving the red cells of the second species, which is also a lysin (hemol-
ysin). The albumin — or, rather, a fraction of the albumin — attaches
itself to a "side chain" of the red blood-corpuscle, and thus exercises
its poisonous action. There is evidence that this poison is not specific,
that is, other tissues can produce albuminuria in rabbits in the same
way; for example, the introduction of portions of the umbilical cord and
of muscle produces the same result. Further, he found that this body
is not present in the serum, as can be shown when the serum of either
artificially " albuminurized" rabbits or of eclamptic women is injected
into the test-animal, for in this case no albumin appeared in the urine.
His experiments dealing with the antitoxin are not yet finished, but he
succeeded in preventing the appearance of albumin after introducing
human placenta, and in another case, in which he obviously did not
employ a sufficient dose, the animal died with albuminuria and con-
vulsions. He does not attribute much importance to the fact of the
appearance of the convulsions. It seems a reasonable suggestion that
the cells of the peripheral part of the ovum play a part in the genesis
of the nephritis of pregnancy; and although he says that there is no
ground for behoving that the "deportation" of fetal cells, or rather of
cells of the periphery of the ovum, can cause actual nephritis, we have
to explain the fact that in eclampsia these cells are frequently present
in the maternal blood, and that albuminuria has often been noticed
with hydatid mole. A further important condition (which has been
shown by Wychgel, who carried out the experiment at the request of
Veit) is that in the pigmentation of the skin in pregnancy there is an
excess of free iron, and Veit believes that this is due to the dissolving
action of the syncytium on the red blood-cells, which frees the hemo-
globin. Wychgel also found an excess of iron in the urine of gravid
women as compared with that of nonpregnant women. Following the
matter further, he found that at times the serum of pregnant women
contains hemoglobin, while in other cases the serum is turbid, and
although it does not contain free hemoglobin, it nevertheless differs from
that of nonpregnant women. There are 3 possibilities which could
explain the presence of iron in the pigment, etc.: (1) The toxic body,
cytotoxin, may contain free iron. That this is unlikely is shown by the
fact that while the free iron in the tissues can always be found in preg-
nancy, hemoglobinemia is seldom met. (2) That the cytotoxins in the
process of being cast off from the red blood-cells produce such a damage
to the latter that the hemoglobin is set free; and (3) that the cytotoxins
act hemolytically. Against the last supposition he mentions that in
test-tube experiments the serum of pregnant rabbits does not act as a
more powerful hemolytic than that of normal rabbits. He therefore is
inclined to regard the second theory as the most probable. In conclusion,
he points out that a further study of these phenomena is very likely
to reveal important facts, and to lead to great progress in the direction
of therapeutics.

The Autointoxications of Pregnancy. — W. A. Potts^ regards as
' Med. Rec, Dec. 6, 1902.

364 OBSTETRICS.

causes of this class of maladies flatulency and constipation, they leading:
to toxic influences and frequently causing abortion. Pernicious vomiting
is another result of toxemia. Colitis and appendicitis, ptyalism, cramps,
phlebitis, and chorea are all toxic manifestations. As regards eclamptic
seizures, the author says that: (1) All cases of eclampsia are found to
have recently suffered from constipation, generally of extreme degree.
(2) All remedies which have met with any general measure of success
are remedies either of elimination or of dilution of toxins. (3) In 85 %
of cases of eclampsia examined postmortem, the kidneys, which are the
safety-valves of toxin elimination, are found to be diseased. (4) The
only other lesions frequently found postmortem are in the liver, the
organ chiefly concerned in the metabolic processes; and, lastly, serious
disease of organs other than the kidney and liver does not predispose
to eclampsia. The obvious consequence of all the foregoing is to bring the
eliminative plan of treatment to the front and to place greater reliance
upon it than all other measures combined. Potts advises also the use of
thyroid extract as increasing excretion and greatly stimulating metabolism.

Pregnancy following Nephrectomy. — Although nephrectomy is
such a frequent operation, only 3 cases have been reported in which
pregnancy followed the operation. Two further cases are now reported
by J. F. Baldwin.^ In one case the kidney was removed for hydro-
nephrosis, and in the other for a pyelitis. Normal pregnancy followed in
both cases and the convalescence was uneventful. While numerically
insufficient to form a basis for generalization, these 5 cases would seem
to indicate that the prognosis of pregnancy following nephrectomy is
by no means imfavorable.

Hematuria in Pregnancy. — Bouman^ has collected 17 cases in a thesis
(Amsterdam, 1901). The blood in all was clearly from the kidney, and
disappeared after delivery; it reappeared in several cases in a subsequent
pregnancy. Bouman doubts if the blood represents ''essential hema-
turia" as recorded in 5 published cases. In 2 of these cases a kidney
was removed and no histologic change detected (Schade, Klempner); in
the others nephrotomy was practised, but nothing more done, as the
kidney showed no naked-eye appearance of disease (Broca, Loumeau,
Debesargues). Whether this affection be a form of hemophilia or due
to some neurosis, pathologists cannot as yet determine. Bouman sees
no reason to doubt that in his 17 cases of hematuria in pregnancy there
was renal disease already existing before conception, though latent or
showing very mild symptoms. The pregnancy aggravated the organic
affection, either through congestion or autointoxication. The hematuria
was noted as ceasing abruptly in one case when the membranes ruptured.
In one of Guyon's cases blood reappeared during lactation. Disease of the
kidney has been detected in more than one instance; this recurrence of
hematuria a year after delivery in another case of Guyon's led to the dis-
covery of tuberculosis of the kidney. Van Herson records a similar case,
and Treub reports a recurrence of hematuria without pregnancy. Yff*

1 Cleveland Med. Jour., May, 1903. ^ Monats. f. Geb. u. Gyn., June, 1902.

3 Ibid.

THE PATHOLOGY OF PREGNANCY. , 365

reports a case in which hematuria set in during a fourth pregnancy; it
was clearly renal, and disappeared after delivery. It transpired that
abortion had been induced in the second month of the second pregnancy
on account of renal symptoms.

No Essential Fever of Pregnancy. — Pinard ^ absolutely denies the
existence of the fever of pregnancy described by Burns, of Glasgow, in
1809. Tarnier and Budin admitted that fevers in pregnant women
offered no characteristic symptoms. Vinay in 1894 showed how modern
experience had proved that pregnancy plays an entirely secondary share
in the production of the fevers with which it is sometimes associated.
Pinard insists that there is distinct danger in maintaining a belief iii
an essential fever of pregnancy. It may cause the medical attendant to
overlook many conditions little known in the days of Burns, such as
appendicitis, torsion of ovarian tumors, and dilated tubes, cholecystitis,
and other diseases, which often complicate pregnancy and involve rises
of temperature. When such a rise occurs, the cause, which is never the
pregnancy as such, should be sought for. In the course of 1902 Pinard
observed many ''temperatures" in pregnant women under his care in
the Clinique Baudelocque; many of the patients were nearing term, but
some were in very early pregnancy. One woman had distinct fever in
the fourth month, and the cause was not clear; apparently there was no
local tenderness. An exploratory incision was made, and an ovary full
of pus was detected and removed.

Incarceration of a Retrofiexed Gravid Uterus. — W. Albert"^ claims
that the physician often fails to cure or uses wrong measures because
of error in diagnosis; but diagnosis is not difficult when two points are
sufficiently considered: (1) The cessation of the menses; (2) the imme-
diate catheterization of the bladder in obscure conditions of the female
pelvis. In incarceration of the retrofiexed gravitl uterus, naturally the first
measure is manual reposition, ^\'ith or without an anesthetic, according as
the case requires. A breaking up of adhesions by the finger may be neces-
sary, and this in many cases may prevent abortion. When manual reposi-
tion, however, cannot be effected, or sigas of difficulty occur, before resort-
ing to surgical measures the kolpeurynter should be tried. Albert has
used it for 5 years in such conditions, and reports 5 cases. The method
is simple, but should always be preceded by emptying the bladder and
bowel. The rubber balloon of moderate size is introduced between the
uterus and the pelvic floor and filled \vith. 200 cc. of sterihzed w^ater. If
this does not suffice to replace the uterus, after one-half or one hour, it
should be repeated with an increased amount of water, 600 cc. being about
the limit, until reposition takes place. In the cases reported these measures
were employed at an early stage of pregnancy, varying from the second to
the fourth month, with restoration of the uterus to its normal position
and the continuance of pregnancy. Doleris' treats this condition by
opening the abdomen, separating adhesions, and shortening the round
ligaments. He reports a successful case in which the patient, who was

' Ann. de Gyn6c. et d'Obstet., March, 1903.

=* Mvinch. med. Woch., March 24, 1903. ^ La Gyn^cologie, .Tune, 1902.

366 OBSTETRICS.

in the third month of pregnancy at the time of the operation, was de-
livered easily at full term, the uterus remaining in its normal position
after involution had occurred.

Tiimors Complicating Pregnancy. — [Pregnancy complicated by
cancer of the rectum is extremely rare, only 16 well-authenticated cases
being reported in literature. This fact is explained on the grounds that
cancer usually follows the climacteric, and that carcinoma of the rectum
is more rare in women than in men. The proper procedure from the
standpoint of obstetrics for cancer of the rectum in pregnant women
is, according to Holzapfel, the total extirpation of the neoplasm, mani-
festly because its presence so narrows the pelvic canal that a living
child can otherwise hardly be born. In cases, however, in which the
cancer itself does not permit of operation, the indications are to provide
otherwise for the birth of a living offspring. These inoperable cancers
ordinarily take up a great space in the pelvis, and the birth of a full- term
living child through the natural channels is almost always impossible
for this reason. It is almost always necessary to perform a cesarean
section. Of the cases reported in literature, 7 concerned such an opera-
tion. If the carcinoma is advancing so rapidly that the death of the
mother is foreshadowed before the end of the pregnancy, cesarean section
must be carried out, or, if the birth-canal is still large enough, a pre-
mature delivery must be brought about. Another condition is when the
child within the womb is already dead, and the mother presents an
inoperable cancer. In such cases cesarean section must be performed
only when absolutely indicated ; that is, when other obstetric operations
are no longer possible on account of narrowing of the pelvis. It is to
be remembered in this connection that carcinomatous tissue has very
little elasticity, and is therefore more easily torn than the normal tissue.
Cniveilhier and Kiirsteiner both reported great damage to the rectum
in their efforts to extract the child under just such conditions. There
are, however, many of these cases in which a vaginal operation will
permit the delivery of the child with sufficient readiness, and yet with
greater safety to the mother than a cesarean section.] Quite otherwise
are those cases of cancer, according to Z. Endleman,^ which permit
removal of the growth by surgical measures, a procedure which must be
carried out as quickly as possible. The chief question is whether the
pregnancy should first be ended and then the growth removed or vice
versa. In literature there is only one case of carcinoma of the rectum
operated on as late as the sixth month in pregnancy, and that was fol-
lowed by abortion 4 days afterward, and then on the fifth day by the
death of the mother. With only this one case as a guide, it is impossible
to say that no operations of this kind should be done during pregnancy.
Probably a good "rule will be that if the tumor is small and situated
low down in the rectum, its removal without interfering with the preg-
nancy is proper. During such an operation it is necessary to expect
greater hemorrhage, because all the organs of the pelvis are in this
state more richly supplied with blood. It would also be natural in the
1 Zent. f. Gyn., No. 32, 1902.

THE PATHOLOGY OP PREGNANCY. 367

majority of cases to expect abortion, not only through infection, but
also through various accidental damages to the womb and its contents.
Since the lochia will invade any fresh wound, it is advisable to separate
the operations of abortion and removal of the neoplasm by as many days
as possible. Whenever during pregnancy there are pains localized in the
back and sacral region, and painful stools, Rossa^ advises an examination
of the rectum without delay, the same as in case of like pains in the non-
pregnant. A. W. RusselP draws the following conclusions : (1) If cancer
of the rectum is discovered early in pregnancy, immediate radical opera-
tion should be considered. (2) In advanced pregnancy Avith a small
circumscribed growth the uterus should be emptied before attempting
removal of the growth. (3) In advanced pregnancy with a viable child
cesarean section and hysterectomy should be performed, and, if possible,
inguinal colotomy should follow, and the diseased rectum should be
detached from above so as to allow the operation to be easily completed
by the vagina according to the method of Rehn or Liermann. (4)
When, on the other hand, the disease is beyond radical treatment, the
child should be saved by cesarean section or hysterectomy with or Avith-
out colotomy as may be necessary. (5) If the child is dead and the
cancer is beyond operation, cesarean section is still likely to be needed
unless labor can be accomplished easily and without undue crushing or
laceration by the aid of perforation, embryotomy, or version. (6) With
modern improvements in methods of operation better results may be
expected than those of allowing labor to take place or inducing it through
the natural passages.

Piirckhauer' analyzes reports of 12 cases of ovarian tumors com-
plicating pregnancy, from Hofmeier's clinic, with the following conclu-
sions: (1) An ovarian tumor complicating pregnancy must be regarded
as an ever-present danger for both mother and child. (2) Ovariotomy
is always indicated, and the prognosis is good even if peritonitis has
already developed. (3) Abdominal section should be performed at once
if a cyst ruptures during labor. (4) If for any reason ovariotomy is
contraindicated during pregnancy, it should be performed as soon as
possible after delivery. Of the tumors of the lower abdomen and pelvis
which may complicate labor, dermoid cyst is certainly a very uncommon
one. A case of this class is reported by J. B. Macauley.* The primipara
was 27 years old ; she had been in labor about 10 hours when first seen ; was
suffering feeble pains, with a slowly dilating os, and a head-presentation
in the left occipitoanterior position. The pains ceased that night, and
the patient slept through it. Labor began again the next morning. On
examination the patient showed little advance, but was visited every
few hours that day, and in the evening the os was fully dilated, and
the pains, although very severe, did not advance the head. Chloroform
was administered and the forceps applied, but, notwithstanding the use
of these instruments, the head did not move appreciably. On relaxing
traction on the instrument, without symptoms or warning there appeared

* Amer. Med., Dec. 27, 1902. * Scottish M. and S. Jour., June, 1903.

» Inaug. Dis. ; Zent. f. Gynak., 1902, No. 32. * Lancet, Nov. 8, 1902.

368 OBSTETRICS.

at the pelvis a large cyst vdth. a long pedicle. At first it suggested a
cystocele, but a catheter did not "withdraw urine from it. Then degen-
eration of the amnion was considered, together with that of placenta
praevia, because the cord had already prolapsed as if the placenta were
situated low down. An incision was made in the cyst, and a large
quantity of matted hair was removed. Then the cyst and its long
pedicle was brought down and kept outside of the vulva by means of
a ligature. The child was then delivered without difficulty, instrumen-
tally. Death followed in the mother by peritonitis in a few days, and,
unfortunately, no autopsy was allowed, so that the precise origin of the
cyst within the abdomen cannot be stated. Examination by the vagina
seemed to show that traction with the forceps had caused the cj^st to
rupture through the cervix, and thus pass dow^n the vagina.

Baecker,^ in reporting 6 cases, states his belief that in spite of the
fact that the tumor is benign, pregnancy in a fibroid uterus is a con-
dition which is fraught mth danger, during both the pregnancy and the
puerperium, varying according to the size and location of the neoplasm.
Before the third month it is advisable to empty the uterus in a doubtful
case. After the third month the expectant treatment should be followed,
but if serious complications arise, the writer prefers hysterectomy to a
palhative operation, which may expose the patient to the risk of fresh
danger from a subsequent pregnancy. Hence, he does not approve of
enucleation, even when combined with castration. Of course, the intelli-
gent consent of the patient to a radical operation is necessary. The
decision of the operability of fibromyomas of the uterus is difficult even
in the presence of modern advanced technic, but when pregnancy occurs
to complicate the proposition the seriousness of the clinical question is
enhanced. Submucous myomas by altering the endometrium usually
prevent conception ; subserous forms have no effect on impregnation, but
may interfere with later pregnancy and delivery, w^hile interstitial masses
especially about the lower segment of the corpus or in the cervix com-
monly cause very great obstruction in the parturient passage.

H. C. Coe^ distinguishes 3 periods of pregnancy complicated by
fibroid tumors: (1) Up to the fourth month: (a) Empty the uterus in
the case of large interstitial or broad-ligament tumors, or where they are
situated in the lower uterine segment; also in cases of impacted intra-
pelvic growths, (fc) Small tumors should be enucleated by the vagina,
if possible, though pregnancy would usually be interrupted. Intrauterine
polypi should be removed, if accessible, (c) Enucleation should be done
by the abdominal route. Subperitoneal pedunculated growths should
be removed, (d) Impacted growths should be liberated under anesthesia
when no adhesions w^ere present, and they should be kept out of the
pelvic cavity until they were held out of the way by the growing uterus.
The wishes of the patient should be followed as far as this could be done
with safety. (2) Fourth to seventh month: The location of the tumor
is important, as well as its size and variety. Pain and pressure-symptoms
furnish indications for treatment, (a) Large interstitial growths. The

' Zent. f. Gynak., No. 38, 1902. ^ ^ Y. Med. Jour., June 6, 1903.

THE PATHOLOGY OF PREGNANCY.

369

uterus might be emptied, although the danger of hemorrhage from
such a course is greater. (6) He advises enucleation by the abdominal
route, and speaks of the propriety of removing multiple small tumors
which do not encroach on the uterine cavity, (c) The patient should be
kept under observation. She might go to full term and be delivered
normally, (d) Impacted tumors, pressing on the bladder, bowel, or
ureter, might call for radical operation, (e) Twisted pedicle, degenera-
tion of the tumor, disease of the adnexa, peritonitis, etc., might require
interference mthout reference to pregnancy. (3) After the sixth month:
Viability of the fetus should be obtained, if the life of the mother is
not actually jeopardized. Can the woman be delivered at term? Yes —

Fig. 60. — Fibromyoma obstructing labor, reiiiDved bv cesareiiii hysterectomy ((iilesi, in Cliii. Jour.

1902, vol. XX,' No. 14).

(a) with subperitoneal growths, if they are not too large and favorably
situated; (b) mth small interstitial fibroids, if they are not in the
lower uterine segment; (c) polypi presenting at the os can easily be
removed at any time. (4) After the eighth month the Porro-Cesarean
operation, suprapubic amputation, or hysterectomy should be performed.
Conservatism should be practised here, as in other gynecologic operations,
but not carried to extremes. Giles ^ reports an interesting case of fibroid
tumor obstructing labor and treated by cesarean section. The child pre-
sented by the foot, the tumor lying in the hollow of the sacrum (Fig. 60).
Celiotomy during Pregnancy. — When formerly a surgeon made a
mistake in his diagnosis on opening the abdomen and found pregnancy,
' Clin. Jour., 1902, vol. xx. No. 14, p. 222.

370 OBSTETRICS.

he quickly closed it and let the case alone, even if some growth or some
pathologic condition existed, says J. M. Carstens.^ To-day we know that
operations can be just as safely done'as if no pregnancy existed. Tumors
are removed that \\411 interfere with delivery, and other acute conditions,
such as appendicitis or injury to the bowels, in spite of existing preg-
nancy, are operated upon most promptly. Carstens has operated in the
case of existing pregnancy 21 times with 5 deaths, so that the mortality
was over 23 %. He believes that the mortality is less in the more
modern cases. These 21 cases were as follows: Appendicectomies, 5;
fibroids, 4; hernia, 1; abdominal hysterectomy, 1; ovariotomy, 3; vagi-
nal hysterectomy, 3; miscellaneous, 4. Tumors above the brim of the
pelvis, or which can be moved above the brim of the pelvis, need not
be interfered with; still, all tumors take on rapid growth during preg-
nancy, and the increase in size may interfere with the functions of life
and then require surgical interference. Christ^ considers the rela-
tions between pregnancy and operations, especially dental operations.
Whether extraction of teeth exerts a bad influence upon existing preg-
nancy, is a question of interest to physicians and dentists alike. He
concludes: (1) With a normal uterus any necessary operation may be
undertaken. Only in operations upon certain parts which have a special
relation to the genital function must the possibility of an interruption of
the pregnancy be taken into .account. (2) With a healthy uterus the
month of the gestation does not make any difference. (3) Whenever
necessary teeth should be extracted without considering the pregnancy ;
so with other dental procedures and operations.

, PLACENTA PRiEVIA.

F. Hitschmann and 0. LindenthaP review the theories of many
authors and the observations made upon animals in order to ascertain
the normal place of implantation, and the modifying circumstances
which cause abnormal attachment of the impregnated ovum. A known
development of the impregnated ovum, requiring a definite time, must
take place before it reaches the stage of attachment. Under nonnal
conditions the ovum will find itself mthin the upper segment of the
uterus when this stage of development is reached. But if impregnation
occurs at an earlier period in the journey of the ovum, or the impregnated
ovum meets with unusual hindrances to its passage, the time of attach-
ment will be reached before the normal place of implantation, and then
the ovum will attach itself to the lower uterine segment as in placenta
praevia, or at a still earlier period in its journey to some portion of the
tube as in ectopic gestation. [The normal place of impregnation is not
yet certainly determined, neither are the circumstances that control the
movements of the impregnated ovum fully known, hence the causes of
tubal gestation are still obscure. The statistics touching the frequency
of occurrence of placenta previa are not at all in harmony; for instance,

1 Am. Jour, of Obstet., March, 1903.

2 Boston M. and S. Jour., Sept. 25, 1902. ^ Zent. f. Gynak., Feb. 28, 1903.

PLACENTA PREVIA. 371

according to Kaltenbach's figures, placenta prsevia happens, on an aver-
age, once in 1600 cases of labor, while in the famous Rotunda Hospital
the proportion is put down as 1 in 175 cases, thus constituting a very
wide difference. Without doubt this condition is found much more fre-
quently in a strictly hospital lying-in service, because patients suffering
with cases of this character, having foreknowledge of the condition, will
voluntarily go to, or be referred to, a hospital as by far the best course
to take. For this one reason obstetric hospitals will always show a much
larger proportion of these cases than found in private practice. An English
obstetrician, however, says that in an experience extending over a period
of 22 years, and covering 2067 cases of labor, he has had 13 instances
of placenta prsevia, one case being very unique, in that placenta prsevia
occurred in 2 successive pregnancies.] In re\4ewing the cases at the
Sloane Maternity Hospital it was found by F. A. Dorman^ that placenta
prsevia occurred in one 1 of 133^ cases. This simply shows the high
percentage of operative cases in hospital practice, for the usual propor-
tion is about 1 in 1000. Any condition which tends to interfere with
the fixation of the ovum as it comes from the fallopian tube serves as
a causative factor. In this series the ratio of multiparity to primiparity
was 8 to 1. The diagnosis must be made upon' the history of the case
and vaginal examination. A history of bleeding during the later months
of pregnancy always demands examination, for a second warning may
not be given, and a profuse bleeding causes rapid death unless help is
at hand. These statistics show a mortality of about 12 %, but it usually
ranges between 20 % and 25 %. According to J. S. Rose,^ the mortality
in recorded severe cases is heavy — 50 % (GoodaU), 46 % (Stover). On
account of the operative interference which is usually necessary in the
interests of the mother, the fetal mortality ranges between 50 % and 60 %.
Treatment of Placenta Praevia. — According to Dorman,' expectant
treatment is permissible only before the seventh month in order that
the time of complete viability may be reached. Fatal cases before that
time are seldom heard of. The induction of labor may be by a vaginal
tampon or by a bougie, but the best method is by the Champetier de
Ribes bag as modified by Voorhees. With this in the cervix we have
a good uterine stimulant and a perfect tampon. One rule laid down as
invariable is that the patient should never be left alone till she is de-
livered, and pregnancy should never be allowed to advance beyond the
seventh month. If the bags are not obtainable, the cervix must be
rapidly dilated and a podalic version done, so that a leg may be brought
down to act as a tampon and stop the hemorrhage. An external version
is frequently possible in these cases, because the head remains high up
above the pelvic brim. After bringing down a leg the completion of
the dilation may be left to nature. The first consideration is to control
hemorrhage, and the second is to combat shock, which is so often present.
Intravenous injections of salt solution are very beneficial. A compara-
tively frequent complication is rupture of the uterus on account of the
force sometimes used in extraction and on account of the vascularity of
^ Med. Rec, Aug. 30, 1902. » Brit. Med. Jour., April 25, 1903. » Loc. cit..

372

OBSTETRICS.

the cervix. As the chances of the child are bad anyway, too great risk
should never be taken M-ith the mother in rapid extraction. A sug-
gestion is made that cesarean section might be justifiable if the mother
is in good condition, the cer^^x hard and undilatable, and the surround-
ings favorable for a laparotomy. J. B. De Lee^ states that the best way
to induce labor is to puncture the bag of waters and introduce the kol-
peurynter into the uterus, resting on the placenta and pressing against
the cervix, and then to put traction on the tube. Traction should not
be too rapid, nor should there be too early delivery. The cervix in cases
of placenta prsevia is altered so that it is easily distended. The placental
site if ruptured is certain to open vessels of some size. The retractile
power of the lower segment is slight, and a hemorrhage from such a
laceration is often obstinate and severe. In the treatment mth Carl
Braun's kolpeurynter the instrument is sterilized by boiling for 20 min-

Fig. 61.— Kolpeuryuter bag in use (De Lee, in Am. Gynecol., vol. i. No. 2, 1902).

utes, is rolled as compactly as possible, and grasped by forceps, and
under the guidance of the index-finger is placed inside the membranes.
The bag is then filled with a weak lysol solution, using from 12 to 16
ounces. The head is pushed to one side or directly upward. The tube
is clamped with an artery-forceps and traction is made on the bag. The
bag acts like the breech, stops hemorrhage, excites pain, and dilates the
cervix. If the case promises to take a long time, a tape may be fastened
to the forceps and attached under tension to the foot of the bed (Fig.
61). The writer prefers manual traction, relaxing the tension occasion-
ally to allow blood to enter the cervical tissues. The tension ought not
to exceed 2 pounds. The bag is commonly expelled in from 2 to 8
hours. When the bag has passed the cervix, and it is found that the
head has followed, the case may be left to nature. If the cervix is not
dilated completely, a version may be done, or the kolpeurynter replaced
and distended with a larger quantity of fluid. A. Kurrer^ offers a sug-
gestion which should make the employment of the rubber bag for the
1 Am. Gynecol., vol. i, No. 2, p. 151, 1902. ^ Zent. f. Gyniik., Feb. 14, 1903.

PLACENTA PREVIA. 373

induction of labor a simpler matter. The ordinary method of filling such
bags with a syringe requires constant supervision in order to prevent
their premature expulsion as the cervix dilates. The author's method
is, after introduction of the bag, to connect its tube with an ordinary
irrigator filled with sterile saline solution and suspended at 6 feet above
the level of the bed. This keeps the bag distended at a sufficient pressure
and makes it keep pace with the relaxation of the cervix, so that it
cannot be expelled until full dilation is effected. R. L. Dickinson^ pre-
fers the simple, strong, short cone of Voorhees, which is inelastic, thin
enough to slip in, when rolled, wherever the finger-tip will pass, and
with no stop-cock to get out of order.

Accouchement Forc6 ; the Bossi Dilator. — As announced last year
(see Year-Book, 1903), Bossi (Genoa) has invented a new obstetric
instrument which may be described as a cervical dilator (Fig. 62), in-
tended for use in certain obstetric cases in which rapid dilation of the
cervix uteri and immediate delivery are indicated. Leopold' de-

Fig. 62.— The Bossi dilator (Canad. Pract. and Uev., March, 19a3).

scribes his use of the instrument. He became impressed with the
value of this instrument during a visit to the inventor, when he saw
him completely dilate the cervix in a case of pernicious anemia in
a multipara in whom it was necessary to deliver the child speedily.
In 25 minutes the cervix was completely dilated, the membranes were
ruptured, and the patient as soon as possible delivered by forceps. Leo-
pold has tried the instrument in 12 cases: in 7 of eclampsia, 1 of ad-
vanced phthisis, 1 of pregnancy with uterine cramp, 1 of labor com-
plicated by fever, and 2 cases of contracted pelvis. The instrument was
satisfactory in his hands. Dilation was secured in from 20 to 30 minutes.
In 3 cases an unimportant laceration of the cervix occurred which was
immediately closed by a stitch. In eclampsia its use was especially
successful. In 2 cases the convulsions ceased after the dilation. All
the patients so treated recovered. The instrument is composed of 4 arms,
which are made to radiate from a center by turning a screw with a
circular handle. The extremities of these arms may be covered by
" Chicago Med. Recorder, April, 1903. ' Arch. f. Gyniik., 1902, Bd. Ixvi, Heft 1.

374 OBSTETRICS.

additional pieces having corrugations of considerable size, which prevent
the instrument from slipping. It ma}'- be inserted without these pieces,
and these may be added as dilation advances. The instrument can be
introduced when the os will admit one finger. J. B. De Lee^ has made
a careful study of reported cases of the use of this instrument and has
used it himself 3 times. He reaches these conclusions: (1) There is a
small field of usefulness for this instrument in cases in which rapid
dilation of the cervix is necessary after effacement. Before effacement
the kolpeurynter should be used. It will be more successful in multip-
aras. (2) The instrument will be useful in dilating the cervix in those
cases in which manual dilation would be successful. It possesses advan-
tage over the hand in the asepsis, and in that it is not so tiring, so that
the operator may carry out the subsequent delivery comfortably. (3)
The instrument is not safe, but requires careful and skilled watchfulness,
and one must search for and be ready to repair more or less extensive
lacerations. These are greater in primiparas. (4) It should never be
used in placenta prsevia. (5) It does not replace the kolpeurynter, the
use of the hand, or cervical incisions in all cases. Ludwig Knapp, Wagner,
C, W. Bischoff, H. Langhoff, and A. Mueller^ discuss Bossi's new method.
They praise it individually and collectively, and bring reports of cases
to bear upon their views. In the hands of all it has been most successful.
The main indications for the use of the instrument, as brought out in
the papers, are protracted labor with danger to mother or child, eclamp-
sia, and placenta prsevia. In some cases a laceration of the cervix could
be subsequently demonstrated, but in all cases a rapid dilation was
accomplished. An unopened cervix can be fully dilated in from 20 to
30 minutes. A. OstreiP reports 4 cases in which he used Bossi's or
Frommer's dilators, 3 times for eclampsia and once for tetanus of the
uterus. Ostreil employs the rapid dilators only for eclampsia, preferring
the metreurynter for cases of placenta prsevia. The 4 patients recovered.
Leopold Meyer* also refuses to use Bossi's instrument in placenta prsevia
or for the induction of premature labor, although he thinks the fear of
hemorrhage from laceration of the cervix has been exaggerated. Meyer
has used the instrument 15 times, 6 times in eclampsia, twice in cases
of infection, twice in placenta prsevia, twice in heart-disease, twice in
pyelitis, and once for accidental separation of the placenta. Two of
these patients died, the rest recovered. Meyer saw, in no instances,
hemorrhage from cervical tears. Rissmann^ gives the history of 3 cases
in which he used Bossi's instrument, describes the method of introduction,
and claims this advantage, that its use enables one to see the pulsation
of the fetal head and thereby to determine by sight whether the child
is living. But there is also the disadvantage that in this procedure
there is no thinning of the edges of the os uteri; they remain thick and
the obliteration of the os never occurs. There is danger of cervical
laceration if delivery takes place immediately after the dilation. He

1 Chicago Med. Recorder, April 15, 1903. ^ Zent. f. Gynak., Nov. 22, 1902.

3 Zent. f. Gynak., March 14, 1903. * Loc. cit.

* Zent. f. Gynak., July 12, 1902.

PLACENTA PREVIA. 375

advises waiting after the dilation, perhaps using the kblpeurynter mean-
time, until there are strong frequent pains before the extraction of .the
child. With proper care in its use, Rissmann considers that the addition
of Bossi's dilators has enriched our obstetric instrumentarium. Zange-
meister^ calls attention to the fact that in the dilation of the cervix
there are always more or less bloody lacerations. By the use of Bossi's
and Frommer's instruments, although he dilated very carefully, he
regards the danger as double, involving not only a laceration but the
danger of sepsis as well. He prefers the use of intrauterine balloons of
the various patterns, combining dilation with some tugging. [The in-
strument is undoubtedly powerful and able to accomplish the object
for which it was designed. The chief criticism which we would offer,
but this unquestionaoly is potent, is that the mechanism of the dilator
is very complicated, and the instrument is so constructed, with its
numerous parts (many levers and screws), that it is practically impossible
to take it apart for cleaning. This feature renders strict asepsis impos-
sible, which is of course a sine qua non in any surgical instrument at the
present time. The instrument is of metal and may be boiled, but its
many slots and crevices will harbor surgical dirt, so that in a short time
mere boiling would be inefficient. It is surprising that this very objec-
tionable feature of the instrument has not elicited criticism before.]

Cesarean Section in Placenta PraBvia. — Schauta^ questions the
value of cesarean section in this condition, and says that for many years
he has used the method of bimanual version, followed by the attachment
of a weight of about 3 pounds to the fetal leg which is brought down
through the vagina. The expulsion of the fetus, assisted somewhat by
the continued traction exerted by the weight, is left to the natural
sources until the umbilicus emerges from the vulva. From this point
the case is managed in accordance with the usual method of dealing
with breech-presentations. A compilation of his cases during the past
10 years shows a total of 234, of which 16 ended fatally. In some of
these cases placenta prsevia could hardly be credited with the mortality.
Even allowing this, however, the percentage, 6.8, is not a high mortality,
especially in view of the condition in which the patients are brought
to the hospital. The advocacy of cesarean section in all cases, which
necessarily includes all cases in which the simplest opening of the amniotic
sac suffices to stop the hemorrhage, hardly deserves serious consideration.
He limits his remarks, therefore, to severe cases of central or total pla-
centa praevia. To replace version by cesarean section in these cases
would only add dangers to those already existing. The operation cannot
be at once performed even in well-equipped hospitals, while version is
always available. Deep narcosis is necessary and there must be a
certain amoimt of blood lost, for often copious hemorrhage cannot be
avoided. The placenta must be peeled off after removal of the fetus
with the danger of uterine atony. He does not perform conservative
cesarean section in patients who were handled before entrance by un-
trustworthy people, provided the indication for operation is not absolute.

1 Zent. f. Gyniik., Jan. 24, 1903. ' Canad. Pract. and Rec, Sept., 1902.

376 OBSTETKICS.

Very few cases brought to the hospital conform to this indispensable
requirement. The question whether the section promises to reduce
maternal mortality in these cases he thinks must be answered in the
negative. As regards the chances of the fetus, he believes, that they
would be better if cesarean section could be performed immediately
on the appearance of the first hemorrhage, but if we look over the reports
of cases we find that only a small number of these children are fully
developed. In his 234 children, only 92 were matured, and the mor-
tality of premature children is much more in these cases because they
suffer from asphyxia due to the partial separation of the placenta from
the uterus, and, therefore, he holds that we would not obtain better
results as regards fetal mortality by operation. P. E. Truesdale^ believes
that cesarean section is the operation of choice in the treatment of
placenta praevia, complete or partial, when the child is viable and when
dilation and version, performed with sufficient rapidity to save the
child's life, are rendered impossible by the pelvic diameters and the
condition of the soft parts. In the hands of experts the mortality in
complete placenta praevia treated by version is, for the mother 18.9 %,
and for the child between 65 % and 70 %. In partial placenta praevia
the maternal mortality is probably not over 5 %, but the infant mor-
tality in such cases probably is as high as 50 %. It is the high mor-
tality of version, in complete placenta praevia, that makes cesarean
section a rational method of procedure. Lateral insertion of itself does
not justify section. [So far, there have been reported 13 cases of cesarean
section for placenta praevia. In these the maternal mortality was 44.4 %,
and the infant mortality also 44.4 %. These figures are, however, mis-
leading, as in one case the operation was undertaken as a last resort
when all other means had been tried, and in another case there was
probably malignant disease of the cervix. In these two cases both
mother and child were lost. In the second the child was shown to have
been dead 2 days before operation. Truesdale excludes these two cases
on the ground that they do not give fair statistics. The revised showing
is, then, 11 cases with a maternal and fetal mortality of 22.2 % each.]

ABORTION.

[While we may fully agree with the contention of a recent earnest
writer that abortion is greatly increasing and that everything possible
should be done to mitigate the evil, at the same time it must be admitted
that the medical profession has within its own ranks the very worst
offenders. While the newspaper advertisements of abortifacients should
be by law prohibited, and the sale of such substances by druggists and
others strictly curtailed or annuled, at the same time it must not be
lost sight of that altogether too many calling themselves physicians, and
legally entitled to the name, are engaged in the nefarious work directly
and indirectly. To be sure, no man or woman morally deserving the
name of physician will lend himself or herself to such practice, and
' Boston M. and S. Jour., April 2, 1903.

ABOETION. 377

there is a very strong feeling in all medical circles touching such pro-
ceedings. A practitioner cannot long extend this kind of aid(?)to
those applying to him without the fact becoming known to all other
physicians in his vicinity, however much he may try to conceal his
ill-doing, and that professional sentiment is against him will be shown
very freely. But this does not alter the fact that such work, in the
eyes of non-discriminating people, lies within professional borders, as in
truth, viewed in one way, it does. The question then remains, that the
medical profession as a whole should devise some way of clearing its
own skirts before berating others for their misdoings in this direction.
We may condemn newspapers as a class for their conscienceless aid to
the exploitation of murder-producing means ; we may denounce the drug-
gists for readily, even eagerly, selling to whoever applies drugs of this
class; but — as a profession — we are not a little inconsistent if we do
not first drive out every offender from under our own roof. And this is
a great question, and has been for a long time. Professional ostracism
does something, of course, but the offender remains a recognized "doctor"
in a legal, and perhaps common, sense, and goes right along doing the
same business it may be for years, until finally a death happens under
suspicious circumstances, calling for a coroner's investigation, when the
culprit either suffers the due penalty of the law, is helped out of the
fix by cronies, or leaves for parts unknown. And thus it continues; and
thus a lasting blight upon the honor of the entire profession obtains.]

Recurrent Abortion. — The classification of recurrent abortion as
given by John W. Taylor* is more rigid and severe than is usually seen.
He includes under the title of recurrent abortion only those cases in
which from the beginning' or from some definite epoch the patient has
aborted with every succeeding pregnancy, and with one exception only
has restricted it to cases of initial or primary recurrent abortion; that
is, to patients who from the beginning of their married life until the
date of coming under observation have never been able to bear a living
child at term. The so-called "habit" in cases of syphilis, especially
when the patient Ls under treatment, tends to alter with each succeeding
pr(>gnancy; recurrent abortion, then, is a better term than habitual
abortion. Of the rare forms of recurrent abortion a few are due to
intraperitoneal adhesions, chronic kidney-disease with albimiinuria, and
a deep laceration of the cervix. When all these rarer forms of recurrent
abortion are accounted for, and when syphilis can be readily excluded,
there still remains a definite group of cases of very nearly equal impor-
tance to that belonging to syphilis. The distinguLshing features which
bind these cases together are indications of low vitality on the part of
the mother or father or both parents, a strumous family history, and
what he calls the remarkable result of an essentially " antistrumous"
treatment when carried on for a long period of time or throughout the
whole of pregnancy. Twelve of the latter type of cases are tabulated.
In syphilitic cases each succeeding abortion, if the patient's general con-
dition remains satisfactory, tends to occur at a later period until the

' Brit. Med. Jour., April 11, 1903.
25 S

378 OBSTETRICS.

pregnancy goes to terai. At this stage dead children are usually bom,
but finally living children may be expected. In the "strumous" class
unless something is done to improve the general health, each abortion
tends to further weaken the patient, each succeeding abortion tends to
occur at an earlier period, and finally in some untreated cases the power
of conception is lost.

EXTRAUTERINE PREGNANCY.

Interesting cases of ectopic pregnancy are recorded as follows: De-
mons and Fieux, ^ a case of pregnancy developing in a tubal diverticuliun ;
E. E. Evans, ^ a Hthopedion in the right broad ligament removed 33
years after the pregnancy; Aspell,^ a fatal case of hemorrhage in a tubal
gestation which was unruptured, the hemorrhage coming from a rup-
tured vessel at the end of the fallopian tube (tubal abortion?); Gyse-
lynck,* a tuboabdominal pregnancy unruptured at the end of 6 months;
Steffeck,^ M. von Hoist,® and Wimmer^ each a successful case of inter-
stitial (tubouterine) gestation; Hoist's patient subsequently passed
through a normal pregnancy; Galeazzi,^ an old case of ectopic preg-
nancy which had ruptured into the bladder from which fetal bones
were extracted; Banga,^ rupture of a tubal pregnancy 7 days after
missing one menstrual period; F. J. McCann,^" the second case ever
recorded of hematosalpinx due to tubal pregnancy complicated by
twisted pedicle, 3 twists being noted (see Fig. 63).

Cases of recurrent extrauterine pregnancy are reported by B. H.
Wells," H. C. Coe,^^ and Harris.^ ^ [The literature upon this subject seems
to be very meager or, rather, the information which would be helpful
in settling several etiologic questions is lacking on account of the oper-
ators' carelessness in not thoroughly examining the other tube at the
time of operation and submitting the specimens to careful microscopic
examination.] Of the various theories which have been advanced relative
to the causation of ectopic gestation, Wells believes that the most potent
factor probably results from a change in the epithelial lining of the
tube following upon a mild infection of that duct and causing an in-
crease in the time occupied by the passage of the fertilized ovum through
the tube.

Double Extrauterine Pregnancy. — Two instances of this extremely
rare condition are reported, one by Maire,^^ the patient having a bicomate
uterus, and one by K. Kristinus.^^ Kristinus's patient, a woman of 30
years of age, was the mother of 4 children, and her last menstruation
occurred on March 1, 1902. During the last week in April there was

> Ann. de Gynec. et d'Obst^t., Oct.-Nov., 1902. ^ Amer. Med., April 11, 1903.
" Am. Jour. Obstet., May, 1902. * Jour. MM. de Bruxelles, Dec. 11, 1902.

* Zent. f. Gyniik., No. 16, 1903. « Miinch. med. Woch., No. 10, 1903.

Ibid., No. 2, 1903. » Giorn. dell. R. Accad. di Med. Torin., Jan., 1903.

« Chicago Med. Recorder, Dec. 15, 1902. " Lancet, May 9, 1903.

Med. Rec, Nov. 22, 1902. " Ibid., Nov. 15, 1902.

" Am. Gyn., April, 1903. " Bull, de la Soc. d'Obst^t. de Paris, Jan. 16, 1902.
« Wien. klin. Woch., No. 47, 1902.

EXTRAUTERINE PREGNANCY.

379

a bloody discharge which was thought to be menstruation, but it was
followed by weakness and dizziness. The hemorrhage continued, and
a membrane was discharged, which was thought to be the remains of
a fetus. On the third day the patient left her bed, though suffering
from pain in the back. Later she was taken with severe pain in the
abdomen, took to her bed, and was soon unconscious. The signs of
internal hemorrhage being pronounced, she was taken to the hospital,
where a diagnosis of a ruptured tubal pregnancy was made. Upon open-
ing the abdomen it was found to contain much fluid blood with some
coagula. After this was removed
there was perceived a sac connected
with the left tube, closely united
with the ovary. This sac was intact.
After this was removed the right
tube was brought well into view, and
was found to be likewise the seat of
an extrauterine fetus. There was a
small opening in the sac, through
which the blood had escaped.

A. Psaltoff ^ at the fourteenth In-
ternational Medical Congress, Mad-
rid, recorded a case of bilateral ex-
trauterine pregnancy which was in
reaHty a recurrent case vnth. an in-
terval of about 3 years.

Coexisting Extrauterine and
Intrauterine Pregnancy. — Cases of
this rare combination are reported by
Vasten,^ K. Reifferscheid,' G. J.
Hagens and J. J. Moorhead,* J.
Phillips,^ G. S. Peck,« J. B. Morri-
son,^ and G. B. Marshall.^ In Mor-
rison's case the ectopic pregnancy
was of the interstitial variety.
Straus* states that no fewer than
32 instances of tubal pregnancy co-
existing with intrauterine gestation appear in literature. In Straus's
table the maternal mortality amounts fo 14 in the 32, but 10 of
the 14 were in cases dating from 1820 to as far off as 1879. In 13
cases both extrauterine and intrauterine pregnancies continued to
term; in 4 both fetuses were living, and out of these 4, only 2 were
cases in which both fetuses were delivered aUve, the one normally,
the other by abdominal section. But one mother was lost out
of these 2 cases. In 3 cases one pregnancy alone continued till term,

* Med. Rec, May 30, 1903. ^ Bol. Gaz. Bolk., No. 40, 1902.

* Zent. f. Gynak., March 21, 1903. ■• Jour. Am. Med. Assoc, May 23, 1903.
^ Lancet, Oct. 25, 1902. « Amer. Med., Aug. 9, 1902.

' N. Y. Med. Jour., June 27, 1903. * Lancet, May 2, 1903.

" Zeit. f. Geb. u. Gyniik., 1900.

Fig. 63. — Tubal gestation witli twisted pedi-
cle. The figure represents tlie natural size of
the tumor and shows the three twists in the
l>edicle (McCann, in Lancet, May 9, 1903).

380 OBSTETRICS.

in 2 it was the normal gestation, in 1 uterine abortion occurred at the
sixth week and the tubal pregnancy continued to term. In 5 cases the
simultaneous pregnancies were diagnosed before uterine labor or opera-
tion. In 9 cases the diagnosis was made after spontaneous termination
of the uterine pregnancy. In 6 cases it was not made at all, being dis-
covered at necropsy; in 6 cases it was detected during abdominal section,
in 2 after abortion of the uterine pregnancy, in 2 at an abdominal section
after abortion, in 1 after detachment of the placenta from the uterine
cavity, while in 1 intrauterine pregnancy was not detected until 2
months after the tubal sac had been removed. This is the only case
in which, after that operation, uterine pregnancy continued to term. The
child was living and was reared.

Twin Tubal Pregnancy in the Same Tube. — Ersilio Ferroni^ reports
a case of t-\\in pregnancy. In the third month of gestation left ovario-
salpingectomy was perfonned. The tube removed contained two fetal sacs
apparently unconnected, and the portion of the tube between them was
in a normal condition, but both openings were stopped with blood-clots.
The two fetal sacs were unequal in size, and showed different stages of
development. It appeared that in the larger sac abortive changes with
the death of the embryo had occurred, while the other advanced to a
later stage of development before a fresh lesion led to further abortive
changes and symptoms requiring operation. The question whether both
ovums came from the same or different ovaries at different times is
also discussed. The symptoms of the patient were those of an ordinary
ectopic gestation, and it was only the anatomic examination which made
kno^vn the existence of a twin pregnancy.

Abdominal Pregnancy. — Witthauer^ claims to have observed a
genuine case of primary abdominal pregnancy. [Ten years ago it was
taught that all ectopic gestations were primarily tubal, so that there
could be no such thing as a primary ovarian or abdominal pregnancy.
But Van Tussenbroek has demonstrated the possibility of primary ovarian
pregnancy, and several genuine cases have recently been recorded. As
for a fertilized ovum developing in the abdominal cavity between the
ovary and the tube, such a condition has not been demonstrated until
the publication of Witthauer's case. J. W. Taylor, of Birmingham, con-
siders that " arrest in the abdominal cavity between the ovary and tube
is probably fatal at once to the unprotected ovum, and consequently
may be eliminated from discussion." He describes abdominal pregnancy
as always secondary'. A tubal sac ruptures, and the ovum manages to
escape into the abdominal cavity without damage to the placenta. The
fetus may in such a case continue to develop, but the placenta always
remains connected in part with the tube. Giles and Bland-Sutton do
not recognize a primary abdominal pregnancy in the last edition of
their manual.] Witthauer takes up another challenge. Referring to a
passage in Alban Doran's paper^ on a fetus found in the peritoneal
cavity he remarks that the author admits that when a minute but recent

» Zent. f Gynak., Feb. 28, 1903. ^ Zent. f. Gynak., Jan. 31, 1903.

^ Trans. Obstet. Soc. of London, vol. xxxv, p. 237.

EXTRAUTERINE PREGNANCY. 381

and entire fetus is to be seen lodged in a true gestation-sac inside the
ovary or on the peritoneum away from the tube, then we shall begin
to beHeve in primary ovarian and abdominal gestation. Since those
works were written a gestation-sac has been detected in the ovary more
than once. Witthauer insists that in his case, though the fetus had
disappeared owing to the early stage of the pregnancy, he found abundant
products of gestation in a b'lood-clot wrapped up in a corner of the free
edge of the omentum. The patient was 23; the period returned 6 weeks
after her second pregnancy, but ceased 10 months later. In about 6
weeks an irregular discharge of powdery dark blood was noted, followed
by violent pains and anemia. The patient was taken into the hospital;
a tumor was detected in Douglas's pouch and the right fornix. The next
day symptoms of internal hemorrhage were observed. Abdominal sec-
tion was therefore performed; over two pints of blood and clot were
found free in the peritoneal cavity. A tag of omentum was found
adherent to the pelvic viscera to the right of the uterus. The right
.ovary was converted into a cystic tumor of the size of a hen's egg, and
was removed A^dth the tube, which was perfectly normal. The left
appendages were healthy; the uterus was not appreciably enlarged. No
source of hemorrhage could be detected in the uterus or its appendages,
but rolled up in the piece of omentum which adhered to the pelvic organs
was a small hematoma, described as of the thickness of a thumb. The
patient recovered, and has recently become pregnant for the fourth time.
The hematoma was found to contain abundant chorionic villi, inclosed
in a capsule of clot, itself encapsulated in omentum. The ovimi itself
had escaped. The corresponding fallopian tube was quite healthy,
patent, but undilated, and no chorionic villi could be detected in its
walls. In association with this case we may turn attention to Kamann's
communication^ on apparent secondary abdominal pregnancy in a rabbit
after primary rupture of the uterus. He gives his reasons for believing
that the fetal sac did not originally develop in the omentum, but that
the pregnancy originated in the litems, Avhich ruptured and permitted
the escape of the ovum into the peritoneal cavity. J. W. Taylor, while
declaring, as above stated, that the unprotected ovum in the peritoneal
cavity is speedily killed, considers that secondary abdominal pregnancy
may be established when a fetus escapes from a tubal sac inclosed in
its unruptured membranes ; not only must the membranes be intact, but
the placenta must retain its attachment to the tube and receive sufficient
blood-supply from the maternal bloodvessels. In Witthauer's and
Kamann's cases the fetal sac had no connection of any kind with the
tube or uterus. [Witthauer's explanation of his case, which deserv^es
careful study, will not absolutely convince skeptics, for he admits that
tubal abortion was suggested by some of the symptoms, yet relies on
the fact that the tube was perfectly healthy. We know that when a
gravid tube discharges an ovum it becomes reduced to its normal size
very rapidly. Still the total absence of any histologic products of con-
ception in the tube supports Witthauer's opinion; in other words, it is
• Brit. Med. Jour., March 7, 1903.

382 OBSTETRICS.

probable that in this case a fertiHzed ovum became primarily implanted
on the omentum. It is singular that hemorrhage so severe proceeded
from so small a body as this hematoma; the same phenomenon is ob-
served when the tubal gestation-sac ruptures. This case must be borne
in mind for medicolegal reasons, when a case of death from intraperitoneal
hemorrhage occurs in a woman, and the ovaries and tubes are found
free from any gestation-sac. Such a sac iiiay possibly be found else-
where, and it may be very small, though the seat of origin of the fatal
loss of blood.] A. L. Galabin^ states that until the report of Witthauer's
case of primary abdominal pregnancy such a condition had not been
demonstrated. He reports a case which he considers presents strong
presumptive evidence that primary abdominal pregnancy occurred. The
patient died from hemorrhage, and a thorough examination of the pelvic
viscera was made. The gestation-sac was placed between the uterus
and rectum, occupjdng the whole of the pouch of Douglas. There was
a fetus 5.5 cm. (2\ inches) long, apparently at the tenth week of gesta-
tion. Both tubes and ovaries and the mesosalpinx were normal, with
the exception that the right ovary contained two small cysts. Neither
tube showed signs of recent dilation. The specimen was examined by a
committee of the Obstetrical Society, which reported that the pregnancy
was probably a primary abdominal one. It was held possible that a
tubal abortion had occurred at a very early stage of gestation and that
the ovum had been transferred to the bottom of the pouch of Douglas.
The author states that obviously such a possibility cannot be excluded
from any apparent case of primary abdominal pregnancy. Other evi-
dences of primary abdominal pregnancy were that the fetal sac consisted
externally, outside of the chorion, of a membrane the outer surface of
which was smooth, somewhat polished, resembling peritoneum. There
was no part of such sac, however, in the ovary, and a space nearly 2 cm.
(f inch) of normal broad ligament intervened between the ovary and
the nearest part of the placental site.

Interesting cases of secondary abdominal pregnancy are reported
by C. P. Noble, 2 W. L. Estes," Doktor,"* Stankiewicz,' Ullmann," 01s-
hausen,^ and Sittner.^ Sittner adds 16 to the previous 126 cases of
extrauterine pregnancy which were ended by laparotomy, with the
fetus living at the time of operation. These belong to a period since
1813. Of the 16 cases, 1 illustrated the rare form of pregnancy in the
hernial sac in the inguinal region; in 7 the fetus had developed to an
advanced stage in the original sac, 5 of these in the uninjured tube, 1
in the ovary, and 1 in the ovarian tube; in 8 the fetus was outside the
original sac, twice through rupture into the broad ligament and in the
other cases into the abdominal cavity, where the fetus lay completely
free in 4 instances; in 2 with the placenta attached to an abdominal
organ. One case was especially interesting, as the fetal sac was found

1 Brit. Med. Jour., March 21, 1903. ^ Phila. Med. Jour., May 30, 1903.

^ Ibid., Dec. 13, 1902. ■• Zent. f. Gynak., No. 31, 1902.

s Monats. f. Geb. u. Gyn., Dec, 1902. « Ibid., vol. xv, Supplement, 1902.

' Zent. f. Gynak., No. 20, 1903. « Ibid., Jan. 10, 1903.

EXTRAUTERINE PREGNANCY. 383

between the liver and the right kidney, to which it was firmly' adherent.
The placenta was about two-thirds attached to the peritoneal fold
between the right under surface of the liver and diaphragm, and one-
third to the tissue of the under surface of the liver itself. The sac con-
tained a living fetus. The maternal mortality in these cases was about
33 %, a veiy high death-rate, probably largely due to the bad condition
of the patients when brought to the hospital. Of the children, 7 had
not reached an age to live after delivery. Of the others, 3 died after a
few hours, 1 after 3 weeks of gastroenteritis, and 4 are still living.

Ovarian Pregnancy. — [The existence of ovarian pregnancy has
been contested, and many supposed cases have been proved to be tubo-
abdominal, with intimate but secondary adhesions to the ovary. Accord-
ing to Kelly, in order to prove the existence of an ovarian pregnancy
it is necessary to demonstrate the criterions laid dowTi by Spiegelberg,
viz., that the tube is intact and has no organic connection \^dth the
gestation; that the tumor is connected mth the uterus by the utero-
ovarian ligament; that the walls of the sac contain graafian follicles in
various places; and that the albuginea of the ovary passes directly into
the tumor- wall. In the very full collection of the museum of Vienna,
Bando found only one specimen of ovarian pregnancy and almost ques-
tioned the possibility of its existence. A. Martin found one instance
of ovarian pregnancy in 77 cases of extrauterine gestation coming under
his personal observation, and cases have been satisfactorily demon-
strated by Sanger, Leopold, Mackenrodt, van Tussenbroek, and others.
Quite recently John F. Thompson, of Portland, Maine, (see abstract
below) has added an interesting case in which oareful microscopic exam-
ination demonstrated an ovarian gestation. Although the clinical
interest of differentiation of the type of ectopic gestation is not great,
the scientific value is sufficient to demand a patient investigation of
every case likely to prove one of this interesting and exceptional variety.]
Thompson^ has demonstrated by careful microscopic examination a
case of ovarian gestation. The patient was a multipara, aged 32 years,
and the pregnancy occurred in the left ovar}^ No rupture had taken
place previous to the operation. Just inside of the base of the tumor
was a small opening on the surface of the ovary with ectropion of the
lining of the graafian follicle. The fallopian tube was unobstructed in
its movement, freely falling forward when the specimen was raised by
grasping the ovary. The fimbrias were entirely free from one another
and the tube was patulous. The fetus was found attached to the wall
of the ovisac by an umbilical cord 1.5 cm, in length. The fetus itself
measured 1,2 cm. in length, not extended. Its appearance was exactly
similar to a fetus of the same age developing in the uterus. The points
which substantiate the claims of this individual case are : The tube is not
concerned in the development of the pregnancy; there is no super-
numerary tube; the pregnancy undoubtedly did not occur at or near
the fimbriated end of the tube, as the sections made from the tube near
the fimbriated end showed no evidence that the structure had been the

> Am. Gyn., July, 1902.

384 OBSTETRICS.

seat of pregnancy ; the fimbriated end was found at the time of operation
to be entirely free from the ovary, so that the case is not one of tubo-
ovarian pregnancy; the fimbria ovarica in this case is found in what
must be considered its normal place, extending from the end of the
tube to the outer end of the ovary; the pregnancy has occurred at the
extreme inner end of the ovary; there is no evidence to be derived from
the examination of sections of ovarian tissue that the fimbria ovarica
has passed up over the surface of the ovary; an examination of more
than 100 sections from different parts of the wall of the ovisac shows
no cells which can be considered as decidual ; there is no trace of decidual
tissue to be found in any part of the specimen examined. Other interest-
ing cases of supposed ovarian pregnancy are reported by Simon, ^ Gotts-
chalk,^ Filth, ^ Mendes de Leon and Holleman,* and J. Oliver/

Ectopic Gestation: Its Diagnosis and Treatment. — Harrison®
confines his remarks to tubal gestation in its earlier months. If, as
rarely occurs, the physician is consulted in cases of tubal pregnancy
before the death of the ovum, the diagnosis may be made with a near
approach to accuracy if menstruation has been absent once or twice;
if the uterus is soft, enlarged, and somewhat elongated; if there are
subjective and objective signs of pregnancy; and if there is felt a soft
tumor involving one tube, with strong arterial development. The soft
elasticity of the tumor is almost pathognomonic. One symptom to
which 'Veit draws attention is a transitory hardening of the tube. The
death of the ovum is proved conclusively when a tumor originates sud-
denly without fever and with the attendant signs of acute anemia, then
becomes hard, undergoes diminution, or remains constant, and when,
in addition, there is a discharge of dark tar-like blood by the vagina.
A very important symptom is urinary tenesmus, a constant symptom
due to the sudden interference with the capacity of the bladder conse-
quent on the development of the hematocele. Most authorities are
agreed in the opinion that so soon as a pregnant tube is certainly recog-
nized it should be removed at once ; for the simple reason that it is not
within our power to ward off the dangers that menace the life and health
of the patient by any means short of radical intervention. For the
operation the author prefers the abdominal route. In cases of rupture
of the tube the same principles that guide us in general surgery are
apphcable. Champneys^ contributes an interesting paper upon this
subject, with the results of his study of 75 cases of tubal gestation from
the wards of St. Bartholomew's Hospital. He calls attention to the
fact that more than 20 years ago these cases were diagnosed as hemato-
cele, while later the same cases were called perimetritis. Before 1893
the diagnosis of ectopic gestation was not very commonly made. From
1865 to 1877 there were at St. Bartholomew's Hospital 129 cases in

> Zent. f. Gynak., No. 50, 1902. ^ Ibid., No. 49, 1902.

3 Monats. f. Geb. u. Gyn., May, 1902.
* Rev. de Gyn. et de.Chir. Abd., May-June, 1902.

^ Lancet, May 23, 1903. » Brit. Med. Jour., Oct. 11, 1902.

' Jour, of Obstet. of tlie Brit. Emp., June, 1902.

EXTRAUTERINE PREGNANCY. 385

which hematocele was diagnosed, and of these 5 were fatal — a mortality
of nearly 3.87 %. During the next 2 years the mortality remained
the same, but a smaller number of cases were diagnosed as hematocele.
From 1891 to 1900 there were 36 cases of hematocele, of which none
was fatal. During the first 12 years the diagnosis of ectopic gestation
was made 6 times, with 1 death. During the second 12 years it was
made in 10 cases, mth 2 deaths, and during the next 9 years in 63 cases,
with 9 deaths. Champneys practises and teaches the following prin-
ciples of treatment in these cases: (1) Cases of early, unruptured, living
tubal gestation should be operated on without delay. (2) Cases of
rupture into the peritoneal cavity with diffuse hemorrhage should be
dealt with according to circumstances : (a) if hemorrhage still continues
when they come under observation some cases ought to be subjected
to operation, taking into consideration the probability of the limitation
and encapsulation of the blood continuing and the state of the patient
at the time; (h) if seen after hemorrhage has ceased they should be
treated expectantly. (3) Cases in which the blood has been encapsu-
lated by adhesions or by the broad ligament should be treated expectantly,
and operated on if pregnancy appears to be progressing. (4) Hemato-
celes which refuse to be absorbed in a reasonable time should be opened,
emptied and drained. In explanation of these propositions it is recog-
nized that it is very difficult at times to diagnose an unruptured tubal
gestation. Regarding those cases which rupture into the peritoneal
cavity, the death of the ovum immediately occurs; hence it ceases to be
a source of danger. If the patient recovers from the shock, she usually
survives the accident. To operate during the stage of shock he believes
is in many cases to kill the patient; to operate after the shock has ceased
is usually unnecessary. Champneys adds detailed reports of 75 cases
which have been under his personal charge in St. Bartholomew's. The
mortality of these cases was 7, or 9.3 % ; 45.3 % of these cases were left
alone and recovered; in 20 % vaginal section was done, without mor-
tality; in 65.3 % nothing was done as soon as the patient was admitted
or during the active stage of hemorrhage, but later on vag'nal section
was performed. Immediate abdominal section was done in but 12 %
of the cases. Secondary abdominal section was done in 22.6 %, and
abdominal sections, both primary and secondary, in 34.9 %. There
were 49 cases, or 65 3 %, in which abdominal section was not done. The
mortality of vaginal sections was nothing, and the mortality of abdominal
sections, primary and secondary, was 26.92 %. Primary abdominal
sections gave better results than secondary. In the former the mortality
was 22.2 %, and in the latter 29.41 %. The mortality of all abdominal
sections in these cases was 9.3 %, or that of the entire series. In 4
cases section was made through the vagina under a mistaken diagnosis.
Five cases were possibly operated upon too late, and there were 2 cases
in which the tumor increased after admission to the hospital, but which
recovered without operation. In 4 cases there were attacks of pain
without increase in the tumor, and in 2 cases the hematocele was dis-
charged through the rectum. Champneys calls attention to the fact

386 OBSTETRICS.

that rise of temperature does not necessarily indicate infection of the
sac. He does not have resort to mere puncture. When opening such
a tumor through the vagina, he cuts through the vaginal wall, stopping
any bleeding before proceeding further and opening the cyst with the
fingers, aided with some blunt instrument. After washing out the sac
he is accustomed to drain with gauze. In summarizing these cases
Champneys calls attention to the fact that 60 % of the whole number
recover without abdominal section.

Strassmann^ prefers operation per vaginam whenever possible, as less
likely to cause future sterility. Scanzoni gives a table from the Leipsic
Hospital, showing that after laparotomy 17 % conceived, and after opera-
tion per vaginam without removal of the gestation-sac 55 % conceived.
Strassmann would use the vaginal procedure in an intact, unruptured tubal
gestation in the early months, operating by expression or evacuation of the
tube; but would hold it advisable to remove the tube in case of rupture
and severe hemorrhage. For this method the size of the tumor to be re-
moved should not be more than that of the third, or, at most, the fourth
month. Laparotomy may be justified if the diagnosis is uncertain, or in
case of peritoneal perforation, in appendicitis, etc., or in case of life-threat-
ening hemorrhage. But it should be considered the exceptional procedure.
The removal of a tubal pregnancy at the end or middle of the term can
generally be avoided, and at an earlier period the vaginal method is
preferable, as more certain and less dangerous. Strassmann gives the
history of 9 cases thus treated, with illustrations.

LABOR AND THE PUERPERIUM.

Chloroform in Labor. — An editorial in "Medicine"^ remarks that
notwithstanding all that has been written upon the subject, it is believed
that chloroform is oftener omitted than given in normal labors. The
reaction to pain is so different that no definite rule can be laid down
that is applicable to all cases. The safety of chloroform is now con-
ceded. There are few obstetric operations in which a general anesthetic
is not employed, and most obstetricians prefer chloroform. The painless
labor is the exception. The time to employ chloroform is at the end
of the second stage, at which time it will tend to preserve the perineum,
and will do much to lessen some of the dangers incident to parturition.
The teaching of De Laskie Miller on this subject deserves a wider recogni-
tion and acceptance by the profession than has been accorded it. It
may have been published, but if so we have never seen it, and certainly
little harm can result from a repetition of a method at the same time
safe and valuable. For years he instructed his classes to use chloroform
in the second stage of labor after the following plan : An ordinary glass
tumbler is taken, in the bottom of which is placed some gauze or a linen
handkerchief. Upon this a few drops of chloroform are poured. This
the patient holds over the mouth and nose. The shape of the container
is such that as soon as the slightest muscular relaxation takes place

1 Berl. klin. Woch., Nos. 24, 25, and 26, 1902. * June, 1903.

LABOR AND THE PUERPERIUM. 387

it falls froEfi the patient's face. In this way the danger of an overdose
is avoided, as the chloroform-vapor being heavy, as soon as the container
is away from the mouth and nose no more is inhaled. This method
of giving chloroform is safe and practical, permitting the accoucheur
to devote all of his attention to the labor, and at the same time the
administration of chloroform is not entrusted to untrained hands.

Lepage and Le Lorier^ employ ethyl chlorid as a general anes-
thetic during parturition when the pain is not sufficiently severe to
warrant the use of ether or chloroform, but the patient desires to avoid
suffering. Under these circumstances ethyl chlorid presents many
advantages: (1) It is easily administered, the doses being always the
same. (2) Anesthesia is obtained in from 30 to 60 seconds, and lasts
for about 4 minutes without renewal. (3) The return to consciousness
occurs very rapidly without headache, and is accompanied only occa-
sionally by shght vomiting. Inhalations of ethyl chlorid may be em-
ployed with advantage under the following conditions: (1) In the course
of labor, when it is urgent to extract the fetus with forceps, when an
internal version is practised, or when the anterior foot is pulled down
in incomplete presentation of the buttocks. In the latter case anes-
thesia by ethyl chlorid has the advantage of allowing the patient to
awake rapidly and to complete the expulsion of the fetus by her own
efforts. (2) During delivery ethyl chlorid may be used when the ac-
coucheur is obliged to remove the placenta from the uterine cavity, or
exceptionally to extract the membranes when the greater part of them
remain in the uterus and it is necessary to remove them. (3) After
delivery it may be used when the insertion of several sutures into the
perineum is required. During pregnancy ethyl chlorid may be used as a
means of diagnosing pelvic deformities.

The Rational Conduct of the Third Stage of Labor. — Rudolph
Wieser Holmes^ details the third stage of labor from its anatomic, phys-
iologic, and clinical standpoints. He is in perfect accord with those
who declare that a proper conduct of the third stage will give a minimum
amount of aberrancies, but he declares he can prevent the evil conse-
quences of atony of the uterus from faulty innervation or maldevelopment
of that organ, from pathologic distention of the pregnant uterus, the
enervating influences of "society," unhygienic surroundings, partial or
complete retention of the secundines, etc. Methods of delivering the pla-
centa as suggested by Crede, Kabierske, Dohrn and Ahlfeld are detailed.
Holmes holds one hand on the uterus until completion of second stage
of labor; and when the placenta passes from upper to lower segment,
which may be within 10 minutes to 2 hours, at the height of contraction
the uterus is grasped anteroposteriorly, brought to the middle line, if nec-
essary, raised perpendicular to the brim, and then compressed and de-
pressed. All lacerations are sutured at the termination of this stage.

The Importance of a More Careful Examination and Treatment
of Women after Childbirth. — B. C. Hirst^ states that the medical

' Amer. Med., Feb. 14, 1903. ^ Amer. Med., Aug. 23, 1902.

' Amer. Med., Nov. 29, 1902.

388 OBSTETRICS.

profession is responsible for five-sixths of the diseases of women as the}' are
met to-day. Most of those consequent upon childbirth can be prevented
or cured before they can affect the individual health. Every woman
should be subjected to three examinations after labor: the first,, within 48
hours, to detect injuries to the parturient tract; the second, before she
leaves her room, to determine the position of the uterus ; the third, at the
end of 6 weeks, to observe the condition of all the pelvic structures and
organs, the abdominal walls, the coccyx, and the position of the kidney.
A woman should be left in as good condition after childbirth as before. In
the Maternity Department of the University of Pennsylvania the ordinary
injuries due to lacerations are repaired after the first examination (within
48 hours). All injuries to the cervix without exception have been repaired
in the University Maternity for several years past. Hirst finds that 48
hours should elapse after labor before closing lacerations of the cervix. A
successful result can then be obtained whatever their extent or number,
unilateral, bilateral, or multiple. If there is a reason against early opera-
tion, c. g., infection, the operation should be performed before or at the
completion of the puerperium. He also pays attention to Waldeyer's
triangle or urogenital trigonum, believing that unattended injuries have
led to cystocele. In conclusion, he states that if all classes of society
could secure the same good treatment which the poorest are receiving in
the modern maternity hospital an advance will be made which will rank
with vaccination, anesthesia, and asepsis.

Laceration of the Vagina during Labor. — Kaufman^ contributes
an extensive paper in which he has collected 82 cases of this complication
of labor. But only a portion of these were available for statistical study,
as many of them were imperfectly reported. Most of them occurred when
the fetus presented by the vertex, next in frequency in transverse posi-
tions, and least often in breech presentations. In 78 cases, 49 happened
in spontaneous labor. In 29 some violent effort at extraction had
been made. The condition of the pelvis was reported in 58 of these
cases. In 38 the pelvis was said to be normal and in 20 to have
been contracted. In 3 cases myoma of the uterus was present as a
complication, and in 1 case a divided uterus, and in 1 scars were found in
the vagina and adjacent tissue. Almost all of the patients were mul-
tiparas, as the accident happens very rarely in primiparous patients.
In a few of these cases the children were of excessive size, although in most
they were of ordinary development. In 68 cases the abdominal cavity
was opened through the peritoneal sac. In 14 of these the intestine
prolapsed, and in 1 case an ovary and tube. In 29 of these cases the child
made its way out of the uterus, in 26 into the abdominal cavity, and in
3 into the subperitoneal tissue. The placenta was found in 30 cases out-
side the uterus, in 27 cases in the abdominal cavity, and in 3 cases in the
tissue beneath the peritoneum. As regards the method of delivery most
likely to result in injury to the vagina, it was found that version and
extraction was especially dangerous, next the forceps, next extraction
only, while craniotomy was more apt to produce the accident than even-
^ Arch. f. Gynak., Bd. Ixviii, Heft 1, 1903.

LABOR AND THE PUERPERIUM. 389

tration or decapitation. Of these patients, 3 died undelivered. The
treatment of the compHcation may be divided into those cases. in which
abdominal section, with or without extirpation of the uterus, was prac-
tised, and those cases in which the accident was treated by suture or
tampon applied through the vagina. Treatment was selected in accord-
ance with the extent of the laceration and the involvement of the uterus
When the uterus was uninjured and the laceration could be reached from
the vulva, it was closed by suture; and if the uterus was uninjured and
the laceration could not well be reached, tampon and drainage with gauze
was the method employed. The mortality was 35 % in cases in which
both the uterus and vagina were injured, the most frequent cause of death
being septic infection, and next in order hemorrhage. In cases in which
the vagina only was injured the mortality was 25 %. In these cases the
mortality from bleeding was but 5 %, septic infection playing the more
important part. The symptoms of this accident depend entirely upon
the extent of the laceration. A small rupture of the vagina during labor
may give rise to no symptom, and may not be discovered until an ex-
amination is made after the birth of the child. Some have laid stress upon
the contraction of the round ligaments and upon the suffering and anxiety
of the patient. Uterine contractions are not always excessive in these
cases, and the patient may not complain of excessive suffering. The
iTiortality from hemorrhage is considerable, and depends upon the exten-
sion of the laceration into the connective tissue about the uterus. In
diagnosing the condition, examination by the introduction of the entire
hand is necessary to accurately localize the injury. So far as the prog-
nosis is concerned, the mortality of rupture of the uterus as variously
stated at present is from 60 % to 73 %. The mortality of ruptiu'e of the
vagina is much less, and may be reckoned at 25 %, as has been stated,
in favorable and uncomplicated cases. The prognosis for the children
is exceedingly bad in cases of vaginal rupture. The placenta is almost
invariably prematurely separated in these cases, and as a consequence
the fetus rapidly perishes. The prognosis for the child is so bad that its
interests must not be considered in selecting a method of treatment.
In the treatment of these cases, if laceration happens before the ter-
mination of labor, the patient must be delivered as rapidly as possible, no
attention being paid to the life of the child ; hence, craniotomy or any other
method of delivery which will subject the mother to the least violence
should be chosen, Perforation of the after-coming head should be em-
ployed if the slightest difficulty arises in its delivery. Usually the for-
ceps can be employed to advantage when the head is presenting.

Ligation of the Umbilical Cord. — V. A. Petroff' describes the fol-
lo\^^ng method of treating the lunbilical cord, which has given him
excellent results. This method was originally devised by Kousmine, but
it was applied to a very large number of newly born children during
a period of 4 years by the author. Instead of using the ordinary ligature,
Kousmine suggested the application of a rubber ring to the umbilical
cord by means of an instnunent which he devised specially for this
' Roussky Vratch, Sept. 7, 1902.

390 OBSTETRICS.

purpose. The rings used are made of the best quahty of gray rubber,
with a diameter of from 0.9 cm. to 1 cm., a thickness of 0.2 cm. to 0.3
cm., and a diameter of the lumen of about 0.3 cm. The instrument is
constructed in the form of a forceps with hollowed or deeply grooved
blades, in the middle of which is a raised portion for the compression
of the umbihcal cord. The ring is placed on the forceps before the labor,
and the whole is immersed into a 2 % boric acid solution, whence it
is removed when needed. The cord is compressed about 0.5 cm. from
the body by means of the forceps, and the navel-string is cut just above
the forceps. The ring is then moved down from the forceps upon the
cord, and the forceps is removed. The ring usually remains just at the
skin edge of the cord or a few millimeters above this point. The stump
is now shortened to 1 cm., and, after the bath, covered with cotton,
wliich wraps the ring and partly separates the ring from contact with
the skin. Next comes a compress of squares of gauze, over which is
powdered a little dried gypsum, and over that another layer of squares
of gauze and a bandage. In from 10 to 12 hours the stump so treated
dries and becomes mummified to the consistency of cartilage. At the
end of 24 hours the rubber ring begins to sink into the depression of
the navel, thus leaving no part of the umbiHcus uncovered, as in the

usual method of treatment. The children
were bathed every day, and in no case out
of a series of children numbering 400 was
there any absorption of septic material into
the navel. A. Duke^ recommends a simple
'?IritMld'!tuV^'ZrK form of clamp (Fig. 64) which he considers

will be found in practice a great improve-
ment on the old system. When the infant
has been washed, the stump of the funis is passed through the hole in
the flat plate of the clamp, which is then placed close to the abdomen,
while the spring portion is uplifted by pressure of finger and thumb;
the spring is then released and holds the cord firmly. Anything pro-
truding beyond the clamp is cut off with scissors, and the binder and
dress put on. The clamp need not be interfered with, dropping off in
the usual time with its contents. The small portion of dead tissue it
holds can be removed, the clamp dropped into boiling water, and when
dry is fit for use when next required. The simplicity and cleanliness of
the clamp should give it preference over the old plan of dressing. The
fact of haAdng no dead or dying stump of funis in contact for several
days with the infant's abdomen is a considerable advantage, the scorched
rag being anything but reliable in keeping the funis and abdomen from
contact.

Baths during the Puerperium. — [Baths are usually regarded in the
present obstetric teaching as contraindicated during the puerperium,
except for cases of septicemia in which cold hydrotherapy and cases of
postpartum hemorrhage in which hot hydrotherapy fulfil respectively
the usual indications for hyperthermia and shock. Except these unusual
» Brit. Med. Jour., March 14, 1903.

MATERNAL DYSTOCIA. 391

conditions, most accoucheurs do not allow baths until after the puer-
perium is over and the woman again on her feet.] G. Martin/ -however,
after a careful study of the subject, offers the following indications of
the bath for the puerperal woman. By their sedative action tepid baths
at from 32° to 35° C. are of value to quiet the nervous system whenever
it has been affected; for example, as is shown by cramps, urinary reten-
tion, mental excitement, and the hke. By their diaphoretic and diuretic
influence they will be found to meet the usual calls of both these functions.
Distended and painful breasts "vvill go down at once or after a few hours
through the action of warm baths lasting from 20 to 25 minutes. Errors
in the involution of the uterus, lymphangitis of the breasts, galactoph-
oritis, and other inflammatory conditions are all benefited. There are,
of course, absolute contraindications of body-baths during the puer-
perium which are summed up in the dangers of infection from any
possible source; of such, lesions of the external genitals, ulcers of the
leg, abscesses, ulcerating gummas, and the like, are familiar and emphatic
examples.

MATERNAL DYSTOCIA.

Puerperal Eclampsia; Pathogenesis. — Blumreich^ has previously
made a series of investigations to determine whether increased sensibility
is characteristic of the nervous system during pregnancy. His experi-
ments were conducted by injecting kreatin into the brain of pregnant
animals after trephining, and in the second group of cases by injecting
a solution of kreatin into the blood-current through the carotid artery.
His results demonstrated the fact that in pregnant animals a condition
of increased sensibility to reflex irritation is found in the nervous system.
This is corroborated by clinical observation, which shows that eclampsia,
tetanus, and chorea are found with special frequency in pregnant patients.
In order to determine as nearly as possible the source of the irritating
material causing eclamiDsia, Blumreich experimented upon pregnant and
nonpregnant animals, by causing complete retention of urinary excreta
by extirpating both kidneys. This operation is performed without much
difficulty by placing the animal upon the abdomen, and, under anesthesia,
making an incision along the back at the eleventh vertebra, in such a
position that both kidneys can be readily removed through one incision.
The first animal operated upon died from peritonitis through an accident
which opened the peritoneal cavity; the others showed no evidence of
infection. Ten pregnant animals and 12 nonpregnant were operated
upon. In most of the cases rabbits were used. There was no immediate
effect following the operation. The animals moved about freely and ate
with appetite. The first evidence of disease was increased irritability,
so that the skin could not be touched or stroked without causing great
uneasiness. Convulsions in groups of muscles then followed, with draw-
ing of the head backward and toward the right side. In some cases
clonic convulsions occurred. This gradually extended until most of the
» La Sem. Med., 1902, No. 23. == Arch. f. Gyniik., 1902, Bd. xlvi, Heft 2.

392 OBSTETRICS.

muscles of the body were involved. They resembled those which fol-
lowed the injection of a solution of kreatin into the carotid artery. The
nervous system showed not only increased excitability, but very soon
in the progress of the case an anesthetic effect was noticed. The animals
not only ran about eagerly, but at times lay quietly, as if anesthetized.
In nonpregnant animals convulsions began, on the average, 71 hours
after the operation. Death occurred, on the average, 79 hours after the
operation. In pregnant animals convulsions occurred in 63.4 hours after
operation, and death followed the operation, on the average, in 70.8
hours. The shortest period in which convulsions occurred after opera-
tion was 40 hours; the longest, 104 hours. Further experiment was
made by feeding wdth the same food two groups of animals — one preg-
nant, the other nonpregnant — operated upon, when it was found that
the difference in the frequency and prompt occurrence of the convulsions
between pregnant and nonpregnant animals is very much lessened. The
conclusions drawn from these experiments strengthen our belief that
the brahi of the pregnant animal is more sensitive to irritation than
that of the nonpregnant. The substances which produce convulsions
exist essentially in the nonpregnant as well as in the pregnant. [One
fact stands out very clearly from these and other experiments upon this
subject; eclampsia is not the result of uremia. While lesions in the
kidney may assist in producing eclampsia, these lesions are the result
of the circulation of poisons which in themselves cause eclampsia. Ex-
periments show that animals, whether herbivorous or carnivorous,
generate poisons in the body during pregnancy. To isolate poisons which
produce eclampsia it will be necessary to isolate from the blood, the
central nervous system, or the urine, substances which are capable of
exciting irritation in the nervous system during pregnancy.]

Miiller^ concludes that eclampsia is the result of a general and sys-
temic poison. The place of origin for this poison he believes to be the
interior of the genital tract, and especially the interior of the uterus.
Reasoning by analogy, he concludes that the same or analogous causes
which produce fever during pregnancy and labor produce eclampsia also.
He bases his decision upon a careful comparison of those complications
of pregnancy and labor resulting in fever with the conditions which
precede eclampsia. He finds that, so far as the fetus is concerned, both
fever and eclampsia greatly jeopardize its life. He draws a close parallel
between all of the circumstances attending fever in pregnancy and labor
and those which result in eclampsia. He believes that necrosis of the
decidua, with the presence and activity of bacteria, produce eclampsia.
He calls attention to the fact that eclampsia is most frequent as the
intrauterine tension increases through the progressive growth of the
ovum. His suggestions for treatment are to empty the uterus promptly,
taking special care to remove the decidua and all portions of placenta
and membranes. So far as the prophylaxis of eclampsia is concerned,
nothing can be done except to keep the patient as clean as possible.
[This paper is chiefly valuable for the excellent review w-hich it contains
' Arch. f. Gynak., 1902, Bd. Ixixvii, H. 2.

MATERNAL DYSTOCIA. 393

of the literature of the subject. It is hard to reconcile the writer's
theory with facts observed through clinical observation. If the ulterior
of the uterus is the source of the poison-producing eclampsia, why
should a restricted diet diminish the danger of eclampsia? If the only
available treatment is the complete emptying of the uterus, why is it
that many patients do best when the uterus is not emptied until nature
gradually accomplishes this, while the patient is made to eliminate
freely by packs, baths, and other means? We are quite agreed with
the writer that eclampsia is the result of systemic poison, but we must
have further evidence before we can accept his statement that the genital
tract is the source of the poison.]

According to E. T. Abrams,^ the relation of the thyroid to eclampsia
is very interesting. An enlargement of this gland takes place in primip-
aras about the sixth month, and in multiparas about the fifth. The
function of the thyroid is to regulate metabohsm. Lange has demon-
strated that the enlargement is physical, or rather physiologic. In 20
out of 25 cases of pregnancy, in which enlargement of the gland did
not take place, albuminuria and convulsions did develop. Herzfeld holds
that pressure on the ureters is an etiologic factor in the causation of
the disease. In his 81 fatal cases all showed pathologic changes in the
uropoietic tract. [The effort to prove that eclampsia is identical with
uremia has gone down as "not proved." However, it is the incomplete
urea in the blood that (in the form of toxins) doubtless causes the con-
vulsions. Therefore the diminution of the urea in the urine ought to
be to us an indication that the toxins are being retained. The urinary
tract must not alone be watched, but the other organs should receive
their quota of our attention. Jaundice is always a very grave symptom.
It is a good rule to consider every pregnant woman constipated until
otherwise proved by a competent nurse. The experiments of Tarnier,
Ludwig, and Savor certainly show that the toxicity of the blood-serum
is increased in eclampsia, while, on the other hand, those of Charrin
and Volhard seem to prove just as conclusivol}- that it is not.]

Constipation as a Factor in Eclampsia. — According to John
Ashell,^ no one will doubt the close relation between renal and intestinal
diseases, not those intestinal diseases in which there is structural change,
organic diseases, but in which there are chemical changes occasioned by
malassimilation or a disturbance of digestion by miscellaneous indigest-
ible articles of foodstuffs; again, in adults whose sole complaint is con-
stipation the gradual appearance of albumin is noticed if the intestinal
chemical changes are not rectified. How this condition is brought about
is not yet explained. Whether it is due to disturbed metabolism, toxe-
mia, or destructive cell-masses that are carried, from the intestine by
the blood and deposited in the liver, producing areas of necrosis and
further finding their way to the kidneys, producing a destruction of
the parenchyma, is more than we can at present explain. Certain it is
that pregnant women are capricious in their appetites and indulge in
foodstuffs that they would never crave were they not pregnant. The

' Am. Jour. Obstet., Jan., 1903. ^ Am. Jour. Obstet., April, 1903.

20 S

394 OBSTETRICS.

majority of the author's cases occurred in Avinter, when the skin was
inactive and the waste-products of metabohsm were not excreted because
of the dermal inactivity. During January and the early part of Febnaary
of 1902 in the New York Foundhng Hospital, the examination of the
urine of the women in the waiting wards showed in about five-sixths
of the number the presence of albumin, ranging between a very faint
trace and an abundant quantity, with a lowered specific gravity ; in some
cases nmning as low as 1.004 and 1.000 and occasionally 1.001. There
were from 30 to 40 women in waiting and practically all were primi-
gravidse. In addition to the presence of albumin, one-fourth showed
signs of toxic symptoms; headache, nausea and vomiting, edema of the
legs, and increased arterial tension. There was no striking reason why
five-sixths of the waiting women should have albumin and so many
others show toxic symptoms. The ordinary routine for each patient —
diet, baths, exercise, recreation, clothing — apparently existed as in pre-
vious months. The presence of constipation, however, was well marked,
but whether the women were more unfortunate in this regard than the
preceding inmates could not be said. Several of these patients were
taken Avith eclampsia and were treated by catharsis alone, and the
greater proportion recovered ^^ithout any alarming symptoms. In fact,
only one death was recorded, and this was due to a sudden heart-collapse.
Treatment of Puerperal Eclampsia. — Ahlfeld^ employs the hot
pack systematically in pregnant women who present edema, albuminuria,
or other threatening signs of eclampsia, in order to relieve the kidneys
by stimulating the other emunctories of the body. The patient is stripped
and wrapped in a sheet which has been dipped in hot water and wrung
out; a dry blanket is then wrapped over the sheet, care being taken
that the arms are not exposed ; another cover is placed over the patient
and she is allowed to remain thus for about 3 hours, during which time
she may be given plenty of water or milk to drink. This procedure is
repeated twice a day. Of 36 patients thus treated, 23 of whom were
primiparas, not one had an eclamptic seizure. One patient, who in two
previous pregnancies had presented albuminuric retinitis, was enabled
to go through her third pregnancy without any return of the trouble
by the use of the hot pack daily for 7 weeks. The usual medicinal
treatment of these cases should be continued at the same time. Accord-
ing to J. Veit,^ when the cervix is fully dilated, the indication is for
immediate deHvery; if it is partially so, mechanical dilation should be
practised. When the cervix is closed, expectant treatment is usually
the best. Of the remedies recommended to lessen the convulsions,
morphin is the most important, but it cannot be regarded as in any
way curative. The most that can be said for it is that it lessens the
severity of the attacks. Chloral is also useful. Potassium bromid,
veratrum-viride, and amyl nitrite have not given brilliant results. Bleed-
ing with injection of salt solution and also sweating are probably of
use. Veit does not believe either cesarean section or forcible delivery

1 Bull. G6n. de Th6rap., vol. cxliii, No. 14. 1902, p. 554.
^ Therap. Monats., April, 1902, xvi, 169.

MATERNAL DYSTOCIA. 395

justifiable in uncomplicated eclampsia. When, however, the convulsions
are g^o^ving more severe and labor does not progress, the latter -method
should be adopted ; or in the eclampsia of pregnancy when the narcotics
have failed section is indicated.

Herman^ disagrees mth those who contend that emptying the uterus
is an almost certain means of arresting eclamptic convulsions. Schauta
quotes from the records of the lying-in clinic of Vienna 342 cases of
eclampsia, in 185 of which the fits began during labor. In only 62 of
these did they cease on delivery, while they continued in 123, in 50 with
increased violence. Brummerstadt gives a record of 63 cases, in 18 of
which the fits ceased on delivery, in 17 became less severe, and continued
unaltered in 28. Herman cites the figures of Diihrssen, Olshausen, and
others showing similar results, and then reports from his own experience
2 cases of eclamptic fits Avith a temperature of about 105°. In the
treatment the use of tepid baths reduced the temperature and resulted
in the abatement and early cessation of the convulsions and final re-
covery of the natients. [Although chloral hydrate is generally considered
as the best medicinal treatment of eclampsia, it is nevertheless a fact
that this remedy is only occasionally used in a rational manner and
in suflScient dAses. Most practitioners administer the drug by rectum.]
According to the experience of Commandeur^ (Lyons), this method is
defective because the rectal mucosa does not always absorb the drug.
A certain number of patients do not retain an injection containing it,
but reject it more or less without the perception of the attendant. The
remainder of the patients do not fail to show a rectal intolerance of
such a degree that it is often impossible to administer more than 5 or
6 enemas containing it. For this reason this authority prefers giving
this remedy by the mouth, observing, however, two important precepts,
formulated originally by Foucher. Before administering the drug, the
stomach should be washed out to quiet the irritabiHty of it. Then the
medicine must be dissolved in a large quantity of water, namely, 100 to
150 drams to every dram of chloral. Given in this manner it is well toler-
ated, fully absorbed, and may be given in large doses for some time.
Commandeur has been able to give 14 grams (3^ drams) within 40 hours.
In 4 cases in which he has tried this method of administering the drug
he has seen the pregnancy follow its course to the end in a manner which
might be described as entirely exceptional.

At a meeting of the Obstetrical Society of Philadelpliia the subject
of eclampsia was fully discussed. Referring to the use of normal saline
solutions, R. C. Norris^ said: "I would like to give a word of warning as
to the use of salt solution. I have found in some cases that an excessive
amount of salt solution has aggravated the condition of the kidneys, has
produced edema of the lungs, and helped to do the very thing which
we aimed to avoid. I should place as a limit one quart of salt solution
and no more until free diaphoreses, diuresis, or catharsis has occurred.
"WTien there is some edema of the lungs it should not be employed at

* Canad. Pract. and Rev., Aug., 1902. ^ La Sem. M^d., Oct. 1, 1902.

'Canad. Pract. and Rev., Jan., 1903.

396 OBSTETRICS.

all. I have seen edema of the kings aggravated and the patient's serum
run out of her mouth as the result of too free use of salt solution. Large
amounts of salt solution are of the greatest value when profuse catharsis
from saline purgation has occurred."

Venesection in Eclampsia. — An editorial in "American Medicine"^
says that venesection is so rarely practised to-day in general medicine
that a prominent therapeutist has observed that very many of the pro-
fession have never abstracted blood for therapeutic purposes, nor have
ever seen it done by some one else; and yet bleeding is a measure un-
doubtedly of the greatest value in many conditions. The indications for
venesection are as clear and well defined as are the indications for any
other remedy. In no condition is it more positively indicated than in
certain cases of eclampsia. In this condition the reaction against the
indiscriminate use of the lancet has undoubtedly gone too far. Our
medical forefathers were wrong in making venesection the common rou-
tine treatment in eclampsia, but we are equally wrong in entirely rejecting
it. It is of great value in selected cases and often rescues the patient
from the impending danger of pulmonary edema and apoplexy. Wlien
the physician has to deal with a strong, full-blooded patient \nth high
arterial tension, the abstraction of from 20 to 35 ounces of blood is
recommended. In the report of 15 cases, cited by Hirst, in which bleed-
ing seems to have been the only thing done there was only 1 death.
By this procedure a large amount of noxious principles in the system
may be directly eliminated, and, according to Peter, it further removes
from the convulsive centers the poisonous blood by restoring contraction
of the small vessels. Although Winkel, Martin, and others have con-
demned the practice, yet undoubtedly in strong plethoric women with
great cyanosis it has favorable results. In all cases after venesection it
is vnse to dilute the toxin of the blood by the emplo5'ment of hypo-
dermoclysis. This is, we think, preferable to direct venous transfusion,
as the liquid is slowly absorbed and does not overtax the kidneys. We
have recently observed successful results from this treatment and believe
that the profession generally recognizes that it rests upon a sound clinical
basis.

Thyroid and Parathyroid Insufficiency in the Pathogeny of Puer-
peral Eclampsia. — [We appear to be admitting of late years an ever-
growing list of possible causes of puerperal convulsions. The theory of
renal disease as the chief, if not the only cause, long ago ceased to receive
general acceptance. Within recent years it has been to a great extent
supplanted by the doctrine of an hepatic pathogeny. Still more recently
the idea that insufficiency of the th5Toid gland or of the parathyroid
bodies was at the bottom of the trouble in many cases has been urging
itself upon a number of excellent observers, notable among whom are
A. FlTihinsholz and P. Jeandelize,^' who contributed a highly suggestive
article on the subject. They set out with the assumption— surely not
a forced one — that puerperal eclampsia is due to poisoning by some
material that may either be generated in the system or be taken in

» September 27, 1902. ^ Presse MM., Oct. 25, 1902.

MATERNAL DYSTOCIA. 397

from without, and that the injurious action of this material is o^\ing
to defective functional activity on the part of the eliminating, organs
or of those organs whose office it is to destroy or transform such products ;
and they set forth a strong argument in favor of including the thyroid
and the parathyroids among the latter. About 3 years ago Lange^
reported the results of his observations upon the relations between preg-
nancy and the thyroid gland, and our authors cite the drift of his article
as follows: Of 133 women examined during the last 12 weeks of preg-
nancy, 108 showed thyroid hypertrophy, in 3 instances its existence was
doubtful, and in 22 cases it was manifestly absent. Of the 22 women who
had no thyroid hypertrophy, 20 were albuminuric, and 16 of the 20
had not only albumin in the urine, but casts also. On the other hand,
of the 108 women who had this physiologic thyroid hypertrophy, onlv
2 were albuminuric, and both of them had had nephritis before the
pregnancy occurred. The frequency vdih which this hypertrophy of the
thyroid takes place during pregnancy may be inferred from the fact
that Lange's observations were made in Konigsberg, in a country where
goiter is exceptional. In primiparas it generally did not show itself until
the sixth month, but in multiparas it began in the fifth month. Lange
subjected 10 pregnant women with the hypertrophy to medication with
small doses of the active principle of the thyroid gland, and found that
the enlargement disappeared in from 11 to 14 days, but generally re-
curred after the medication was suspended. These facts, together with
others of like purport which they cite, have convinced the authors that
in certain cases of eclampsia there is a relation of cause and effect between
thyroid insufficiency and the convulsions, but they question if it is really
the thyroid itself that is at fault. It appears from the observations of
Moussu, of Vassale and Generali, of Lusena, and of Gley, that thyroid
insufficiency gives rise to chronic disturbances, such as myxedema,
whereas parathyroid insufficiency occasions acute troubles, such as con-
vulsions. But the thyroid and the parathyroids, although differing
embryologically and histologically, are associated in function, so that
apparently thyroid medication suffices to remedy troubles due to para-
thyroid insufficiency. This being the case, it certainly seems feasible
to subject women threatened with puerperal convulsions to a test of
the question by means of such medication, and it seems well also to
be on the lookout for the physiologic thyroid hypertrophy with which
Lange has met so frequently.

Many of the symptoms which patients develop under thyroid treat-
ment are probably due to profound circulatory changes produced by
the drug, says H. Oliphant Nicholson. "^ It is a well-established fact that
the thyroid gland is enlarged in normal pregnancy. In eclamptics the
normal enlargement of the gland is said to be absent. It is well known
that under the action of iodothyrin the metabolic processes of the body
are greatly stimulated and there is a striking increase of the secretion
of urea. In eclampsia and in all conditions of hypothyroidism the quan-

' Zeits. f. Geburts. u. Gynak.

' Jour. Obstet. and Gynec. for Brit. Emp., July, 1902

398 OBSTETRICS.

tity of urea is greatly diminished. The symptoms of a typical attack
of puerperal eclampsia closely resemble those of complete experimental
athyroidea. When a pregnant woman who exhibits eclamptic symptoms
is put to bed and kept on a milk diet, the demands made on her thyroid
secretion are greatly lessened, and the process of nitrogenous metabolism
is again efficiently carried out. The thyroid gland may under normal
conditions participate in controlling renal function as follows : (1) The iodo-
thyrin may exert some specific action upon the kidney; (2) urea — the final
product of nitrogenous metabolism when efficiently carried out in the
presence of an adequate supply of iodothyrin acts as a powerful diuretic ;
and (3) the well-known changes produced upon the circulation (vaso-
dilation) by iodothyrin tend to promote and maintain renal activity. It
is thus evident that the real significance of the pre-eclamptic is the
break-down of the defensive mechanism, the result of some inadequacy
of the thyroid and parathyroid glands, whereby the process of nitrogenous
metabolism, instead of resulting in the formation of urea, ceases with
the production of intermediate substances, which, when absorbed, excite
the symptoms of toxemia. A large dose of morphin is a valuable ad-
junct in thyroid treatment, because it gives the thyroid gland time to
recover itself by inhibiting metabolism and removing the arterial spasm.
Operative Treatment of Puerperal Eclampsia. — An interesting
new suggestion has been advanced by G. M. Edebohls,^ namely, renal
decapsulation for the cure of eclampsia of puerperal origin. He believes
that renal decapsulation for puerperal eclampsia of renal origin is the
logical outcome of the encouraging results following his operation in cases
of chronic Bright's disease. He has successfully performed bilateral
renal decapsulation for puerperal eclampsia upon a primipara 2 days
after forced dehvery. The convulsions began before labor and continued
to the time of operation, the patient indeed having a convulsion while
under chloroform on the operating table. This operation, performed
on February 17, 1903, was behoved to represent the first instance of renal
decapsulation, or, for that matter, of any operation upon the kidney or
kidneys, ever undertaken for the cure of puerperal convulsions. [The
favorable results, immediate and remote, in this case, full details of which
are given in this paper, at once assign a place to renal decapsulation
as one of the resources at our command in the treatment of puerperal
eclampsia. A woman suffering from uremic convulsions is entitled to the
positive benefits of decapsulation whether pregnant, in labor, or in the
puerperium. In those cases of eclampsia which appear just at the be-
ginning of childbirth two possible methods of treatment claim attention ;
namely, intrauterine kolpeurysis and cesarean section. Without doubt
the former is, for the average practising physician, the easier; but one can-
not overlook the fact that forcible dilation of the mouth of the womb
has an unfavorable influence upon cases of eclampsia. Whether tropa-
cocain (Winckler) is to prove in this connection a new means of over-
coming the difficulty is still to be proved. On the other hand, however,
the ordinary cases of eclampsia are in our hospitals and clinics most suc-
1 N. Y. Med. Jour., June 6, 1903.

MATERNAL DYSTOCIA. 399

cessfuUy treated by cesarean section, because the uterus is so quickly
emptied by it, and the other dangers of this disease thus stopped.]
Jahreiss^ (Augsburg) reports 2 cases of eclampsia in which he 'emptied
the uterus by the vaginal cesarean section, as originally suggested by
Diihrssen, in the first case with favorable, and in the second case mth
unfavorable results.

Contracted Pelvis. — Hugo Ehrenfest^ has devised a method of
determining the internal dimensions, configuration, and inclination of the
female pelvis. He demonstrated 2 instruments constructed by Julius
Neumann and himself, called pelvigraph and kliseometer. The construc-
tion of the first-mentioned instrument is based on the following principle :
If a straight rigid rod is so moved within a plane that in all points of its
course it is kept parallel to its first arbitrarily chosen position, and at the
same time one of its ends is permanently kept in touch with a given line,
then necessarily its other end will create, if approximately equipped with
a marker, an exact dupUcate of said line. In this way it is possible to
produce in a comparatively easy manner, by means of the pelvigraph,
an exact picture of a median vertical section through the pelvic canal in
the living, or to measure the distance between any two points within the
pelvic cavity. The writer explains the manipulation of the instrument
on a skeleton pelvis, and demonstrates a number of such diagrams taken
from different patients with pelvic deformities. These diagrams show
the character of the deformity, and give all the conjugates in actual size.
Their value for scientific and especially for teaching purposes is obvious.
The second instrument, called the kliseometer, is very simple in its construc-
tion. The author claims that it is destined to directly measure the inclina-
tion of the external conjugate. The combined use of both instruments
permits of determination of the inclination of the true conjugate in the
living, a problem that as yet has been unsolved. By means of the kliseom-
eter, the inclination of the conjugate at the obstetric outlet is measured.
The angle found is with a protractor transferred upon the diagram of the
pelvis, and in this way an angle is constructed, representing the real in-
clination of the pelvis. If these pictures be so held that the chosen line
parallels the horizon, a very instructive conception is gained as regards
the position the pelves had in the upright women. These two instru-
ments offer the possibihty of graphically reproducing the form and exact
dimensions of the most important sections through the pelvis, and of per-
mitting measurement of its real inclination.

Treatment of Contracted Pelvis. — Kroenig' discusses the treatment
of labor complicated by contracted pelvis, and bases his arguments on
the material at the Leipzig Maternity chnic. He finds that .one practises
5 methods for this condition, and he deals with each of these separately.
Before doing so, he says that it is impossible to make hard-and-fast rules
for each degree of flattened or generally contracted pelvis, since the size
of the fetal head, the strength of the labor pains, and, above all, the im-
possibility of directly measuring the conjugata vera must upset any such

» Zent. f, Gyn., 1902, No. 35. ^ Med. News, March 28, 1903.

' Munch, med. Woch., Aug. 12, 1902.

400 OBSTETRICS.

rule. First he turns to version, and says that in the cases in which the
after-coming head may be supposed to pass through the contracted inlet
of the pelvis, one can never be sure whether it will not come through in
the position of a vertex presentation, if one will wait; version must be
performed either before the membranes have ruptured or immediately
after, and at this time one has no means of estimating how much good
pains and molding may do. He has compared the results obtained in
clinics where version was largely practised with those where this means
was not used, and finds that the prognosis for the child is not improved.
Next comes the high forceps-operation, and of this, he says, gynecologists
are mostly agreed that one should not apply forceps with the intention
of attempting to overcome the disproportion between the pelvis and
fetal head. A forced delivery by this means is not safe for the mother,
and almost certainly will sacrifice the life of the child. The third means
of dealing with this condition is the induction of premature labor. The
same difficulty must be raised against this proceeding as against version,
that one does not know if one cannot obtain a living child by waiting,
and he considers that the chances for the child are incomparably better
if the fetus is allowed to come to full time. He therefore also puts this
method on one side. The remaining two methods are symphyseotomy
and cesarean section. "When the conjugata vera is not less than Sf inches,
these two operations may be considered as rival methods. Against the
former it must be remembered that after it has been performed the labor
will not be completed at once, that it is a very difficult operation and
requires a skilled surgeon and obstetrician. Once performed, however,
the future labors of the patient are not infrequently rendered more easy.
Cesarean section is much more easily performed, and the child is delivered
at once. But these procedures still have a mortality of about 2 %, and
this risk for the mother must be considered. He thinks that the best
way is to wait to see if the head will pass through the inlet of the pelvis,
and if it does so, the labor may be completed with forceps; if the mother's
life becomes endangered during the waiting, one always perforates the fetal
head, which one may do to save the mother's life, and if the two are in
no immediate danger, then one should consider symphyseotomy and the
abdominal operation.

On the Treatment of Uterine Rupture, with Statistics of 77 Cases.
— Draghiesco and Cristeanu^ state that in 21 3^ears (1880-91) there were
seen in the Maternity at Bucharest 77 cases of ruptured uterus, with
various complications. These occurred in a series of 23,016 accouche-
ments, and 54 recovered and 23 died. The determining causes assigned
for the rupture are as follows: pelvic contractions, 34; malpresentations,
22; hydrocephalus, 4; ergot given at home, 4; vaginal cicatrices, 2; mal-
formation of genitals, 2; forceps at home, 2; forceps in the hospital, 2;
hand by side of head, 1 ; unreduced mentoposterior position, 1 ; placenta
prsevia, 1 ; decapitation at home, 1 ; unknown, 1 ; total, 77. The seat of
rupture is shown in the following table: —

1 Ann. de Gyn. et d'Obstet., Feb., 1902.

MATERNAL DYSTOCIA. 401

In com- Re-

cces. Complete. i)lete. covered. Dead.

Rupture of uterus 8 4 4 0 . 8

" uterus and vagina 33 23 10 8 25"

vagina 29 13 16 12 17

" bladder and vagina .... 6 2 4 3 3

" vagina and rectum .... 1 1 0 01

77 43 34 23 54

In reading this paper one is struck with the extraordinarily large nuinber
of cases in proportion to the total number attended, 77 in 23,016, or 1
in 298. Now, Bandl found 1 case in 1200 confinements. Jolly estimated
the frequency at from 1 in 1300 to 1 in 5000. Hence we look for the
cause of the frequency and find it in the want of proper attendance and
the maltreatment which the women had experienced. The majority of
the women were received into the Maternity Institute several hours and
even days after the rupture had occurred. Most of them had been at-
tended by the gossips of the district (commcres du faubourg), who, seeing
the strong pains and the difficult labor, had ])ractised massage of the
abdomen, succussion, and violent traction on that part that presented.
It was only in face of the obvious impossibility of completing the delivery
or the threatened collapse of the patient, that she was brought to the
hospital. [This article appears to us to be chiefl}^ an object-lesson on the-
possibilities of the practice of midwifery by unskilled hands.] The
authors treated 6 cases by tampon, with 5 deaths; 117 by drainage, with
13 deaths; 48 by injections, with 35 deaths; 3 by laparotomy and suture,
with 1 death; and 3 by total abdominal hysterectomy, without a death.
They argue that for complete rupture abdominal hysterectomy is the
only reasonable treatment, and they further argue that for incomplete
rupture abdominal panhysterectomy with vaginal drainage is best.

According to C. Sauvage,^ the frequency of ruptures incomplete to
those complete is in the proportion of 1 to 2. The principal sites of
rupture are, in the order of frequency : Rupture of a border of the uterus,
usually the left intraligamental, incomplete or complete — ordinarily this
rupture is a little in front of or behind the vascular pedicle of the uterus ;
a transverse or oblique rupture, complete, and sometimes incomplete,
of the anterior wall of the uterus; a transverse or oblique rupture, very
rarely incomplete, of the posterior wall of the uterus; a rupture involving
two segments, uniting at a variable angle. Ruptures in a great majority
of cases are located in the inferior segment; very rarely are they prolonged
into the body of the uterus or into the vagina. In extracting the fetus,
if a diagnosis of rupture has been made, no effort should be made to deliver
along the natural channel, unless the head has engaged in the pelvis and
there is an absence of dystocia. Laparotomy is indicated in all cases
in which the diagnosis of rupture has been made. Amann^ has collected
statistical information upon the subject, and finds that in cases in wliich
the uterus has been ruptured with wounds of the bladder, out of 15 col-
lected by Klien but 2 recovered. In complete lacerations the closure of
the lacerated womb gave a mortality of 53 %. When the child was re-

> Th^se de Paris, No. 305, 1902. " Zent. f. Gynak., No. 5, 1902.

402

OBSTETRICS.

moved through the vagina and the uterus then closed, the mortahty was
47 %. Supravaginal amputation of the ruptured uterus gave a mor-
tality ranging from 42 % to 45 %. The entire removal of the ruptured
uterus through the abdomen had been performed 13 times, mth 7 deaths.
Of late years the vaginal extirpation of the ruptured uterus has been
urged as the best method of operation. Of 9 cases collected by the
writer, 6 perished, but this mortality must be considered as excessive.
Those cases treated without operation, but with drainage by gauze, show a
considerable percentage of recovery. In 198 cases of rupture treated
without operation 48 % recovered and 52 % died ; 42 of these cases were
treated by drainage Avith gauze or with the drainage-tube, and of these 42,

Fig. 65. — Jay's case of pregnancv in a double uterus : a, Body of uterus ; h, ri);ht tube and ovary ; c,
cervix; d, turuoi- containing fetus attacl)p<l to left wall of uterus by a (e) pedicle having the anatomic
characters of a uterine cervix;/, left tube aud ovary removed with tumor; a, vagina (Australasian
Med. Gaz., May 20, 1902).

35 recovered, or 83 %. A. Donald and W. K. Walls ^ record an interest-
ing case of spontaneous rupture of a bicornute uterus during pregnancy
at the onset of labor (Plate 3). There was an extensive tear between
the two horns with escape of the fetus into the abdominal cavity. The
patient recovered after operation. [It seems evident that the result of
rupture of the uterus depends more upon the circumstances of the case
and the extent of the rupture than upon the method of treatment. When
the rupture is complete, the mortality is high under any form of treat-
ment. When the rupture is incomplete and but a small portion of the
fetus, if any, escapes into the abdominal cavity, the treatment by drain-
age with gauze gives the best results yet obtained. It is worthy of note
that what is called " secondary operation" through the abdomen gives a

^ Practitioner, Jan., 1903.

PLATE 3.

FETAL DYSTOCIA. 403

better result than primary operation. By the term "secondary" is meant
the fact that the operator removes the child through the vagin^ before
opening the abdomen to care for the uterus. Whenever possible, the
vaginal removal of the child and appendages lessens shghtly the mor-
taUty for the mother.]

Pregnancy in a Double Uterus; Removal of Pregnant Portion. —
M. Jay^ reports the following case (see Fig. 65) : The subject of this
remarkable tumor was a woman 25 years of age, the mother of one child,
the confinement having been normal. She was not subject to any disturb-
ance of menstruation. She consulted the physician in September, 1901,
complaining of backache, lassitude, and a vaginal discharge which com-
menced with a miscarriage some months previously. On examination
there was found some erosion of the os, the uterus was enlarged, retro-
verted, and pushed to the right. An ill-defined swelhng was found in
the broad hgaments, this tumor seeming to spring from the left uterine
wall. An operation was advised. In November pregnancy supervened
and the operation was postponed. In December there was uterine hemor-
rhage, recurring daily, and a curetment was done. The uterus was
found to be enlarged and pushed still more to the right. It was empty.
The tumor had considerably enlarged. She improved after the curet-
ment with the exception of persistent nausea. The following Februar5^
the abdomen was opened and a tumor found to the left of the median line.
On the right the uterus was brought into view, and attached to it was
only one tube and ovary. The left tube and ovary were normal and were
found attached to the left side of the tumor. The tumor took its origin
about 2 inches from the fundus of the uterus. The patient was placed
in the Trendelenburg position and the left ovarian artery and the la3'ers
of the broad Hgament were opened. The tumor was then enucleated down
as far as the uterine artery, which was tied. The tumor was found to
spring from the uterus at the junction of the cervix with the body, by a
pedicle an inch in diameter. This was fixed and tied, and the tumor re-
moved. On cutting through the pedicle which resembled an ordinary
cervix, a small opening was exposed in the tumor, from which projected
a thick plug of mucus. The pedicle was tied off and the stump covered
with peritoneum, the tumor being removed. The uterus, which presented
a lop-sided appearance, with its one tube and ovary, was then fixed to
the parietal peritoneum and the wound closed. On opening the tumor
it was found to contain a 3 months fetus. The specimen presented all
the anatomic characters of a pregnant uterus removed at the cervix, and
having only one tube and ovary. The patient made a good recovery.

FETAL DYSTOCIA.

The Mechanism of Posterior Presentation. — [The variations in
the form of the mechanism are dependent upon the size of the pelvis and
upon the size and degree of flexion of the child's head. The greatest
' Australasian Med. Gaz., vol. xxi, No. 5, May 20, 1902.

404 OBSTETRICS.

complexity manifests itself at the brim.] Sigmar Stark ^ believes that
there are 4 forms of mechanism encountered at the brim: (1) The en-
trance of the occiput in the "diameter of favorable engagement" with the
head in the state of excessive flexion; (2) arrest of the occiput,, descent
of the sinciput, release of the occiput with re-establishment of flexion;
(3) arrest of the occiput, descent of the sinciput, and conversion into a
face-presentation; (4) arrest of the occiput, descent of the sinciput, im-
paction, and arrest of labor. When the occiput reaches the pelvic floor,
and often even earlier, the next phenomenon in the mechanism of labor
becomes manifest. The occiput rotates either anteriorly or posteriorly.
The requisites for anterior rotation are good pains, flexion, and a relatively
rigid pelvic floor. If the head be in a position of extension, the sinciput
rotates anteriorly according to the law of obstetrics, that the most de-
pendent portion rotates to the front. Good pains and a relatively rigid
floor are essential in order to establish the proper balance between the
forces of expulsion and resistance. In every case of labor in an occipito-
anterior position when the occiput gets locked beneath the arch of the
pubis, the following take place: The chin, being the only portion free
to move, leaves the breast of the child and the head extends ; the occiput
is arrested; it can advance no further; it can rotate neither forward nor
backward ; and finally the chin, as the only part of the head free to move,
leaves the breast of the child and the head extends, and labor terminates
as a face-presentation. The occipitomental diameter of the head is 5
inches, the oblique diameter is 6 inches ; hence the extension of the head
is entirely impossible. Probably this form of mechanism may occur,
but the author cannot conceive that it is possible unless the head is imder-
sized or easily molded.

The Management of Posterior-occipital Positions. — [Posterior
positions of the occiput almost always right themselves, even when left
to nature, and the management should consist in properly understanding
and facilitating nature's methods.] W. J. Cavanagh^ points out that
this rectification on the part of nature depends, however, upon a proper
flexion of the head, so that when the occiput strikes the pelvic floor it. will
be the most advanced presenting part and will be rotated by the forces
around to the front. If the case is seen early before the membranes
have ruptured, it is frequently possible to avoid any dangers by a pre-
liminary rotation of the head, which may be effected by having the
woman assume the true genupectoral position and retain it as long as her
strength permits, or until vaginal examinations without change of posi-
tion show that rotation has taken place. Should the occiput, after
becoming anterior, show a tendency to return to its posterior position,
rupture the membranes to hasten engagement of the head. If this is
unsuccessful, ho hesitation should be felt in allowing nature to take her
course in these early cases. The degree of flexion should then be watched,
and if not satisfactory, firm resistance, not pressure, should be made
upon the sinciput to prevent any further advance, and the actual flexion
of the head should be left to the pressure exercised on the occipital end

1 Am. Jour. Obstet., Jan., 1903. ^ N. Y. Med. Jour., April 11, 1903.

FETAL DYSTOCIA. 405

by the uterine forces. If the case is not seen till labor has so far advanced
that simple pressure is of no avail, one of two methods may be employed :
(1) Anesthetize fully, pass the hand into the vagina, push the head gently
up out of the pelvis, above the superior strait, then flex it and rotate
the occiput forward, holding it in position till the pains, aided by pressure
from without, cause an engagement of the head. (2) Delivery by the
forceps reversed. This is not a difficult procedure. The blades should
be introduced so that the cephalic curve passes over the ears, with the
convexity forward and the tips resting upon the occiput. When traction
is made, which should be gentle and with one hand, the occiput is naturally
drawn down, the head, tilting on its attachment to the spinal column,
yields to the leverage thus applied, and, the frontal end being forced up,
flexion is at once established and the occiput becomes the lowest part.
The forceps should then be removed, and, if necessary, to complete de-
livery they should be applied in the normal method. Rotation will
almost always occur if good flexion is obtained even though the head
is very low. [This is a dangerous procedure save in the hands of the most
expert.] Sometimes when flexion seems impossible a safer and more
speedy result may be obtained by causing complete extension of the
head, thus converting a brow-presentation into the most favorable variety
of face-presentation, viz., that in which the chin presents under the pubic
arch.

Heredity and Twins, — [The question of multiple births is one of
perennial interest. Physiologists and obstetricians have exhausted
their ingenuity in the endeavor to find out how they occur, but hitherto
Avdthout success. In 1879 Goehlert, in a long article illustrated by nu-
merous genealogic tables, declared that there was nmch reason to believe
that the tendency to produce twins was hereditary-. The same thing has
been asserted and denied mth regard to the lower animals, although there
can be no doubt that multiple births are the rule in certain species, and
single births in others. Moreover, there can be no doubt that this ten-
dency bears a close relation to the size of the animal, the larger animals
rarely having more than one offspring at a birth, the smaller animals
rarely so few. Of course, the relationship of multiple births to the man-
ner of life, to the dangers to which the offspring is exposed, and to various
other factors, is quite obvious. We know, for example, that a single
pair of certain species of fish could fill the ocean with a solid mass in the
course of a very few years if all their offspring developed and in their turn
had the usual number. It is not a priori impossible, therefore, that this
hereditary tendency could exist in human beings. Of course, the cases
that are cited in which a single married pair -will have a series of tmns, or
a series of triplets, or in which, as in one instance, two Vjrothers had each
a series of twins, may be accidental, even if they actually occur. The
doctrine of probabilities applied to such a vast number of variable in-
di^dduals as is the childbearing part of the human race could give rise
to some very extraordinary facts without implying the existence of
recondite laws.] Recently Naegeli-Akerblom,^ in a most interesting
' Virchow's Archiv, Bd. clxx, H 1 u. 2, 1902.

406 OBSTETRICS.

article, has undertaken a careful critical study of the whole subject. The
amount of labor that this has involved is enormous, and the frankness
and evident sincerity with which the results have been stated lead us to
place considerable faith in his conclusions. He touches upon so many
points that it is hardly possible to consider his article as a whole. In all
these studies it is necessary for the statistician to select the most dis-
tinguished class of persons, and the family records of the nobility of
Europe go further back and are more accurate than those of any other
class. As a result they were the material from which Goehlert drew his
conclusions, and it has been a renewed study of this material that has
furnished the basis of Naegeli-Akerblom's criticisms. There are several
distinguished famiUes in whom, it has been alleged, a tendency to have
t\vins existed. Possibly the most distinguished is the house of Capet of
France. Another is the family of Solms-Laubach, and another the house
of Hanau. The cliief criticism found with Goehlert's data regarding
these three famiUes is that his historical studies were inaccurate. In
many instances he stated that twins were born of certain families, when,
as a matter of fact, we have no historical data upon which to base such a
conclusion. Another factor, however, upon which Naegeli-Alcerblom
lays great stress, is the confusion of the lines. The tendency to inter-
marry is so pronounced among European nobility that the house of Solms-
Laubach, for example, is related by marriage to no less than 65 reigning
famiHes of Europe, practically all there are. The point which seems to
have escaped Goehlert is, whether to these families, taldng the genealogy
as given, more twins are born than occur ordinarily, according to the
statistics obtained from large maternity hospitals. Now, it is known
that in every 84 births 1 tmn birth occurs, and from a study of these
tables it appears that, as a matter of fact, only 1 birth in 89 is multiple.
Now, as a result of the continual intermarriage, it seemed reasonable
to suppose that the tendency to produce twins would be greatly exalted,
and this is undoubtedly not the case. This whole question of heredity,
and particularly hereditary tendencies occurring in many generations,
is exceedingly involved. It is not generally appreciated how rapidly a
man's ancestors increase in the not-too-distant past. Presuming that
there were no intermarriages, the ancestors of any individual now Hving
must, at the time of Charlemagne, have exceeded considerably the great-
est possible total number of inhabitants in the world. It requires merely
a feeble imagination to picture the great diversity of hereditary influences
that act upon each of us, for in such a vast number there must have been
representatives of every type of character from a genius to a criminal, of
every type of conformation, of feature, or of physical tendency. And if
one should be sufficiently curious, and have access to the data, it would
be possible to ascribe the minutest peculiarities of any individual to
atavistic inheritance. What profits it, then, to waste time, energy, and
intelligence upon such fruitless and impractical inquiries? Naegeli-
Akerblom takes occasion, as a result of the very considerable statistical
information, to discuss the expectation of life in tmns, and he finds, con-
trary to the statements of Goehlert, Weinberg and others, that, granted

FETAL DYSTOCIA. 407

they survive birth and the first year of life, their expectation is quite as
good as that of single births. He notes some remarkable instances' in
which both members of a twin birth survived past 80 years of age. . In
151 instances 97 of the t^vin births exceeded 21 years of age, and, of these,
34 exceeded 60 years of age. [Not a bad showing if we compare it with
the expectation of Hfe in insurance-tables ! Now, what is the conclusion
of all these extensive historical investigations going back to the eighth
century? We may quote the final paragraph, which runs as follows:
" What may we conclude from this? Only that for the moment we rest
under the ban of systematic investigations; that we continually strive
to classify all natural phenomena as well as we can. Further, that we
know notliing concerning the cause or origin of tuins, triplets, etc., and
that it is not hkely that in any reasonable time we shall know any more."
And the lame but not altogether impotent conclusion of all is that we
do not know. This is at least better than fine-spun theorizing or high-
sounding terms and periods with which to cloak our ignorance.]

Multiple Pregnancies. — An editorial in the "Lancet"^ remarks that
the subject of prolificity and multiple pregnancy has always excited the
greatest interest among both ancient and modern writers. We find
Aristotle, who thought that the population should be fixed as regards
numbers, recommending legislation to prevent its increase and, as he
thought, the consequent deterioration of the race. Whether we regard
multiple pregnancies as a result of heredity, or as an example of atavism,
or merely as a consequence of undue prolificity, we are confronted with
problems of much interest. It is, indeed, only of late years that our
knowledge of the laws of fecundity have been based upon well-ascer-
tained facts. The influence of heredity in the production of multiple
births has long been a matter of popular behef, and the investigations
of numerous observers have shown that this belief is well founded.
Goehlert, from a study of genealogic tables which enabled him to ascer-
tain the fruitfulness of certain families throughout several generations,
has found that the tendency to the production of multiple pregnancies
is undoubtedly transmitted from parent to child, and that the hereditary
influence is decidedly greater when not only the mother but also the
father are members of such prolific famiUes, J. W. Ballantyne has pub-
lished some most interesting cases of this kind, in which the relationship
between large families and multiple births is well shown. One of the
most striking is that of a woman who had 22 children in 18 confine-
ments— 4 times twins and 14 single births; one of her sisters had had
triplets and another had given birth to twins. The influence of the male
parent has been pointed out by Goehlert and is illustrated by the case
recorded by Merriman. It is that of a woman who had 21 children
in 7 consecutive births. They were all born alive and 12 survived.
That some of the credit for this extreme fecundity may justly be ascribed
to the father would seem to be shown by the fact that a female servant
seduced by him gave birth to triplets who lived for 3 weeks. Leroy
quotes the case of 4 brothers in whose famihes 2 pregnancies in the

1 February 7, 1903.

408 OBSTETRICS.

parents of a collateral branch had been observed. All 4 were the fathers
of twins, 3 of them twice each and the fourth 4 times. Possibly this
record afforded the foundation for the story of the French family, the
male members of which had acquired such a reputation as the fathers
of twins and triplets that after a time no woman could be found who
would consent to marry any one of them. If we may accept the ob-
servations of Hellin, it would appear that the occurrence of multiple
births is directly connected with a relatively large number of egg-follicles
in the ovary, and is due to a persistence of the embryonic condition of
that organ in which the number of follicles is very much greater than
it is at subsequent periods of life. The chances of triplets surviving are
but small. Ruppin has calculated that the mortality of the children in
twin pregnancies is double and in triplet pregnancies 4 times that of
the mortality in single births. The fact that more boys than girls are
born in the population as a whole appears to hold good in the case of
triplets. The figures given by Ruppin show that the commonest com-
bination of sexes is 2 boys and 1 girl, then 1 boy and 2 girls, then 3
boys, and, lastly, 3 girls. According to him, the relative proportion of
the two sexes in this variety of multiple pregnancies is 104 boys to
every 96 girls. The interdependence that exists between general pro-
lificity and multiple births is shown by the statistics of the two condi-
tions. In France, for example, where the general prolificity is low, twin
pregnancies occur about once in every 92 births, as compared with a
general frequency of about once in every 80 births, according to Hellin.
He finds that the frequency of multiple births varies not only in different
countries but in different districts in the same country. The formula he
gives is a convenient one for estimating roughly the frequency of the
occurrence of multiple births. If twins be taken as occurring about once
in every 80 births, then 80^, or 1 in 6400, represents the frequency of
the occurrence of triplets; 80^, or 1 in 512,000, that of quadruplets; and
80," or 1 in 40,960,000, that of quintuplets.

OBSTETRIC OPERATIONS.

Use and Abuse of Forceps in General Practice. — M. Dewar^
thinks the large majority of injuries attributed to forceps is due to
their use by the inexperienced. Every obstetrician ought to be an expert.
City women demand help much more frequently than country women,
who endure all kinds of pain heroically. Inertia is common in city
practice, and if unduly prolonged requires help. He has never had post-
partum hemorrhage after forceps-delivery, not even in inertia. He
almost never applies instruments unless conditions indicate their use,
never unless the os is fully dilated, or dilatable, except at the onset
of convulsions or other dangerous complications. He records the mor-
tality statistics collected from other practitioners, together with those
of 1000 dehveries of his own. Of 300 city cases with a forceps percentage
of 35 the maternal mortality was 0.3 %; infantile, 1.6 %; this is much
» Amer, Med., Dec. 20, 1902.

OBSTETRIC OPERATIONS.

409

better than that of the 700 (30untry cases -with a forceps percentage
of 11 and a maternal mortality of 0.57 %; infantile, 2.8 %. [This-com-
pares favorably with records of hospitals, where strict antisepsis can be
employed.] L. V. Friedman^ has devised an excellent modification, of
Tarnier's axis-traction forceps (see Fig. 66). This instnmient is cleanly
and the supplementary handle is easily apphed.

Pubiotomy in Obstetrics. — [The results of 346 cesarean operations
performed by 11 renowned operators show^ed a mortality of only 23,
or 6.6 %, and a competent man working under favorable circumstances
on suitable cases. need fear no mortality from this procedure. In sym-
physeotomy injuries may occur which cause a prolonged convalescence
and even lead to the death of the patient. Rubinroth, examining the
world's literature of 3 years, 1896-98, found 136 cases of symphj'seotomy
with a maternal mortality of 11 % and an infantile mortality of 14 %.
These statistics are not encouraging to the advocates of this operation;
neither will American obstetricians be likely to regard with much favor

Fig. 66.— Friedman's modification of Tarnier's axis-traction forceps: 1, Instrument in iwsition for
traction ; 2, sliows side view in t>etter tletuii. Tlie rods nttaelied by Higgin's modification (a) are short ;
\tlien in place tliey do not reacli liie loclf. Tliey follow the curve of, and lie flat on the under surface of
the slianks. It is this inward curve (b) which is mentioned alwve as a protection to the perineum.
During application each rod is held f^st to the shank by a small pin {v). At the lower end of each
rod is an oval eyelet (d) to receive the hooks of the handle. The bar is similar to tho.se now in use,
but at (e) it holds by a iock-joint, instead of a screw, tlie curve<l upright which bears the hooks.

the revival of the operation of pubiotomy, which has been selected by
some obstetricians in preference to symphyseotomy. The operation has
been chosen for cases in which the symphysis is a synostosis instead of
a synchondrosis. It probably has its place in a Naegele pelvis delivery
in which the operation termed ischiopubiotomy has been performed by
some operators. The distinctive feature of a Naegele pelvis is the atrophy
of one lateral mass of the sacnnn, producing an obliquely contracted
pelvis. On the side on which the ankylosis of the sacroiliac joint is
found, the pelvis is cut with a chain-saw in tw^o places, in the ascending
branch of the pubis 5 cm. from the median line, and where the descending
ramus joins the ascending ramus of the ischium. After the bones are
cut, according to Garrigucs, it is necessary bluntly to separate the ob-
turator membrane along the outer border of the iscliiopubic branches in
order to obtain a separation of the ends. By the gaping of these bones,
combined with the mobility at the symphysis and the other sacroiliac

1 Boston M. and S. Jour., April 9, 1903.

27 S

410 OBSTETRICS.

articulation, enough space is gained for the passage of the head.] H.
van de Velde^ has advocated in cases of obstructed deHvery a similar
operation, terming it hebotomy, claiming that it has Kttle danger for
the mother and is favorable to the child, besides presenting no difficulty
for the obstetrician. [In spite of such advocacy, we still believe in the
superiority of cesarean section over either of these operations upon the
osseous structure of the pelvis, the comparative mortality being sufficient
ground for this preference.]

Pelvic Changes in Symphyseotomy. — Sandstein^ finds that after
symphyseotomy 3 sorts of motions occur in the pelvis. The first is the
movement of the pubes outward by rotation of the innominate bones
on vertical axes passed through their respective iHac joints. This he
considers of little importance. The second movement consists in rotation
of the innominate bones on a horizontal transverse axis passing through
the sacrum; this carries the pubes downward. Besides these two move-
ments, a third and hitherto undescribed movement occurs. This consists
in rotation of the innominate bone on its axis so as to cause the iHum
to become more erect or vertical. This movement of itself would cause
shortening of the interspinous and intercristal diameters were it not more
than compensated by the outward movement of the bones after pubic
section. The writer considers that Walcher is correct in maintaining that
the pubes move downward to a considerable extent. Regarding the
increase in the various diameters of the pelvis, the conjugata vera was
increased 1.67 mm. per centimeter of pubic separation. Roughly speak-
ing, 6 cm. of pubic separation give 1 cm. of increase in the conjugata
vera. The diagonal conjugate increased nearly 2 mm. and the inter-
trochanteric over 6 mm., the intercristal 2.4 mm., and the interspinoflis,
5.61 mm. per centimeter of pubic separation. The transverse diameter
of the brim increases 4 mm. and the right and left oblique diameters
of the brim 3.84 mm. and 3.9 mm. respectively. By comparing the
gain in various diameters, it is seen that the true significance of sym-
physeotomy during labor Hes mainly in the fact that it permits increased
descent of the pubic bones. Symphyseotomy is a means of obtaining
greater effects than we can by Walcher's position. By Walcher's posi-
tion the pubes can be depressed not more than 5 mm., whereas by sym-
physeotomy with 6 cm. of pubic separation the mean depression of the
pubes is 8.4 mm. The danger of pubic separation hes in the damage
done to the vulva, to the anterior vaginal wall, the urethra, and the
bladder. Pubic separation should be limited, if possible, to a maximum
of 6 cm. Symphyseotomy, then, must be limited to cases in which
by a gain of 1 cm., or f inch, in the true conjugate, the child may safely
be dehvered. The true conjugate must certainly not be below 7 cm.,
and should be above this measurement. The child must be hving, and
Walcher's position must be used, "vvith support to the sides of the pelvis.
Care must be taken to counteract unequal movements on the two sides
of the pelvis. By flexing the thigh of the non-mo\dng side and abducting

1 Amer. Med., Nov. 15, 1902.
•^ Jour, of Obstet. and Gynec. of the Brit. Emp., March, 1902.

OBSTETRIC OPERATIONS. . 411

the bent-up knee, that side can be made to move equally with the "other
side, and the rupture of the Hgaments avoided or delayed. The sym-
physis should be severed with a broad-bladed knife, and division of the
subpubic Ugament should not be aimed at. The Hgament prevents the
extension of the wound down into the vulva. Ossification of the pubes
does not occur, and hence the operator can always cut through cartilage.
In 13.3 % of cases the joint was in the median hne, in 66.3 % on the
left side, and in 20 % on the right. The tubercle upon the upper surface
of the pubes is the best guide. Rigid asepsis is necessary, and infected
cases should not be subjected to the operation.

Fritsch's Fundal Incision. — In connection with the operation of
cesarean section, there are at the present moment 3 important questions
sub jvdica. These are : (1) The conservative section versus Porro's, or
intraperitoneal hysterectomy; (2) the steriHzation of the patient if the
conservative operation is chosen; and (3) the direction of the uterine
incision. So says J. M. Munro Kerr.^ In -1897 Fritsch first recom-
mended the transverse fundal incision, because of the ease with which
the child can be extracted from the gravid uterus. The advantages
claimed by Fritsch and substantiated by the writer are: (a) The abdo-
men is opened into higher up, and so there is less risk of subsequent
hernia; (&) by pulHng the fundus well forward, the escape of blood and
hquor amnii into the abdominal cavity can be better prevented ; (c) the
child can be more easily extracted; (d) the placenta is less frequently
cut down upon; (e) there is less bleeding; (/) there is greater diminution
of the wound, and less stitching is required. The objections urged
against the operation are: (1) The incision makes adhesions to the bowel
more Hable, which may interfere with the involution of the uterus, and
that discomfort from dragging on the abdominal wall will follow; (2)
the uterus may become fixed to the abdominal wall 3 to 5 inches above
the symphysis ; (3) in case of any infection of the uterus general perito-
nitis is more hable to follow. This is not so great with the longitudinal
incision, for it becomes shut off from the peritoneum by adhesion with
the anterior abdominal wall. The danger of rupture of the uterus in a
subsequent pregnancy is stUl a matter on which one cannot speak with
any assurance, and certainly one cannot yet compare the danger of
rupture after a longitudinal with the danger after a transverse fundal
incision. Curschmann^ collected 119 cases of cesarean section by trans-
verse incision of the fundus. He gives statistics to prove his belief that
the transverse incision offers no essential advantage over the usual in-
cision upon the anterior uterine wall. He supports his assertion by
measurement of the uterine wall at the fundus and anteriorly, by a
comparison of convalescence after the two methods, and by minute study
of the cases. The mortality was 12.1 %, or 13 cases, 11 of which were
cases in which the uterus was retained, and 2 cases in which the uterus
was removed. One patient was admitted to the hospital in a septic
condition. The causes of death were as follows : Carcinoma of the uterus, •

' Jour, of Obstet. and Gynec. for Brit. Emp., July, 1902.
' Monats. f. Geburtsh. u. Gynak., 1902, Bd. xvi, Heft 5.

412 OBSTETRICS.

1 ; purulent bronchitis, 1 ; embolism of the lung, 1 ; death from shock
immediately after the operation, 1; peritonitis, 8. In 3 cases autopsy
showed adhesions of coils of intestine with the uterine wound. . This was
also seen in several cases which recovered in which it was necessary to
do abdominal section for the relief of obstruction of the intestine. Re-
peated cesarean section was done in 10 cases, in 8 of which the first
operation was made by longitudinal incision in the anterior uterine wall,
while in 2 transverse incisions of the fundus had been practised. In all
of these cases there was adhesion between the uterus and the abdominal
wall and omentum. No scar in the uterus could be discovered in these
cases. Of these 10 repeated sections, 7 recovered without fever, 1 had
fever and recovered, and 1 died.

Vaginal Cesarean Section. Bumm^ describes 13 cases of this
operation with 1 death which occurred 3 hours after the operation in
case of eclamptic coma. The 8 cases which came to the hospital in an
aseptic condition recovered without fever. Fever occurred in 4 cases,
one after removal of a fetid cancer, two were cases of eclampsia and
one of nephritis. While at first cervical carcinoma was the most frequent
cause for vaginal cesarean section, Bumm thinks it should now be used
in many cases of eclampsia, he having been brought by a year's experience
of different methods to the opinion that in cases of eclampsia delivery
should follow the first attack, and that the vaginal method is simpler
and less dangerous than the classic cesarean section, and in his opinion
is much more certain and exact than the use of the metallic dilators
now in vogue. In one case this method was used on account of severe
hemorrhage from a deep-seated placenta. He deems it advisable also
when a torpid uterus reacts very badly, or not at all, in response to any
irritant or stimulant such as manipulation or introduction of instruments
so liable to cause infection. He advises early operation so as to preserve
the fetus intact and uninjured.

THE PATHOLOGY OF THE PUERPERIUM.

The Treatment of Septic Infections with Intravenous Collargo-
lum Injections. — Crede^ states that the intravenous injection of collar-
golum by no means does away with the use of unguentum Crede; on
the contrary, the great majority of the cases can be cured by ointment
inunction, which is more readily employed and more agreeable to the
patient. But when the skin is not sufficiently al:)sorptive, when inunc-
tions are painful, and when the infection is so virulent that the greatest
possible rapidity and energy of action are required, the intravenous
injections are indicated. The syringe, which should hold from 5 to 10
grams (1^ to 2^ drams), should not be cleansed with chemical solutions,
but should be sterilized by boiling, followed by distilled water or alco-
hol. A few drops of the new collargolum in water should give a clear
brown color; while the decomposed collargolum gives a turbid, gray
emulsion. The technic of the intravenous injection in subjects with well-

1 Zent. f. Gynak., Dec. 27, 1902. ^ ^g^ gj^g ^^^ Monthly, April, 1903.

THE PATHOLOGY OF THE PUERPEMUM. 413

filled visible veins is extremely simple. A bandage or handkerchief is
tied around the pendant arm tight enough to render the veins «,t the
elbow tense and swollen. The detached iieedle is inserted through the
cleansed skin into the vessel, the flow of blood showing when its point
is free within the vein. The cannula is steadied with the left hand,
and the syringe, not quite filled with the silver solution, is attached;
a small amount of blood is then drawn up into the solution, so that
any air-bubble that may be present rises to the top of the fluid and
is not injected. During the injection the arm is steadied in a horizontal
position to facilitate the rising of the air. Introduction of the needle
attached to the syringe, and determining the fact of its introduction into
the vein by the mobility of its point, are liable to occasion error. Col-
largolum is not absorbed when employed subcutaneously, but it may
possibly be absorbed when injected into very vascular muscular tissue.
The solubility of the improved collargolum allows the use of a 2 %
solution; so that 2 to 10 cc. (^ to 2^ drams) or 0.08 to 0.12 gram (li
to l^ grains) suffices for an injection. When the collargolum is employed
in time, before the brain and heart have lost their powers of resistance,
and before metastases have occurred, there is a plain improvement in
a few hours after its introduction into the blood. The patient becomes
quieter, and feels better; sweating may set in, and the pulse and tem-
perature improve. In severe cases the improvement may be short and
transitory, and the injection must be repeated in 8 to 12 hours; but it
usually persists for from 24 to 36 hours, about as long as the silver
remains in the body. The quicker the improvement disappears, the
sooner must the silver be given again and the larger the dose required.
Cumulative action does not occur; as many as 20 injections have been
given to one patient, though Cred^ himself never gave more than 7.
Crede puts on record the fact that neither in his own extensive experience
nor in that of others has there ever been any mishap from the intravenous
collargolum injection; there has been no undesirable general reaction, nor
any trouble from the local puncture of the vein. Wernitz' advocates
the abundant and methodic introduction of fluid per rectum as an
effectual means of combating sepsis. By this means the urinary and
perspiratory secretions are greatly stimulated and the poison which is
circulating throughout the organism is rapidly eliminated. This elimina-
tion is so abundant and rapid that in some cases of severe sepsis in 7
of 8 hours the dangerous condition is overcome by this simple, safe,
and practicable means. At the beginning of this treatment there should
be a thorough cleansing of the intestinal canal and the freeing of the
same from gases. The excessive distention of the abdomen interferes
with the heart-action and can easily lead to a fatal result. Hence the
emptying of the intestinal canal may be essential to save life. He empha-
sizes the statement that the introduction of copious amounts of fluid
per rectum is generally a valuable remedy for acute septic infection.

The Formalin Treatment of Septicemia. — An editorial in the
"Journal of the American Medical Association"^ very wisely remarks as

' Amer. Med., July 26, 1902. ^ February 7, 1903.

414 OBSTETRICS.

follows: A patient with puerperal septicemia recovered after the intra-
venous injection of formalin solution. We are told that the case was
regarded as hopeless and that the effect of the formalin injection was
"magical." This episode has been exploited in a sensational manner in
the daily press and it has been heralded in medical journals as a dis-
covery and an epoch in the history of medicine. While all would welcome
the demonstration of a successful treatment of septicemia, there is un-
fortunately the very best of reasons for questioning the correctness of
the inference that the recovery in the case referred to resulted directly
or indirectly from the injection of formalin. The reasons for this doubt
may be presented under two heads: namely, (1) the now well-known
occurrence of spontaneous recovery from various forms of septicemia,
or blood-poisoning, and (2) the inadequacy of available evidence to show
that formalin solution has any bactericidal or curative effect when intro-
duced into the circulation of infected animals in nonfatal doses. Every
physician of experience has had the opportunity to observe apparently
"hopeless" cases of septicemia suddenly change for the better, and per-
chance after a remission or two go on to recovery. The bad prognostic
significance formerly and even now attached to the diagnosis of septi-
cemia or blood-poisoning is sure to undergo considerable modification as
the results of bacteriologic examinations of the blood during life and
according to approved methods become more generally knoT\Ti. It has
been shown conclusively that cases of bacteriemia, be it streptococcemia,
pneumococcemia, or staphylococcemia, may recover spontaneously even
when the blood has been found to contain large numbers of bacteria,
and even when metastatic foci, such as articular inflammations and
endocarditis, have developed. This being the case, the recovery in a
single, isolated instance of streptococcemia injected with formalin proves
little or nothing in regard to the value of the latter. For aught we
know it might be nearer the truth to say that recovery resulted in spite
of the formalin injections. We cannot regard the puerperal septicemia
"as an otherwise fatal condition." In 47 cases of bacteriemia, demon-
strated to be such by cultures from the blood during life by Bertelsmann, ^
death took place in 26. In this series there were 28 cases of strepto-
coccemia, and of these 13 died. Other examples of this kind could be
cited. Recently Herrick^ has collected a number of cases from the
literature of recovery after undoubted malignant endocarditis. He is
fortunate enough to furnish the anatomic proof of the healing of ulcera-
tive endocarditis, in 3 cases in the form of healed valvular perforations.
[In view of these facts it is self-evident that the actual value of formalin
injections in septicemia can be determined, from the clinical standpoint,
only by systematic use in a large series of cases under careful control
by persons capable of sober judgment.] Coming now to the experimental
study of the curative and bactericidal action of formalin solutions in
infected animals, then we may say, in brief, that the result,s so far are

> Verb. o. Gesellsch. f. Chir., 1902, xxxi, 291-304.
^ Trans. Assoc. Am. Phys., 1902, xvii, 468-483.

THE PATHOLOGY OF THE PUERPERIUM. 415

not at all encouraging. Fischer and Tieken^ found that repeated intra-
peritoneal injections of formalin 1 : 2000 or 1 : 1000, in doses of" from
4 to 8 cc, had an unfavorable influence in guineapigs with peritoneal
tuberculosis. The injected animals were less able to resist the tubercu-
lous infection than those not injected. Fortesque-Brickdale^ found that
formic aldehyd in large doses so depresses animals infected with pneu-
mococci that they die sooner than an untreated animal used as control.
Formalin, i. e., formaldehyd, — according to Waldemar Koch,^ interferes
with the normal proteolytic processes in the cells, and hence it would
tend to reduce rather than strengthen the cellular resistance to noxious
agents. [Certainly not much may be hoped from the use in human
septicemias of an agent that has proved so disappointing in animal
experiments. Pending scientific investigation, an emphatic caution
should be given to the general practitioner. Six or more cases in which
this agent was used are already reported in the newspapers, and most
of these trials were undoubtedly suggested by the accounts of C. C.
Barrow's case in the lay press. This indicates the eagerness of the pro-
fession to avail itself of any hope of relief in a desperate condition. The
trial should certainly be left to cases in extremis.] Barrow* warns the
profession against the indiscriminate use of this agent when proper blood-
cultures have not been made to determine the cause of the septicemia.
The technic of the injection is simple — that of any intravenous infusion
and with all the surgical precautions. The solution used has been of a
strength of 1 : 5000 of formalin in physiologic salt solution. As much as
750 cc. has been injected. [In determining the results the value of
injections of physiologic salt solution itself, either with or without ab-
straction of some of the sepsis-laden blood, should be remembered.
Control-experiments would be of exceeding value in such cases if they
were possible.]

Curettage of the Puerperal Septic Uterus. — ^W. R. Pryor^ says:
"In all cases of puerperal fever about 75 % are septic. Therefore the
ignorant operator, indifferent as to precise methods, if he curets all
cases, will do an indicated operation in about three-fourths of the cases.
What will be the result of his work in the other one-fourth — the septic
cases? The commission of the American Gynecologic Society, appointed
in 1898, made an analysis of every case of puerperal fever reported in
the literature of the world for the 5 preceding years, covering the period
during which the bacteriology of the puerperal state was actively pro-
mulgated. The two men whose observations are the most reliable and
whose treatment of septic cases is identical, Whitridge Williams and
Kronig, apphed no local treatment whatever to the inside of the uterus,
doing nothing to it other than what was necessary to establish the
diagnosis; and having a mortality of only 5 %. Here, then, we have a
basis upon which to work, and we are warranted in saying that, excepting
epidemics of particular virulence, but 5 % of women with puerperal

> Trans. Chicago Path. Soc, 1902, v, 61-63.

' Lancet, Jan. 10, 1903. ^ Am. Jour, of Phys., 1902, vi, 325.

* N. Y. Med. Jour., Jan. 31, 1903. ' Canad. Pract. and Rev., Sept., 1902.

416 OBSTETRICS.

sepsis will die if the uterus, is let alone. The normal mortality of puer-
peral sepsis then is 5 %. How is this modified by the mistaken curettage
of the puerperal septic uterus? In the analysis made by the commission
mentioned, we found that curettage of the uterus when bacteriologic
examination had been made and the streptococcus found gave the fright-
ful mortality of 22 %. Since being appointed a member of this com-
mission, and for two years previously, Pryor has adopted and perfected
a certain method of treatment which he applied to all cases in which
he found the streptococcus present in the uterus. This method of treat-
ment, which has been described, gave no mortality either in his hands
or in those of the men who have adopted it, except in one class of patients,
and these were those who had been curetted before coming into their
hands. There were 10 such patients, 3 of whom died, a mortality of
33J %; and the lesions remote from the pelvis and in the pelvis which
were found at the time of operation were in these curetted cases far
more general and of a more serious nature than in any others they have
seen.

The Operative Treatment of Puerperal Pyemia. — SippeP is in-
duced by Trendelenburg's success in curing a case of puerperal pyemia
by ligation of the hypogastric and spermatic veins to draw attention to
the fact that in 1894, in a case of purulent phlebitis of the uterus which
took the form of acute pyemia, he proposed to remove the uterus and
resect the internal spermatic and uterine veins, though he did not actually
carry out this proceeding. Of 4 cases of puerperal pyemia, 2 recovered
spontaneously ; the other 2 could not for independent reasons be operated
on, and both died. Sippel is not inclined to the extraperitoneal method
suggested by Trendelenburg, and would only proceed by laparotomy, and
having done so would remove the uterus as well as the veins ; but many
a case of pyemia recovers spontaneously, and operation is not indicated
unless life is endangered.

Hysterectomy for Puerperal Sepsis. — Vineberg^ quotes Fehling's
dictum that the attempt to divide the various forms of puerperal infection
bacteriologically cannot be considered thus far as successful. Fehling
is not an advocate of hysterectomy for puerperal sepsis, though it
might be justifiable in those cases in which the sepsis is of uterine origin,
due to a retained placenta which could not be removed by the ordinary
methods. He does not consider the results obtained by ligating the
thrombic pelvic veins encouraging. Leopold divided the cases of severe
puerperal sepsis into 6 groups: (1) Cases in which the pyogenic germs
have penetrated the uterus and set up a general peritonitis. Hysterec-
tomy in these cases would be useless; for the infection is now in the
peritoneum, and there should be an attempt to treat the peritonitis
surgically. (2) Cases in which the pyogenic germs attack particularly
the venous system and lead to a septic thrombosis. In some of these
removal of the uterus is sufficient; in others the affected veins should
also be removed. (3) Cases in which the infection principally affects
the endometrium and extends and becomes localized in one or other of
1 Canad. Pract. and Rev., May, 1903. ' Am. Gynecol., Jan., 1903.

THE PATHOLOGY OF THE PUERPERIUM. 417

the adnexa, in which case the proper procedure is the removal of the
affected ovary. (4) Cases in which all the symptoms point to multiple
abscesses of the uterine muscularis and pelvic peritonitis. In some of
these drainage of the pus-foci may be sufficient, but if the uterus is
thickly studded with small abscesses its removal is necessary. (5) Cases
in which during labor severe bruising is inflicted upon pelvic tumors,
causing gangrene and subsequent peritonitis and often requiring hysterec-
tomy. (6) Cases in which putrefaction of the uterus occurs in conse-
quence of a retained placenta which cannot be removed by the vagina
and hysterectomy becomes necessary. Vineberg agrees with Leopold's
conclusions. Gradenwitz^ quotes statistics from many surgeons, showing
that the extirpation of the septic puerperal uterus results in a mortality
of about 50 %. In 4 years (1898-1902) 113 cases of puerperal fever
were treated in a Breslau hospital. In 26 of these the fever, caused by
some affection of the internal or external genitalia, decreased after a
brief symptomatic treatment, with 3 deaths. In a second group of 23,
in which the fever was evoked by a fresh perimetritic or parametritic
postpartum abscess, the temperature sank to normal with a conservative
operative treatment, involving no deaths. The third group of 26 suffered
from putrid placental debris, the removal of which resulted in recovery
with one exception. The remaining 38 cases were in an apparently
hopeless condition when received, and of these, 21 died. In only 7 of
these was it deemed worth while to imdertake the extirpation of the
uterus, and of these 5 made complete recovery. In 4 of these there was
a pronounced local infection, and in 1 the lymphatic form of pyemia.
The 2 cases resulting in death were instances of pure septicemia without
the presence of any local lesion or suppuration or swelling of the
lymphatics.

Puerperal Aphasia. — [Loss of speech during the puerperium is one
of the most rare complications, but its occurrence is so alarming to the
family and its possibilities so important to the patient that the following
notes on the subject will be of interest.] M. A. Mclntyre Sinclair^ offers
the following conclusions on this subject. In considering the prognosis
of puerperal aphasia one has to bear in mind many facts which apply
equally to other forms of speech-affection. The nature of the lesion,
whether functional or organic, nervous or vascular, must be taken into
consideration. But looking in a general way at cases one cannot help
being struck with the large proportion of recoveries from a primary
attack of puerperal aphasia. In some the loss of speech is of a very
transitory type; in others complete or partial recovery ensues in the
course of a few days, weeks, or months. He points out that the age
of the childbearing woman is an important factor, and the vascular
conditions are mostly such as to allow of a quick resolution of a thrombus
or the rapid opening up of a collateral circulation. A primary attack of
puerperal aphasia, therefore, will often lend itself to a more or less favor-
able outlook. At the same time the liability to recurrence of the aphasia
in the event of a subsequent pregnancy is emphasized. This unfortunate
1 Miinch. med. Woch., Dec. 23, 30, 1902. ^ Lancet, July 17, 1902.

418 OBSTETRICS.

sequence of events took place in both of Finlayson's caSes, in Bateman's
case, and in the cases of Gignoux and Leven reported by Poupon. More-
over, the second or recurrent attack in each instance was of a much
more serious nature than the attack recovered from in the first instance.
In both of Finlayson's cases the secondary aphasia remained persistent
and in one case was accompanied by permanent rigidity of the paralyzed
limbs. Bateman's case, without the development of fresh symptoms,
terminated fatally in 6 weeks. A recurrent attack of puerperal aphasia
is therefore a serious matter and the prognosis is grave. Indeed, it is
so bad that one must consider the question whether pregnancy ought to
be allowed to recur. Poupon, in recognizing the liability to recurrence
of the aphasia in a subsequent pregnancy, advises that the woman should
be warned to avoid becoming enceinte in the future. The cases of Fin-
layson and Bateman bear further testimony to Poupon's advice. He
would go even further, and say that in the event of the patient again
becoming enceinte the only justifiable course, according to present
knowledge, is to terminate the pregnancy at the earliest possible moment.
Such a procedure was actually carried out in his own case and there
has so far been no recurrence of the aphasia. Much need not be said
regarding the treatment of puerperal aphasia. This will depend to a
great extent on the nature of the lesion, and the attack must be dealt
with on the same lines as guide one in the treatment of any other cerebral
affection. It would be superfluous to add anything on this score. In
addition to special indications for treatment, it will in most cases be
necessary to pay attention to the general health of the patient, and
when signs of improvement manifest themselves to persevere with the
re-education of the faculty of speech. In regard to the latter point he
insists that the seances should not at first be too frequent, and that
care be taken not to fatigue the patient. In the event of a subsequent
pregnancy he expresses the view that for purposes of prophylaxis it
is strongly advisable to terminate the pregnancy at the earliest possible
moment.

PHYSIOLOGY AND PATHOLOGY OF THE NEWBORN.

Fractures of the Clavicle in Spontaneous Labors. — G. Riether^
states that a number of cases are reported in which there was fracture of
the clavicle in spontaneous delivery. This observation seems to be quite
new, and it is of interest to accoucheurs, and has some forensic impor-
tance. From June, 1901, until the end of May, 1902, 65 cases were ob-
served in the 3 lying-in clinics of the Vienna General Hospital. The
most frequent site of the fracture was in the middle of the bone. In
cases in which the separation of the fractured end was incomplete it fur-
nished a greenstick fracture. The symptoms of this condition are not
very distinct, and unless the condition of the clavicles is carefully exam-
ined it is easily overlooked. A falling forward of the shoulder on the
side of the fracture is one of the most constant symptoms. In some
' Wien. klin. Woch., No. 24, p. 619, June 12, 1902.

PHYSIOLOGY AND PATHOLOGY OF THE NEWBORN. 419

cases there is no abnormal mobility. Crepitation is readily obtained in
some cases, and again it is absent. The prognosis is always favorable,
due to the power of repair of bone in early life. As a rule, good con-
solidation is found at the end of 14 days.

Gastrointestinal Hemorrhage of the Newborn. — The occurrence
of this malady in the newborn is less at this period, according to J. F.
Moran,^ than at any other time of hfe, but its mortality is very high — •
50 %. The etiology is very obscure, and the course of the disease in the
cases which recover is about 48 hours. It is self-limited, the hemorrhage
usually ceasing with the complete evacuation of the meconium. Among
those factors which have been mentioned as the cause of the disease are
changes in the circulation incident to the establishment of respiration,
dehcate condition of the bloodvessels, inherited diathesis, cyanosis, ex-
ternal violence, difficult labor, malformation of the heart and other
organs, chilling of the surface, and bacterial infection. There are three
pathologic stages of the hemorrhages of the newborn: (1) Those occur-
ring shortly after birth; (2) those associated with some pathologic con-
dition of the blood or bloodvessels, as purpura hsemorrhagica, hemo-
philia, and eruptive fevers; (3) those due to local causes, as ulceration
in typhoid, severe intestinal inflammation, mechanical irritation, lum-
brici, etc. Many authorities claim that constitutional diseases, sjqjhilis,
etc., are etiologic factors in the production of the trouble. Klebs (1875)
found constantly the bacterium which he named Monas hsemorrhagica
in the vessels of the newborn dying of melena. The writer thinks that the
self-limitation of the disease would seem to show that, whatever the
cause, it is but transitory, and the other signs and symptoms are but
of secondary importance. The indications for treatment are threefold : to
control the hemorrhage, maintain the forces, and remove the cause. In
light cases, the promotion of respiration, absolute rest, external heat,
bland nourishment, preferably albumin-water and brandy, will usually
suffice. The various vegetable and mineral astringents are of little
or no avail, as the stomach in the majority of cases is in an irritable
condition, which is only aggravated by their action. Salt solution by
the rectum is of little use, as it is not retained; combined with gelatin
and administered subcutaneously, it has given excellent results. The
author reports a case thus treated with cure.

Asphyxia Neonatorum. — [There are several well-known and well-
tried methods of stimulating respiration in the newborn, whidh are famiUar
to every one. The following, however, may be quite new, and certainly
is worthy of attention.] M. Munkevitch^ begins by freeing the mouth,
pharynx, and upper air-passages of mucus. Then, after having cut the
umbilical cord, he proceeds to cause artificial respiration by taking care
to give the body of the child a point of support (un point d'appui) instead
of holding it in suspension, which is one feature of Schultze's method,
in common use in France. He seats the infant upon a bed or table,
suitably covered to prevent slipping or chilhng, with the lower legs ex-
tended and separated. Standing behind the child, he places his two

» Am. Gynec, Nov., 1902. ' La Sem. M^d., Nov. 5, 1902

420 OBSTETRICS.

hands beneath the axilla so that the thumbs rest upon the shoulder-
blades, and the fingers upon the ribs in front. He now proceeds to carry
out the movements of respiration with the trunk by flexion and inclina-
tion toward the angle of separation between the lower limbs, exerting
meanwhile uniform pressure with his hands upon the chest. In this
manner he forces the diaphragm upward, while he compresses the chest,
and thus brings about expiration. The reverse of this maneuver con-
stitutes inspiration. In order to make the maneuver still more efficient,
he sometimes places some tunic rolled into a small mass behind in the
small of the child's back. The movements of flexion and extension are
repeated systematically, and their rapidity should not be greater than
that of ordinary infantile respiration, namely, about 40 to the minute
According to this observer's experience, it is a very efficacious method
of causing a child who otherwise might die to breathe. Shucking^ has
been induced by studying the emptying of the placenta and its blood into
the umbilical vein by intrauterine pressure to attempt the infusion of
saline solution into the umbilical vein as a means of resuscitation when
the more common means fail. He reports one case in which the infant was
born in an exhausted condition after a prolonged labor. After failure
of other means of resuscitation, and the heart-sounds were scarcely dis-
tinguishable, he immediately cut the cord and injected about 50 grams
of saline solution into the umbilical vein. This reinforced by Sylvester's
artificial respiration revived the child successfully.

' Med. News, Aug. 23, 1902.

GYNECOLOGY.

By J. MONTGOMERY BALDY. M.D.. and W. A. NEWMAN
BORLAND. MB.,

OF PHILADELPHIA.

PRELIMINARY AND GENERAL CONSIDERATIONS.

The Evil Effects of the Corset. — Cienerations of medical men and
some few enthusiastic refoi-mers have repeatedly protested against the use
of corsets, and have ascribed to them many of the ailments which are
relatively common among women who wear them, but no more compre-
hensive accusation has been brought against the use of these articles of
female attire than that contained in a paper by Williams,^ of Liverpool,
published in the Reports of the Royal Southern Hospital. Williams
asserts that the injurious pressure of the corset on the lower ribs and the
abdominal viscera interferes with, digestion and assimilation, and pro-
duces dilation of the stomach and gastric ulceration with subsequent
anemia, while at the same time by compressing the base of the thorax
corsets throw the diaphragm out of action, and thus are responsible for
the thoracic respiration of females, which is described as both abnormal
and insufficient. In addition, however, to these injurious results, lateral
curvatures of the spine are also said to be due to the injurious pressure
of the corset upon the spinal muscles, and Williams concludes his heavy
indictment with the statement that by the use of corsets the majority of
women are permanently deformed as to their skeletons at 24 years of
age, and permanently crippled at 30. [Most observers will admit that
numerous evils result from the abuse of corsets ; nevertheless it is a fact
that many women live to old age in good health, in spite of the com-
pression to which they subject themselves, and it is difficult to see how
corsets can be dispensed with so long as it is the custom to wear skirts
and petticoats, which are most conveniently suspended from a structure
which has a basis of support upon the hips. It is true that some method
might be devised for suspending the dress from the shoulders during the
day, but this would be impossible in the evening in many cases, and it is
by no means certain that the traction of heavy skirts and petticoats upon
the shoulders would not have a bad effect upon the thorax and its con-
tents. Experience has shown that skirts worn without corsets and
without suspension from the shoulders must be drawn so tightly above
the hips that their pressure is just as injurious as that of the tightest
corsets. Those who have made the experiment find that female dress
1 Brit. Med. Jour., Feb. 14, 1903.

422 GYNECOLOGV.

vdih corsets is much more comfortable than female dress without corsets ;
if the corsets are well built to rest upon the hips, there need be no injurious
pressure upon the waist. In other words, it is the abuse rather than the
use of corsets which should be deprecated while custom prescribes skirts
and petticoats as female garments. Until some series of garments is
devised (and accepted) for female wear as becoming and comfortable as
those which are at present customary, but capable of being worn without
corsets, there is little hope that the latter article will be dispensed with.
It would appear, therefore, that possibly the best way to avoid the evils
corsets cause would be to educate females to the appreciation of the fact
that not only is the normal waist the most graceful, but also that properly
built corsets resting well upon the hips will display the normal waist to
the greatest advantage, and obviate the necessity for any injurious com-
pression.]

The Thyroid Gland and the Genital Organs. — An editorial in
"American Medicine"^ states that the peculiar relationship between the
thyroid gland and the female genital organs is a fact that has been fully
recognized. It is well known that any condition which will produce an
enlargement of the uterus will give a corresponding increase in the size
of the thyroid gland. During pregnancy the gland will become large,
soft, and pulsating, and may so impinge upon the trachea as to produce
a certain amount of dyspnea. After the termination of gestation it
diminishes in size to a certain extent, but seldom returns to its original
proportions. Valentine has noted that in 25 pregnancies in which the
usual hypertrophy of the thyroid did not occur, in 20 there was albu-
minuria. In cases in which large doses of thyroidin were administered
to pregnant women, in whom the physiologic enlargement of the gland
was present, a marked diminution of the gland resulted. Lange has also
given thyroidin to a patient in whom there was a pathologic enlargement
of the thyroid during pregnancy with a similar result. Another interesting
point in Lange's paper is that when iodothyrin was administered to
patients suffering from the nephritis of pregnancy, it was found to pro-
duce a distinct diuretic effect. Of other interesting communications
upon this subject, two are worthy of special mention : the first by Fisher,^
in which he calls attention to the influence of the genital apparatus upon
the healthy thyroid gland, as occurs at puberty, during menstruation,
the puerperium, lactation, sexual excitement, the menopause, and genital
disease. He emphasizes the influence which a removal of part of the
thyroid gland has upon the physiologic and pathologic condition of the
genital apparatus, and concludes: (1) That certain occurrences which
influence the genital apparatus, such as puberty, pregnancy, and uterine
fibroids, which produce a distinct change in the metabolism of the entire
organism, very frequently cause an enlargement of the thyroid gland.
(2) That the deficiency of normal thyroid secretion is often associated
with atrophic changes in the genital apparatus. The second report, by
Hestoghe,^ establishes the fact that women deprived of the thyroid gland

^ October 25, 1902, page 673.

^ Wien. med. Woch., Nov. 6 and 9, 1896. » Rev. Mdd., Jan., 1899.

PRELIMINARY AND GENERAL CONSIDERATIONS. 423

are subject to excessive menstrual discharge; as they grow older the
menses last longer, and finally become almost a constant flow. He also
noted that a hypertrophied thyroid is always accompanied by an early
and copious mammary secretion, and that thyroid extract is useful in
stimulating the secretion of lacteal fluid, and should be administered
when the secretion is diminishing. Hestoghe^ further believes that
thyroidin is indicated in cases of frequent abortion, in which the men-
strual flow is so excessive that it sweeps away the impregnated ovum;
he cites an instance of its advantage in steriUty, and recommends its use
in myoma, prolapsus, and uterine congestion.

The Rontgen Ray in Gynecology. — An editorial in "American
Medicine"^ says that the success attained by Finsen in the treatment of
the various dermatoses by concentrated chemical rays has impressed the
profession with the possibilities of the a;-ray as a therapeutic agent in the
treatment of maUgnant disease. The remarkable results attained at the
Finsen Institute at Copenhagen justify a favorable opinion of this method
of treatment. The action of the remedy is very slow in most instances
and its effect upon an internal growth uncertain. We certainly feel
that the field of experiment with this procedure should be confined to
recurrent or inoperable cases, and that the physician is not justified in
delaying operation upon a favorable case in order to test this method.
However, if the case is inoperable when it comes under the surgeon's
observation, or has recurred after skilful surgical intervention, then
experimentation is undoubtedly warranted. Although the rc-ray may
sometimes be of value to the gynecologist or obstetrician in diagnosis,
it is of far less use to either of these than to the general surgeon who
deals with the osseous system. The x-ray picture of the pelvis, according
to Delphey, is often indistinct and unsatisfactory, and would rarely
afford much assistance to the gynecologist who had already become ex-
pert in the palpation of this region. Better results were obtained above
the pelvic bones; for exarnple, in the study of the ureters and kidneys
and for the locahzation of calculi in those structures. It is possible that
the presence of bone in dermoid tumors or of calcareous plates in benign
growths might be demonstrated, but this is of minor importance, as the
mere presence of such neoplasms is an indication for their extirpation.
Cook considers that although the pelvis of the nonpregnant woman
could be studied by one skilled in the use of the a;-ray, yet many inac-
curacies arise from the distortion of the shadow; and the results cannot
be compared with the usual pelvic examination made by a skilled gynecol-
ogist. The maternal pelvis could be clearly seen after a pregnancy of
4^ months, but later than this the uterus and its contents formed a veil
on the negative. The position and presentation of the child may be
determined near the termination of gestation and the x-ray might prove
of possible value in cases of multiple pregnancy. As to the value of the
Rontgen ray as a therapeutic agent in gynecology, Cleaves has recently
reported a case in which the R5ntgen and ultra-violet rays were employed

' Rev. m6d. et chi. des Mai. des Femmes, Nov. 25 and Dec. 23, 1896.
^ December 6, 1902.

424

GYNECOLOGY.

in the treatment of uterine cancer with marked improvement, and Coe
has cited a case occurring in the services of Jarman in which a favorable
result was obtained in recurrent carcinoma of the cervix. The great
difficulty in the treatment of malignant disease of the uterus is the appli-
cation of the ray to the internal part, and there is probably a legitimate
field for invention in the construction of an instrument suited to this
purpose. Authorities differ as to the necessity of the direct local appli-
cation of the ray, and Cleaves believes that the tissues generally in the
pelvis should be brought under the influence of the x-ray. [To summarize
the present situation, we believe that this method should not supplant

early surgery in malignant dis-
ease, but should be used in re-
current cases; and we agree
with Coley that the greatest
future of this treatment seems
to be as a prophylactic agent,
to be used immediately after
every operation for primary car-
cinoma.] A. T. Orlof^ has ex-
perimented with electric light in
various gynecologic affections.
The "cold" white light was em-
ployed by means of a speciallj'
constructed apparatus. Incan-
descent lamps furnished the
hght, its intensity varying from
5 to 16 candle-power. Reserv-
ing details for a future report,
the author offers these conclu-
sions: Light-treatment is indi-
cated in a series of inflammatory
gynecologic conditions, as metri-
tis, parametritis, oophoritis, and
salpingitis, in the acute as well
as chronic stage; the chief action
of light-treatment is striking re-
lief of pain; exudates, serous and
purulent, decrease in size and occasionally disappear completely; dys-
menorrhea, retroflexion of the uterus, ovarian neuralgia, cervical erosions,
and uterine catarrh, especially the gonorrheal variety, are all benefited by
the method. On the other hand, light-treatment is contraindicated during
menstruation, uterine hemorrhages, and pregnancy. Untoward results,
such as general debility and paresthesias, are apt to follow the first 3 or 4
apphcations. Altogether, in spite of its favorable action, the method
needs further investigation. Curatulo^ (Rome) has devised a speculum
for the application of the electric light to the treatment of diseases of
women. The instrument consists of a double cylinder of glass, closed at
' Roussky Vratch, Jan. 4, 1903. ^ Brit. Med. Jour., Oct. 11, 1902.

Fig. 67. — 1, Horizontnl section of speciilmii : a, b,
Double tube of isoiuuiric glass; r, s, test tubes coiii-
iiiuiiicatiug with space x, Ibrougli wliieli cold water
tiows ; /, iiidia-iubber cork; d, tube for [)assage of
electric wires to iucaiulesceut lamp /; t, tlieriiioiueter
for taking teinperatuie of space m'. 2, Speculum
applied to cervix uteri (Curatulo, in 15rit. Med. Jour.,
Oct. 11, 1902).

PRELIMINARY AND GENERAL CONSIDERATIONS. 425

the upper end by a cupped, oblique and double septum, furnished with an
india-rubber cork, perforated to admit the tube of a suitable Finsen lamp,
and also a thermometer. He explains that by the circulation of cold
water through the space between the double walls light-effects could be
obtained without heat, and by filling the space with fluid containing alum,
copper sulfate, or cochineal, the action of the different sorts of rays could
be obtained; further, that by using a perforated speculum the light or
heat bath could be combined with a douche (Fig. 67).

"Facultative sterility" is the term used by Kock,^ of the Univer-
sity of Bonn, to designate a new procedure he has devised, and which he
recommends for use when it seems necessary to prevent the possibility
of conception for any length of time wdthout permanently depriving the
subject of procreative power. He forms two folds of mucous membrane,
one at the anterior and the other at the posterior lip of the external orifice
of the uterus. These act as valves, permitting the outflow of the men-
strual fluid and preventing the entrance of the spermatozoa. He uses
the word "facultative" because by the removal of the folds fertility may
be restored. [Since the days of Sims and his artificial impregnation no
procedure has been introduced to the profession which seems quite so
original and ingenious as this. It remains to be seen, however, how
effective these artificially produced valves will be against the sper-
matozoa, possessing as they do such remarkable motility. Should they
prove effective, the procedure will be of great value in the class of cases
in which tubal ligation or exsection has hitherto been practised, and par-
ticularly in married women suffering from diseases of the lungs, heart, or
kidneys, rendering pregnancy peculiarly perilous.]

The Relation of Gonorrhea to Sterility. — [There has occurred of
late a marked reaction in the accepted belief as to the etiologj^ of sterility
in women. It was formerly the rule to ascribe the larger percentage
of sterile marriages to anteflexion of the uterus with accompanying
cervical stenosis; to enforced sterility from the use of shields; to some
obscure change resulting from the higher education of women ; to syphil-
itic endometritis; and to some sexual incompatibility between the man and
the woman. There is not a shadow of a doubt that all these and other
factors not mentioned have a share in the production of sterility in some
of its forms. It is now very generally recognized, however, that, while
cherchez la femme is an excellent adage for one's guidance in many lines
of life, it should not overshadow exploration elsewhere on the question
of sterility. The extreme importance of gonorrhea in the male in the
production of sterility is universally admitted. A very perceptible per-
centage of unfruitful marriages, which are unjustly attributed to some
defect on the part of the woman, results from a double epididymitis
with hermetic closure of the tubes, or from an obscure affection of the
spermatic tubules resulting in the discharge of deformed or effete sper-
matozoa. In addition to this male sterility, the result of the action of
the gonococcus, the same germ, when introduced into the genital tract
of the woman, produces such radical changes in the mucous membranes

> Zent.'f. Gynak., No. 37, 1902.

28 S

426 GYNECOLOGY.

that sterility on the part of the woman is produced. The alkaline
leukorrhea that results is inimical to the vitality of the spermatozoids
should they be healthy. Again, if the fallopian tubes be involved in
the process, the cilii are quickly shed, and by their absence prevent the
ingress of the ovum into the uterine fundus. The activity of the patho-
genic process also produces such a tumefaction of the tubal walls that the
lumen of the tube is obliterated, and hermetic closure follows from ad-
hesive inflammation. Gonorrhea must, therefore, be regarded as a very
prolific cause of sterility in the woman and in the man.]

Operations upon the Appendages for Sterility. — [A laparotomy
is an operation which always carries with it considerable risk to life,
and the question in regard to the advisability of interference simply for
the restoration of this function will depend largely upon the urgency of
the desire or necessity for offspring, and must be settled according to the
exigencies of the individual case.] W. M. Polk^ reviews a number of in-
stances in which remarkable results have been obtained when previous
chronic inflammatory conditions have so changed the ovaries and tubes
as to make pregnancy impossible. The operation will undoubtedly be-
come more and more popular as the danger to life decreases. Simply
freeing the uterus and appendages when these are bound by adhesions
is sometimes sufficient to restore the function. When the ovary is dis-
eased, it should be our aim to leave as much as possible of the normal
organ, and it has been found that even a small portion may suffice. If
a hydrosalpinx, pyosalpinx, or hematosalpinx exists, it must neces-
sarily be removed, but the cut end may be left free or sutured to the ovary.
Everting the opened end and stitching the lining membrane to the outer
surface seems necessary when any part of the infundibulum is to remain
or when the fimbria have been destroyed. When the entire infundibulum
is removed, the pouting mucous membrane appears to be sufficient to
insure potency, but even if it should not be, the surface is too minute
to tolerate the added irritation of a suture. ,

Gonorrhea in Women. — Etesse,^ in a recently published thesis,
studies the effects of the infection of Skene's glands with the gonococcus
in causing chronicity of gonorrhea in the female patient. These glands,
which are regarded as homologs of the seminal vesicles, are found on each
side of and below the vulvar segment of the female urethra, their orifices
opening right and left, j-q to ^ of an inch inside the free border of the
meatus urinarius. They are almost as frequently infected with the
gonorrheal virus as the glands of Bartholin. The infection of these
glands may happen primarily, but generally it is caused by the gonor-
rheal discharge bathing the parts around the meatus urinarius in cases of
urethritis in the female. The disease is generally chronic, rarely acute,
and causes no subjective symptoms, so that the surgeon must seek for
it, as his attention will not be called to it by the patient. Once en-
sconced in Skene's glands, the gonococcus may cause repeated infections
of the patient's urethra, as well as proving the occasion of numerous
attacks of gonorrhea among her male visitors. In Etesse's opinion the
1 Med. Rec, Dec. 6. 1902. ^ Canad. Jour, of Med. and Surg., Sept., 1902.

PRELIMINARY AND GENERAL CONSIDERATIONS. 427

only efficacious treatment is destruction of the glands of Skene in the
patient by the use of the galvanocautery, as ordinary topical treatment
yields only uncertain results. P. Michin^ has made an exceedingly in-
teresting study of the presence of trimethylamin in the normal vaginal
secretion. This substance is universally found in the vaginal mucus,
though the quantity varies with the general nutrition and the local condi-
tions. It was found diminished in cases which had been operated upon at
the period of the climacteric, and also in emaciated patients. An acute
inflammation of the genital tract also diminished it. The tests were made
by taking one gram of dry cotton and passing it over the mucous mem-
brane. When it had taken up sufficient mucus, it was weighed, the
mucus was dissolved in distilled water, and the chemical test was applied
to the resulting opalescent fluid. The substance was found to have distinct
bactericidal power, it preventing or inhibiting the growth of the staph-
ylococci, typhoid bacillus, bacterium coH, and proteus vulgaris. In aU,
the writer has examined 154 cases in reference to the presence of this
substance in the vaginal mucus.

The Yeast-treatment of Gonorrhea in Women. — [A curious and
interesting revival in the arena of modern practical therapeutics of a
treatment practised by Hippocrates and Dioscorides is afforded by this
mode of therapy. Rediscovered by Landau in 1899, the method has
recently received at the hands of Otto Abraham^ a critical overhauling.]
He studied the subject, apparently with great care, from the chemical,
bacteriologic, and clinical standpoints, and it would seem as though the
yeast-treatment might not unUkely take a permanent place in thera-
peutics. Chemically, after numerous experiments, Abraham found the
most active form of yeast to be the living cells plus asparagin, Bac-
teriologically, too, he found that this combination exerted the maximum
effect in destroying gonococci in cultures of gonococcal vaginal mucus.
Clinically, 40 patients were examined who presented the following
conditions: Acute vulvitis, 9 times; urethritis, 3; bartholinitis, 3;
kolpitis, 10; erosions of the portio, 12; endometritis cervicis blenorrhoica,
34; and endometritis corporis blenorrhoica, 3. Vulvitis, kolpitis, and
erosions were the conditions most rapidly influenced; after one or two
days the pruritus and burning lessened, the flow became clearer and lost its
purulent character, and after a few days vanished. Even dollar-sized
erosions healed in 4 to 8 days on an average. Two cases of bartholinitis
required incision; the other subsided without it. Urethritis was en-
tirely uninfluenced. Of the 34 patients with endometritis cervicis, 30
were completely cured within 5 to 23 days. The flow shortly became
clearer and thinner; in the first days it increased in quantity, then rapidly
subsided. Of the 3 cases of endometritis corporis, one was entirely
cured, which shows the possibility of influencing the body of the uterus
from the vagina, at least \vith yeast, which may, so to speak, multiply
its Avay in. Of the 6 refractory cases of endometritis (cervicis 4, cor-
poris 2), 3 were afterward cured by the insertion of a "pencil," consisting

* Shumal akuscherstwa i shenskich bolsnei, 1902, Nos. 7 and 8.
' Monats. f. Geburts. u. Gynak., Dec, 1902

428 GYNECOLOGY.

of yeast, asparagin, and gelatin, into the cervical canal. In all the cases,
even those last mentioned, the treatment was effected without any un-
pleasant results or any untoward reaction; only 2 patients complaining
of sUght itching during the first days. The patients were examined for
gonococci before, during, and after treatment^ Of the 40, 28 showed
gonococci before treatment; after it the most careful search failed to
detect any. Other cocci and bacteria in the vaginal mucus, staining
with Gram's method, decreased in number and colorability. The gono-
coccicide action of the yeast is chemical, and due to an enzyme. The
yeast-cells do not live long in the vagina ; 3 days after the discontinuance
of treatment they could no longer be found. Whereas former observers
have used the yeast by injections of fluids containing it, Abraham in-
troduced a decided improvement by employing a suppository of yeast,
asparagin, and gelatin ; and in the case of cervix uteri, a '' pencil" of the
same ingredients, but of firmer consistence. A suppository is inserted
at night and the napkin put on, and in the morning the vagina is syringed
out.

AFFECTIONS OF THE VULVA, VAGINA, RECTUM, AND

BREAST.

Kraurosis Vulvae with Rodent Ulcer. — Kreis^ reports a case of
kraurosis vulvae complicated by "rodent ulcer," a combination which,
though rare, is too frequent to be merely coincident. A woman, aged
42, entered the hospital in June, 1901. She had been married since
1884, had had 4 children at term, the perineum being ruptured on each
occasion, and one abortion. Menstruation was regular. She had suffered
from pruritus vulvae for years. Four years before admission a wart was
excised from the left labium majus, but 2^ years later a fresh wart
appeared to the left of the clitoris; this had recently rapidly enlarged, and
caused pain and excoriation. An ulcer formed below the wart, and
steadily increased in size. The pruritus was also intensified. Nothing
abnormal could be found in any organ except the vulva, and the urine
contained neither sugar nor albumin. The external genitals were greatly
atrophied, and the pubic hairs were scanty. The clitoris had disappeared
entirely, except for a trace of the prepuce, and the nymphse were absent.
The whole introitus was greatly narrowed, and of a whitish color. The
skin was fissured, inelastic, and covered on the inner side with small,
shallow ulcers. The ulcer beneath the wart was of about the size of a
sixpenny piece; the surface was red and smooth, and the base indurated.
There was a hard gland of the size of an almond in the left groin, but
nothing could be felt in the right. The internal genitals were normal.
The ulcer with the wart and a portion of the altered kraurotic skin was
excised, after its malignant character had been determined micro-
scopically, and the wound was closed by catgut sutures. The enlarged
inguinal gland was also removed. Both wounds healed by first intention.
Microscopically the changes in the kraurotic skin consisted in consider-
1 Corr.-Bl. f. Schweiz. Aertze, Jan. 1, 1902.

AFFECTIONS OF VULVA, VAGINA, RECTUM, AND BREAST. 429

able narrowing of the epithelial layer, especially of the rete Malpighii,
with complete absence of sweat and sebaceous glands. Near the ulcer
the epidermis became thicker and was separated from the corium by
dense masses of round cells. The ulcer was composed of solid epithelial
processes which had invaded the corium. Mitosis was everywhere
marked. The most superficial layer of epithelium was absent. It was,
therefore, a typical cutaneous carcinoma or rodent ulcer. The structure
of the wart was that of a benign papilloma. The excised inguinal gland
contained one suspicious focus. On October 2 the woman was readmitted
with an inguinal gland of the size of a pigeon's egg on the right side, and
an excoriation on the skin just below the former position of the clitoris.
The gland and the suspicious skin were excised. The structure of the
former was typically carcinomatous, that of the latter typically krau-
rotic. The writer agrees with those who assvmie that in kraurosis the
stage of atrophy and contraction is preceded by hypertrophy and hyper-
plasia, and that the process is of an inflammatory nature. The frequent
history of long-continued pruritus makes a causal connection between
it and kraurosis probable. The patient in this case had constantly
washed the ulcer with a decoction of herba equiseti, and afterward with
a strong solution of alum, and the resulting irritation possibly produced
malignant degeneration of an originally simple ulcer. [The case shows
that, in kraurosis, fragments of suspicious ulcers should be removed for
microscopic examination, as malignancy cannot be determined early
clinically, and also that if malignant degeneration has occurred the in-
guinal glands should be dissected out on either side whether they are
palpable or not.]

Pruritus Vulvae and Allied Conditions. — [While this affection is
not, strictly speaking, a disease, but only a symptom of a disease, it is,
like diarrhea, a symptom of such overwhelming importance that it over-
shadows the original disease and becomes the point of attack.] E. H.
Balloch^ defines it as a hyperesthesia of the nerves of the vulva leading
to and accompanied by an intense itching. Beginning as a slight irri-
tation, it produces an irresistible desire to scratch the affected parts.
This procedure naturally leads to increased inflammation, making the
itching more intense than ever. Thus is established a vicious circle, the
final result in severe cases being that the very existence of the unfortu-
nate patient is rendered miserable and that life itself becomes a burden
to the worn and despondent woman. Fortunately the itching is not al-
ways so severe or constant. It may be interinittent, coming on when the
patient is overheated from any cause, or presenting itself, for instance,
at the menstrual period only. In some reported cases it was a symptom
accompanying pregnancy. A common type is a form which comes on
at night. This type was present in one of the author's patients and was
so severe that it interfered with sleep. The cases of pruritus may be
grouped under 3 general heads : (1) The contact of irritating discharges.
Among these may be mentioned as specially important, leukorrhea,
hydrorrhea, diabetes, dribbUng of the urine from any cause, urethritis,
> Am. Jour. Obstet., May, 1903.

430 GYNECOLOGY.

and the discharges from maUgnant disease of the uterus or neighboring
organs. (2) Local derangement of the vulva, such as vulvitis, aphthae,
vulvar eruptions, animal parasites, vegetations, urethral caruncle, and the
growth on the vulva of short bristly hairs. (3) General diseases of the
nervous system or those diseases leading to debility of the system. One
of the most interesting diseases of this region, in which pruritus is the
chief and initial symptom, is that known as kraurosis vulvip, first de-
scribed by Breisky. The alternation of atrophy and hypertrophy is
characteristic of the disease. No disease of the nerves has as yet been
discovered. There is a patchy hyaline degeneration of the tissues be-
neath the epidermis, especially in the elastic tissues. The treatment of
pruritus resolves itself into a search for its cause in the disease that it
accompanies and an effort to remedy it. The uterus should be examined
and any discharge, however slight it may be, should be remedied by
curettage or otherwise. The urine should, of course, be examined for
sugar, in view of the fact that many cases are associated with diabetes.
In this connection, attention should be paid to the bladder and urethra
and any dribbhng of the urine corrected. Any disease of the liver or
digestive apparatus should be regulated by dietary restrictions. As to
local treatment, suffice it to say that every powder, salve, or lotion that
has ever been suspected of having antipruritic properties has at one time
or other been used or suggested for this disease, with a result that our
pruritic patients still continue to scratch. The sviccess obtained in
kraurosis by excision has led the author to advise this procedure in cases
of simple pruritus, where, after a reasonable time, the application of
the usual remedies do not prove to be efficacious. According to B. C.
Hirst,^ the treatment of idiopathic pruritus vulvae is one of the
unsolved problems of gynecology. Hirst believes that surgical inter-
vention promises better results than any other line of treatment so far
suggested. It is too early, as yet, to decide as to the value of nerve-
resection. Apart from the question of the cure of the condition by nerve-
destruction, one must carefully weigh the possible consequences. There
is reason for believing that atrophic changes may take place and be fol-
lowed by kraurosis vulvae, and possibly also the operative inters^ention
may favor the development af epithelioma of the external genitals.
The author describes his method of exsecting the necessary nerves and
gives the report of one operation. Hirst concludes his paper with the
following queries: "(1) Which is the better of the two surgical treat-
ments of pruritus vulvae, exsection of the affected skin, or resection of
the sensory nerve-supply? (2) What is the best surgical technic for
isolating and resecting the sensory nerves supplying the vulva? (3)
What has been the permanent result of this operative procedure in the
experience of the members who have performed it or have had the
opportunity of watching cases afterward? ■(4) If a cure of pruritus can
be expected, is there a likelihood, or has any one clinical evidence to
present, of the development of kraurosis vulvae, and possibly of an
associated epithelioma? "

1 Amer. Med., May 16, 1903.

AFFECTIONS OF VULVA, VAGINA, RECTUM, AND BREAST. 431

Mycosis Vaginae. — A. J. Smith and O. H. Radkey^ report a case of
this rare disease. The condition may be found well outlined in the older
writings, being described as especially liable to occur in the course of
pregnancy, particularly in women having patulous vaginas, as being of
comparatively sudden oc-
currence, accompanied by
considerable pain, intense
burning and pruritus and
attended with an intensely
acid vaginal discharge, in
which more or less blood-
discoloration is apt to be
present. The appearance
of the vaginal wall is de-
scribed much as is detailed
in the present paper, the
aphthous patches being
sometimes of the ordinary
appearances of those in
thrush of the mouth, but
sometimes as grayish or

somewhat darker, slightly elevated points of a mucous or gelatinous
appearance, leaving a raw base on removal, with the intervening mucous

Fig. 68. — A group of vaginal epitlielial cell.*, overlaid by
mycelial threads and conidia of Oitliiim albicans (Smith and
Radkey, in Med. New.s, June 27, 1903).

Fig. 69. — Anderson's ca.se of congenital absence of the vagina. Lines of incision for making an arti-
ficial vagina (Pacific Med. Jour., Feb., 1903).

membrane sometimes normal and at other times red, angry, and swollen
(Fig. 68). It is best treated by vigorous applications of mercuric chlorid
solution.

' Med. News, June 27, 1903.

432

GYNECOLOGY.

Congenital Absence of the Vagina. — W. Anderson^ reports a case
of complete congenital absence of the vagina in a woman 20 years of
age (Plate 4). The vesical and rectal walls were separated by only ^
of an inch of tissue. On the right side near the brim of the pelvis was
found an oblong semisolid enlargement, evidently a partially developed
unicorn uterus. At the corresponding site on the left side no organ
could be found. Extending outward and upward to the right could be
felt a cord-like fallopian tube. Near the outer extremity was found
a small enlargement, evidently a rudimentary ovary. On the left side
a small cord-like fallopian tube could be determined with an ovary at-
tached. The operation for the restoration of the vagina was begun by
an incision through the labia minora, near the clitoris on each side.

Fig. 70. — Glass plug used in operation for
aitilicial vagina (Anderson, in I'acitio Med.
Jour., Feb., 1903).

Fig. 71.— Shows tlie artificial vagina carried
up to tlie sJTigle liorn of the Vartially developed
rigbl niiilleriau duct, whicLi was found to lie
impervious (Anderson, iii Pacitic Med. Jour.,
Feb., 1903).

This was extended down to a point below the insertion of the nympha
(2, 2, Fig. 69). The mucous membrane of the reduplication of each
labium minor was dissected up so as to form a long flap for transplanta-
tion into the sides of the artificial vagina. A cross-section (3, 3, Fig.
69) was made along the free margin of the fold of hymen attached
posteriorly, using the internal flap and the mucous membrane below
the meatus for the anterior wal(, and the outer half of the hymenial
fold with the membrane extending toward the rectum for the pos-
terior flap of the vagina. An incision was then made from the
' Pacific Med. Jour., Feb., 1903.

Plate 4.

AFFECTIONS OF VULVA, VAGINA, RECTU.M, AND BREAST. 433

insertion of one labium minor to the other midway between the
urethra and the rectum. A large male sound was held in the bladder
with, the convexity against the rectal w^all, and the finger of an assistant
was kept in the rectum against the sound in the bladder. The thin
septum between the bladder and the rectum was then separated by blunt
dissection until a canal was made measuring Sf inches in length by 1-^
inches in width. The mucous membrane obtained from extending the
folds of the labia minora was then sewed into the cavity as far up as it
would stretch on each side. The anterior and posterior flaps were then
united to the walls of the cavity thus formed The mucous membrane
reached to a depth of 3 inches. In the after-treatment a glass plug was
introduced having a diameter of 1^ inches and a length of 4 inches (Fig.
70). Douches of 1 : 5000 potassium permanganate were employed daily.
The artificial vagina was carried up to the single horn of the partially
developed right miillerian duct, which was found to be impervious
(Fig. 71). Anderson writes: "I examined the patient a few days
ago, — October 26, 1903, — over 9 months after the operation. The
artificial vagina was found to be in a healthy state. It measures a
little less than 3 inches and had a smaller diameter at the apex than at
the vulva, otherwise it was in perfect condition. The patient's general
health had improved materially. She had gained in weight and was very
happy to think that she had no apparent malformation and could get
married now. The mdimentary uterus and ovaries had not changed
to any appreciable extent. There had been no attempt to menstruate.
She had occasional headaches and 'flushes,' but she thought they were
decreasing in severity and frequency. She came to consult me about
getting married in about 2 months. I told her she could do so if she would
explain to her fianc6 what had been done and that she could never be-
come a mother. This she promised to do. I also cautioned her to be
careful about her marital relations for some time until her artificial vagina
became accustomed to its new functions."

Cystocele. — Barton Cooke Hirst^ has devised a new operation for
cystocele which will immediately appeal to the practical mind as a method
offering several advantages over the usual technic. He reminds us that
the injuries of the cervix, pelvic floor, and perineum, and the operations
which satisfactorily repair them, are quite w^ell known and definite, but
the same can scarcely be said of the anterior vaginal wall. There are
two kinds of injury infiicted in this region by the passage of the child's
head; first, the anterior wall, thrown into transverse rugae, is nipped
between the child's head and the symphysis, is pushed downward and
outward, and is torn loose from its subjacent connections in the manner
that a glacier pushes ahead of the moraine. Second, there is laceration
of the muscle of the urogenital trigonum in the anterior sulci, just as the
levator ani muscle is torn in the posterior sulci. Any one who thoroughly
studies Waldeyer's recent publication on pelvic anatomy must be con-
vinced that the strongest support of the anterior vaginal wall is the trans-
verse muscle running from the junction of the ischium and pubis, across
» New Orleans M. and S. Jour., Oct., 1902.

434 GYNECOLOGY.

the lower anterior portion of the pelvic cavity, and actually inserted in
the vaginal wall — the only muscle that is inserted in the vagina itself.
This muscle nms across the anterior sulci of the vagina, and is frequently
torn through in labor, usually on the left side. In over 20 cases Hirst
has performed the following operation: The anterior vaginal sulcus is
displayed by 3 bullet-forceps, making traction at 3 angles of the sulcus.
As the woman ^ies in the dorsal position, on the table, the sulcus is not
easily accessible and cannot conveniently be denuded, as it hes hidden
within the vagina; but by fixing one bullet-forceps alongside the orifice
of the urethra, the other one in the opposite vaginal wall, and the third
half-way up the vaginal wall at the apex of the sulcus, the triangular
area involved in the injury comes plainly to view, The triangle is marked
out with a knife, and the mucous membrane is readily dissected off by
scissors in one piece, which takes but a minute or two. The other side is
treated in a similar manner. Usually the tear is deeper on the left side
and may be confined to that side. The sulcus being denuded, the sutures
of silkworm-gut are inserted just as they are in the posterior sulci in an
Emmet operation. They are not yet united, but clipped temporarily
with hemostats. The cervix is pulled out of the vulva and the rest of
the operation is performed in the usual manner for cystocele, with an
oval denudation and the buried continuous tier suture of catgut. After
the closure of the oval denudation the sulci sutures are united with shot.
Hirst calls attention to the importance of repairing the posterior wall, with-
out which any anterior operation is doubtful. It will take some years to
determine the real effects of the operation, but he has reason to hope
that some such operation as this will solve the problem of repair of the
injuries to the anterior vaginal wall as satisfactorily as that problem has
been solved in injuries of the cervix and of the posterior vaginal wall
and pelvic floor.

The Glands in Cancer of the Breast. — Ozenne^ was able to keep
23 cases of cancer of the breast under observation from 2 to 5 years. In
1 1 cases the breast alone was removed, as the glands showed no evidence
of being involved. In one instance, in which the patient Hved for 10
years after operation, an enormous enlargement of one of the retropectoral
glands was not disturbed, as it was regarded as purely inflammatory —
in fact, it disappeared spontaneously. Twelve patients from whom the
axillary glands were removed at the same time with the breast had a
recurrence within a year after operation. The writer refrained from
removing the axillary glands in 9 subsequent cases, with the result that
2 patients are now aHve 4 years after operation, and 5 lived from 2 to 3^
years. The writer infers that the results after these partial operations
are quite as satisfactory as after the radical ones. While the principle
of complete extirpation is theoretically ideal, he does not think that the
results have shown that the hopes of a permanent cure have been realized.
He is even incHned to beheve that the extensive removal of glands may
favor the spread of the disease to distant parts of the body.
1 Rev. prat. Obst^t. et de Gynec, 1901, No. 11.

PERINEORRHAPHY.

435

PERINEORRHAPHY.

The Pelvic Floor. — [An accurate knowledge of the structures com-
prising the pelvic floor is most essential in order that a perfect repair of
the lacerated structure may be made.] J. H. Burtenshaw^ gives a concise
anatomic description as follows: Remove the skin, fascia, and certain
muscular structures over the area bounded by the pubes, the ischial rami,
and the coccjrx, and a portion of the levator ani will be exposed to view,
a more or less apron-like muscle when seen from this position, which en-
circles the urethral, vaginal, and rectal orifices. This is shown in Fig. 72,
the superficial layer of the triangular Hgament (see Fig. 74) having been
removed. The levator ani on each side is attached to the horizontal

Fig. 72. — Tlie levator ani muscle, covered l>v lis fa.soia, as .seen from Ixjlow (Weis.se) ( Biirtetisliaw, in
N. Y. iMell. Jour., Jan. 10, 1903).

ramus of the os pubis, to the inner side of the spine of the ischium, and
the fascia extending between those points (Fig. 73). The insertions of
the muscle are many. "Stretching down and back, the fibers divide
into unequal portions, of which one passes to the anterior aspect of the
rectum, another to its posterior and lateral surfaces, while the fibers
attached to the pubic bone extend along the vagina, with which they are
united by strong connective tissue, but do not terminate ^vithin its walls.
The belly of the muscle sweeps backward, almost horizontally, surround-
ing the rectum" (Piersol). In Fig. 73 these points of attachment are
particularly well shown. It would seem that this dissection should con-
vince those who are averse to attributing sustaining function to the pelvic
floor that every anatomic detail of the parts tends to uphold the theory.

1 N. Y. Med. Jour., Jan. 10, 1903.

436 GYNECOLOGY.

Of very great importance is the fascia which covers the several portions
of the levator and enters largely into the structure of the pelvic floor.
Without entering into details, it may be said that the posterior or outer
aspect of the muscle is covered, from the rami of the pubes to the ischia
and coccyx, by a dense fascia, the levator, which, a short distance above
the external and sphincter, unites with the deep layer of the triangular
ligament (Figs, 72 and 74). The rectovescial fascia (Fig. 74) Burtenshaw
considers the most important fascia of the pelvis, as it undoubtedly is
the prime factor in enabling the pelvic floor to mthstand intraabdominal
pressure at the pelvic outlet. It has its origin from the parietal or main
layer of the pelvic fascia along the so-called "white line," which extends
from the lower part of the posterior surface of the symphysis to the spine
of the ischium, and covers the inner or upper surface of the levator ani
as far as the rectum, where it divides into 4 layers — the vesical, the
vesicovaginal, the rectovaginal, and the rectal. Of these, the recto vagi-

Fig. 73. — The attachments of the levator ani muscle to the pelvis, showing the role of this muscle in
supporting the pelvic viscera (Dickinson) (Burtenshaw, in N. Y. Med. Jour., Jan. 10, 1903).

nal covers the fibers of the levator which pass between the vagina and
lower part of the rectum, while the rectal layer extends behind the rectum
and is attached to its walls.

In performing perineorrhaphy, A. B. Tucker^ suggests passing the
sutures through the mucous membrane of the vagina out to, but not
through the skin, so as to get the greatest point of resistance
within the vagina, and thus restore to its normal place the al-
ready protruding perineal floor. Starting at the caruncle on the left
side, the mucous membrane is split with blunt scissors from the
skin at their junction, and this flap is dissected with the point of
the scissors closed until it is possible to grasp it with a pair of artery-
forceps midway between the two caruncles. The scissors are then pushed
up to the highest point of the rectocele, and opened to the full extent.
The dissection is then completed from without inward with the finger,
holding the flap between the forefinger and the thumb. The flap is next
1 Virginia Med. Semi-Monthly, Dec. 26, 1902.

PERINEORRHAPHY.

437

cut out from the caruncles, completely removing it. This leaves a some-
what triangular denuded surface, the base of which is formed by the
slcin from caruncle to caruncle and the apex, the highest point of the rec-
tocele, with a sulcus midway between the caruncle and apex. A Hage-
dom needle, threaded with silkworm-gut, is passed through the vaginal
mucous membrane midway between the sulcus and the apex on the left
side, and as soon as the needle is through the mucous membrane it is
passed well beneath the mucous membrane outward and downward
around the sulcus, then downward and outward through the denuded
tissue and down through the sphincter muscle. The needle is then

Fig. 74. — Mesial section sliowiiig tlie levator aiii nuisole and it.s enveloping fascia (Dickinson)
(Burtenshaw, in N. Y. Med. Jour., Jan. 10, 1903).

turned upward and inward, and is brought out in the median line
through the denuded tissue. The suture is pulled well through and,
catching the distal end of the suture with a pair of artery-forceps to
prevent its being drawn entirely through, the needle is passed in at
the point of exit and is carried well outward and downward, and then
upward, and is brought out through the mucous membrane at a point
corresponding to its entrance on the other side. The second and last
deep suture is carried through the mucous membrane midway between
the other suture and the apex and carried downward and inward until
it comes out in the median line, ^ of an inch above the skin. The needle

438 GYNECOLOGY.

is then introduced at the point of exit until it comes upward and outward
at a point corresponding to its entrance. On drawing these sutures
together the tissues are brought inward and toward each other in the
median Hne. With a cervix-needle and catgut a superficial continuous
suture down to the second suture is introduced near to the apex, and
tied, and then a superficial line of sutures is carried on until all of the
edges of the mucous membrane are brought together and all denuded
surfaces covered. After the operation the patient is allowed to urinate
^\'ithout catheterization, if possible, and the bowels are moved after the
first twenty-four hours. The stitches are removed at the end of a week
and the patient is then allowed to sit up.

CONDITIONS OF THE CERVIX UTERI.

Laceration of the Uterine Cervix. — Bushong^ thinks that a large
proportion of uterine lacerations can be cured without operation, and
continued experience has led him to advise operation in a smaller percent-
age of cases each year. The great advantage of cure by local treatment
is that the cervix has absolutely no cicatricial tissue left in it. In all but
recent lacerations an area of hard cicatricial tissue is found under and

Fig. 75. — Ramsay's uterine dilator. >

around the torn surfaces, which acts as a foreign body and causes dis-
tressing symptoms. The complete removal of this tissue is the key to
successful treatment. Several drugs possess the power of promoting the
absorption and removal of this hard structure, but Bushong has found
Monsel's solution the best. After all discharges have been removed and
the vagina thoroughly cleansed, Monsel's solution is liberally applied to
the cervix and vault of the vagina, the part over the scars being flooded
with it and a tampon introduced to prevent the escape of the medicine.
The tampon should be ^^ithdrawn on the evening after treatment. The
apphcation may be made about every 5 days, and meanwhile there should
be copious douches of wann or hot water, and a free bowel-movement
daily. If there is an erosion of the cervix, the best remedy is a com-
bination of pure tincture of iodin and beechwood creasote. Bathe the
surface in this before using Monsel's solution. When there is no cica-
tricial tissue, the iron is omitted.

A New Form of Dilator for the Cervix Uteri. — The illustration
(Fig. 75) shows a new form of uterine dilator, which has been made at
the suggestion of F. Winson Ramsay,^ of Bournemouth, and for which
the following advantages are claimed: (1) Being an open tube, no pres-
sure is exerted in front of the dilator, and therefore any blood or dis-
charge flows down the tube instead of being forced onward and into the

* Med. News, Nov. 15, 1902. => Quarterly Med. Jour., Nov., 1902.

UTERINE ANOMALIES OF DEVELOPMENT. 439

fallopian tubes (probably the commonest cause of trouble after^curet-
age) ; (2) the measurements on the dilator (a grooved ring at the normal
uterine length and a boss at one inch distance), both of which can be
felt with the finger, enable the operator to always know how far the in-
strument is inserted, while the length of the uterus having been measured
by the first size, he knows how far he can insert the dilator with saf et}^ ;
(3) the shape of the handle, which fits comfortably into the palm, and
is steadied and rotation prevented by the pressure of the middle finger
on the depression below the handle; (4) the dilators are made in 16 sizes,
f to |-f, representing millimeters in diameter. A series of 8 alternate
sizes forms a useful set for general use; the sizes are marked in large
numerals on the upper surface of the handles, making selection easy.

UTERINE ANOMALIES OF DEVELOPMENT.

Congenital Absence of the Uterus. — W. A. N. Borland^ reports
4 cases of congenital absence of the womb and remarks that the
etiology of such conditions must necessarily be more or less ob-
scure. It is generally admitted as beyond controversy that both
the uterus and fallopian tubes are derived from the embryonic
mijllerian ducts, WiUiams states that "according to His, the first
signs of their development can be noted in embryos having a body-
length of from 7 to 7.5 mm., when a thickening may be noticed
in the celomic epithelium on the outer margin of each wolffian body.
These gradually become converted into two epitheUal ducts, which con-
verge and eventually meet together in the middle line, terminating in
the urogenital sinus. The miillerian ducts reach the urogenital sinus in
embryos having a body-length of 2.5 to 3.5 cm. Their upper ends form
the fallopian tubes, while their lower portions fuse together to form the
uterus and vagina. The fusion of the miillerian ducts is usually com-
pleted at about the third month, though the point at which the process
is to occur is indicated at a much earlier period by the position of the
round ligament." It is plainly to be seen, then, that owing to their
distinct origin ovaries may be present in the absence of the uterus and
vagina, and patients suffering from this curious defect may present all
the menstrual molimina, including ovarian dysmenorrhea, backache, and
general malaise, as well as possess a certain amount of the genital sense.
Nothing definite is known as to what factors are at work in the early
weeks of gestation to prevent the development of these ducts and their
ultimate fusion. An interesting theory has been recently advanced
by Ballantyne, who would claim that all congenital anomalies, such as
absence or rudimentary development of organs, or double formations,
all of which are arrestments of normal embryologic processes or disturb-
ances of embryogenesis, are brought about by the action of traumatism,
microbes, or toxins upon the embryo in utero. While this has not been
absolutely demonstrated, it is a very plausible theory, and one which may
be accepted until controverted or supplanted by a better. Be this as it

^ Am. Gynec, April, 1903.

440 GYNECOLOGY.

may, it remains true that the variety of the congenital defect will
depend upon the time in embryogenesis at which the disturbing factor
becomes operative. Most commonly, judging from the comparative fre-
quency of the varieties, this occurs late in embryonic life, after the ducts
of Miiller have attained their full maturity, but prior to the time at which
they have fully coalesced to form the generative organs. The various
forms of double uteri and vagina are thus evolved. If, however, the
arrest of development occur prior to the formation of the uterus by fusion
of these ducts, or prior to the development of the ducts of Miiller them-
selves, either one or both of these structures fail to appear; in the former
instance there results a uterus unicornis, or one formed by but a single
miillerian duct; in the latter case no trace of the uterus can be detected
on manipulation, even when the patient is completely relaxed under the
influence of an anesthetic. If, however, the pelvic cavities of such in-
dividuals could be examined carefully after death, it is not improba1)le
that in almost all, if not in every case, some trace of the missing struc-
tures could be detected, microscopically if not macroscopically, in the
form of fragments of rudimentary muscular tissue.

FISTULAS.

Apparatus for Urinary Fistula. — No matter what the type of false
passage may be through which urine reaches the surface, the patient
is in a pitiable condition. A. Holowko^ presented the following notes on
a simple means of receiving and disposing of the urine in cases of urinary
fistula. He stated that such patients presented themselves frequently
at a hospital in such a condition that an immediate operation could' not
be undertaken. Such conditions are classed by Fritsch, in Veit's
" Handbuch der Gynakologie," under the follomng : Pus-processes
of any kind about the genital apparatus, ordinary uncleanliness, boils
and pustules, and any other condition involving uncleanliness. All
such patients must first be freed from all possible contamination,
and as a rule many of them require to be "fed up/' so that they will
endure the operation without too much shock. One obstacle against the
successful accomplishment of these necessary aims is that many of these
patients cannot be kept in the ordinary hospital the necessary length of
time, both from the standpoint of the institution and themselves. Often-
times, with the greatest endeavor at cleanliness, baths, and various rub-
ber machines for receiving the urine, the urine changes sufficiently in
the air to render the patient and his surroundings very uncomfortable.
In order to correct the evils of this situation, to receive the urine safely
and carry it off, he feels that he has devised a simple means, consisting
of the following: An ordinary air-cushion is provided with a rubber
bottom stretching across the ordinary open space, and in the middle
of this a large rubber tube is attached. In order to make this device
durable he has caused it to be made of strong fabric, because pure rubber
is ordinarily not suitable for it. This air-cushion is then laid on the
' Z'blatt. f. Gynak., 1902, No. 30.

FISTULAS. 441

mattress, and the tube attached to it is passed through a hole in the
mattress and then into a bottle, which contains the usual antiseptic
fluid, preferably some solution of formahn. The one disadvantage of
this apparatus is that the floor of the cushion often becomes irregular
and kinked, especially around the tube, so that the urine instead of
flowing off collects in it. To avoid this he has placed a metal connec-
tion-tube, incorporated in the floor of the cushion, to which the rubber
tube is attached in such a manner as to prevent these difficulties. He
has used this device in his private hospital and finds that the major-
ity of patients are more satisfied with it than with any other means.
As a rule they remain quite dry, and the mucous membrane of the genital
organs, which usually is so much diseased by the' fistula, is given an op-
portunity to heal so that the operation can be done under the most
favorable circumstances.

Vesicovaginal Fistula. — Drew^ devised an ingenious method for
closing a vesicovaginal fistula, ^ inch in diameter, due to the ulceration
caused by a Zwanck pessary, and situated at the junction of the cervix
with the anterior vaginal wall. An incision was made in the median
line of the anterior vaginal wall from close to the urethral orifice to the
margin of the fistulous opening; this incision was prolonged around the
margin of the fistula. The vagina was then carefully separated from
the bladder, and the two flaps thus made were drawn aside. A U-shaped
flap of mucous membrane was dissected from the anterior lip of the cer-
vix and accurately sutured, by Lembert's method, to the margins of
the fistula. The vaginal flaps were united in the middle line and their
upper margins sutured to the raw surface on the cervix. The fistula
was permanently closed, and the vaginal wound healed weU. McCann^
says that in closing an opening in any hollow viscus two important
surgical principles must be borne in mind: to avoid all tension on the
stitches ; and to avoid passing the suture-material through the inner fining
of the viscus. Hence in operating for vesicovaginal fistula the principle
to be adopted should be a free separation of the bladder from the uterus
and vaginal wall in order to remove all tension, and separate suturing of
the opening in the bladder with Lembert's sutures. The bladder-sutures
are inserted transversely while the vaginal walls are stitched in a longi-
tudinal direction. McCann has abandoned silk sutures for this operation
and prefers properly sterilized chromicized catgut. He does not use a self-
retaining catheter which may produce cystitis, but prefers using a cath-
eter at regular intervals imtil the patient can pass the urine naturally.
He has adopted this method of free separation of the bladder in the
treatment of ureterovaginal fistula, thus bringing the separated bladder
toward the fixed end of the ureter, and implanting the latter into a new
opening made in the bladder.

1 Brit. Med. Jour., 1902, No. 2159. ^ Brit. Med. Jour., May 17, 1902.

29 S

442 GYNECOLOGY.

THE URINARY ORGANS.

The Pathology of Skene's Glands. — [In 1880 Skene contributed
a paper on the anatomy and pathology of two important glands of the
female urethra. It will be remembered that the mucous membrane of the
female urethra, when not distended, forms longitudinal folds. It has
many depressions and blind canals, and near its floor, just inside the
meatus, are found the two urethral ducts described by Skene. They
admit a No. 1 probe-of the French scale and extend upward, parallel to the
long axis of the urethra, for f to f of an inch in the muscular tissue be-
neath the mucous membrane. The mouths of these tubules are found
about ^ inch from the meatus, and, if the mucous membrane is everted,
these openings are exposed to view on either side of the entrance to the
urethra.] Kelly, ^ in an address before the Philadelphia Obstetrical
Society, December 4, 1902, discussed the functions and pathology of
these glands. He believes that their function is to moisten the urethral
labia, particularly during coitus, during the violent displacement of the
labia up into the vagina, when they need constant lubrication to
obviate the injurious effects of attrition; in this way they occupy a
position relative to the urethral orifice corresponding to Bartholin's
glands in their relation to the vaginal orifice. Their affections are
catarrhal or gonorrheal. They may be treated by injection, incision, or
excision. In order to inject them, Kelly showed a little syringe, which
fully meets all the requirements, consisting of a delicate, blunt-pointed
cannula about 5 cm. long and 1 mm. in diameter ; a piece of simple rubber
tubing drawn over the end of the larger cannula after closing the open
end then made an excellent syringe, serving by the elasticity of the walls
of the tubing to draw a few drops of fluid up the cannula. With a simple
syringe of this sort the amount of fluid injected was fully under control.
After citing a number of cases treated by injection and by excision,
Kelly referred to an interesting case in the hands of Hunner, his associate,
in which smegma bacilli were found in the abundant secretion from one
of these glands, showing how readily a tuberculosis of the urinary tract
might have been inferred even though the vulva had been cleansed
before the patient passed her water. If more careful attention was paid
to these tiny structures, many cases of persistent urethritis or dysuria
which have resisted treatment could be relieved.

Plastic Surgery of the Female Urethra. — [Many methods of con-
structing this membranous canal have been tried, some of them with
marked success ; but the literature shows that the same method can rarely
be applied twice, since each of the accidents happens in its own way,
and calls for a new and specially devised operation.] H. P. Newman^
gives the details of a case, the patient being now under treatment at the
Marion Sims Hospital, the progress of which, though satisfactory, has
been tedious, and the patient has not entirely recovered. Cose: Mrs.
S. W., aged 39 years, has been married 3 years. There is a generally

' Amer. Med., Sept. 12 and 19, 1903. ^ ^^^^ Jq^j.^ Obstet., Oct., 1902.

Plate 5.

•i Hi III ■ w ® ^^ ^ ^_4' _^,

•* **>-.-- . .

#«

%-i8 f«. '^'\ ^

1^ •«=■

v6#

Z... ...-^'-^^^^^ t\i t;^'- ^jPorf,s,M

■i&

Primary carcinoma of the female urethra (Viueberg, in Am. Jour. Med. Sci., July, 1902).

THE URINARY ORGANS. 443

contracted pelvis with an ankylosed hip, resulting from a severe attack
of Pott's disease in early childhood. She has had one full-term' clijld
which was extracted forcibly through the narrow pelvis while the
bladder was distended with urine. The floor of the bladder was torn
and the urethra was laid open along its entire length. Six weeks later,
the patient still being in bed, an attempt was made to repair the tear.
This was repeated twice in the following year. Three months later the
patient came to Newman with a complete exstrophy of the bladder.
The following operation was performed : flaps were taken from the vulva
on either side, and after splitting the bladder and the vaginal wall, a con-
siderable closure was accomplished by means of silver wire sutures, a
drain or retention-catheter being inserted in an opening behind the line
of sutures and the patient being kept in an exaggerated dorsal position
until the wound healed. One month later a second operation was done,
still more of the bladder being closed. This operation permits the patient
to retain her urine for a couple of hours. Unfortunately she left the hos-
pital while Newman was away from the city, and so the operation has
never been finished. Newman advises that the uterine appendages be re-
moved from the uterus, and the uterus turned on itself and then the torn
bladder be so sewn about it that the uterus with its canal serve as a new
urethra. He has not tried this procedure, but believes that it would be
most successful and efficacious.

Primary Cancer of the Female Urethra. — Vineberg* operated for
this disease on a woman of 36. Her youngest child was 9 years old. She
had been subject to frequent micturition for many years. For the last 6
months she felt a burning sensation in the urethra. There was smarting
when passing urine, but no discharge or bleeding. The meatus and adja-
cent part of the vulva were free from disease. This is rare, and was
noted in only 7 out of 27 cases of primary cancer of the female urethra
collected by Ehrendorfer. A firm growth could be seen just within the
urethral orifice. It completely surrounded the lower two-thirds of the
urethral canal, and the morbid deposit was thickest posteriorly; alto-
gether the mass was as big as a small thumb. The cystoscope showed that
the bladder and its sphincter were healthy; the adjacent vaginal mucous
membrane was free. The whole urethra was excised, the sphincter of
the bladder was damaged during the operation and repaired, but per-
manent incontinence of urine ensued and a plastic operation proved
unsuccessful. Five months after the removal of the urethra the patient
was in good health and free from any sign of recurrence. The micro-
scopic appearance of the growth is shown in the accompanying illustra-
tions (Plate 5). Vineberg adds 7 to Ehrendorfer's 27 cases of cancer of
the urethra; among the 7 are Campbell Kynoch's^ and 5 others, all pub-
lished since January, 1900, the sixth being McGill's.^

Direct Examination of the Female Bladder.— [Cystoscopy, as orig-
inally practised, is not free from many inconveniences. It necessitates,
in brief, a preliminary injection into the bladder of a set quantity of

» Am. Jour. Med. Sci., July, 1902. ^ Brit. Med. Jour., vol. i, 1901, p. 1208.

3 Lancet, vol. ii, 1890, p. 966.

444 GYNECOLOGY.

fluid ; but this fluid may in part escape, while that which remains behind
perhaps becomes stained with blood. The renewal of this fluid from time
to time is also necessary, interrupting exploration. Moreover, the cysto-
scope itself does not furnish a direct image of the surface of the bladder.]
On account of these obstacles and others which are well known, T. De-
Hott^ had advised the following means for inspecting the bladder directly.
The patient lies upon an inclined plane, at 45°, and the surgeon introduces
into the bladder two curved retractors, about 6 cm. long and 1 cm. wide,
which results in the entrance of a certain amount of air into the bladder,
with a consequent dilation. In the concavity of one of these retractors
or valves a small incandescent electric lamp is fixed in such a manner as
to permit the interior of the bladder to be well seen, and also, if necessary-,
catheterization of the ureters to be carried out. General anesthesia,
without being necessary, is useful for rendering this examination easy
and complete. This method of inspecting the bladder must necessarily
be carried out with careful antiseptic precautions. He claims that this
procedure has the advantage of being very useful and convenient. The
amount of dilation of the urethra is not enough to cause incontinence of
urine. J. C. Webster^ states that in Kelly's method of examining the
bladder the genupectoral position is assumed, or. pillows are placed under
the hips of the patient while she is upon her back. Both of these methods
have certain disadvantages. The elevation of the hips by pads frequently
flexes the abdomen on itself, so that the ascent of the intestines toward
the diaphragm is prevented and the ballooning of the bladder does not
take place. The genupectoral position is favorable to the bladder-
distention, but is unpleasant to the patient unless an anesthetic is used.
While the patient is unconscious the procedure is awkwardly carried out.
During the past 3 years Webster has employed a method which is free
from these objections. The patient is placed on a Boldt operating-table
in the lithotomy position, the ankles being fastened to upright rods, the
buttocks projecting slightly over the end of the table and resting on a
rubber pad ; there is a steel bar with two padded supports for the shoulders.
After the patient is prepared the urethra is dilated and a speculum with
an obturator is introduced into the urethra; the top of the table is turned
on its transverse axis, elevating the lower end. The patient then rests
on an inclined plane, being held by the shoulder supports, the trunk being
flat upon the table. An elevation of about 23 inches will fully distend
the bladder when the obturator is removed from the speculum. The
posture has all the advantages of the genupectoral position and none of
its disadvantages. In the examination of the rectum the position is
highly satisfactory, air-distention being obtained in the majority of
cases. T. S. Cullen* has devised a new cystoscope (Fig. 76). In shape
it resembles a short male cystoscope. Its connections are all covered,
at no point being exposed. The electric lamp is relatively large in size,
thus giving good illumination and diminishing the possibility of burning
out. The instrument is readily controlled vdth a long handle. The

» Sem. med., Sept. 24, 1902. ^ Jour. Am. Med. Assoc, No. 20, May 17, 1902.

^ Johns Hopkins Hosp. Bull., June, 1903.

THE URINARY ORGANS.

445

lumen of the tube is perfectly straight. The controller represented in
Fig. 77 has recently been made and is an admirable addition to our cysto-
scopic armamentarium. It does away entirely with the necessity of the
battery and can be used wherever the electric current has been installed.
The instrument is so small that it can be readily carried in one's pocket.

Fig. 76. — Longiliidinal section of tlie Cullen simple electric female cystoscope. With t lie obturator
ill place the sharp angle near the tip of the in.strunient is c()ni|)lelely lemoved. The lamp is large and i.s
easily withdrawn from tlie tip of the instrument. There are no wires to get out of order. The electric
iittachmeiit is indicated and may l)e made hy an interlocking device if so desired. The wire»- a and 6,
if so desired, can he covered by rublier tubing, allowing of their sterilization. A\ Fig. 77 in a and ft the
other ends of the electric wires which are usuallv 6 to 8 feet long are shown (Culleu, in .lohns Hojikins
Hos|). Bull., June, 1903).

It is to be inserted between the socket and the globe of any electric fix-
ture. To it the cystoscopic wires are then attached, and we can by the
small wheel regulate absolutely the amount of current desired. He has
been using the same cystoscopic lamps for several months without the
slightest difficulty. If by any chance the lamp should give out, the cysto-

Fig. 77. — The new transformer in position. It is inserted between tlie ping and the ordinary
electric bulb. The current is turned on as usual. With the small wheel at "otF" the cystoscope receives
no light. When at "on" there is abundant light for the strongest cystoscope. With the wheel in its
present position there is sufficient light for the cystoscope (Cullen, in .Johns Hopkins Hosp. ]5ull., June,
1903).

scope need not be withdrawn, but can be utilized as a Kelly cystoscope,
the head-mirror and reflected light being used. The instrument is
handled as follows: Both obturator and cystoscope are placed in pure
carbolic acid for 10 minutes, then rinsed in alcohol, then in sterile water.
A small transformer is now inserted between the ordinary electric globe

446 GYNECOLOGY.

and its socket. The cystoscopic wires are attached to the transformer,
care being taken to note that the small wheel indicates the current "off."
The cystoscope is now connected and the wheel gradually turned until
the necessary light is obtained. It is unnecessary to darken the room.
After cleansing the urethral area with mercuric chlorid solution the ureter
and bladder are rendered insensitive by weak solutions of cocain.

The Bladder after Hysterectomy. — The intimate connection be-
tween the bladder and the uterus makes it easily understood that the
bladder is greatly influenced in its circulation and function by all opera-
tions which serv^e to modify the topography of both of these organs. To
begin with the simplest operation, the Alexander, says G. Kolisher/
neither bimanual examination nor cystoscopic examination, performed in
different stages of dilation of the bladder, reveals abnormal conditions.
Abdominal hysteropexy, ventrosuspension, and ventrofixation in some
cases, seem to have a decided influence on the circulation and function of
the bladder. The cystoscopic examination in such cases reveals an ex-
treme paleness of the mucosa; in some instances examined the epithelium
seemed to be swollen and soaked. If we accept the theory that the desire
for urinating is brought on by the stretching of the muscular coat of the
bladder, it is easy to understand that the hanging of the uterus high up
will lead to more frequent calls to urinate. In the case of a virgin oper-
ated upon by hysteropexy, in which the uterus was hung rather high, a
few days following the operation the urine became cloudy and micturition
so frequent that the night's rest was disturbed. This condition has con-
tinued with some diminution for 2 years. Two cases of gonococcic in-
fection of the bladder were much worse following the same operation,
and have resisted all therapeutic efforts to stop the trouble. If the
bladder be properly stripped from the uterus, the bladder will remain
intact. The dislocation of the bladder itself does not interfere with its
function, if no special complications arise. Quite interesting and pecu-
liar conditions arise if vaginal fixation is performed on account of pro-
lapse and cystocele. In Kohsher's 3 patients, all of whom had had
chronic retention within the cystocele, the bladder is spontaneously and
completely emptied at each micturition since the operation. If the uterus
is stitched too low down to the vagina, it pulls the vaginal wall and con-
sequently the posterior wall of the urethra in such a direction as to dis-
tend the urethra posteriorly. This portion of the urethra is now the main-
stay of the continence, and, if weakened, the continence will be impaired.
Prompt and definite relief was furnished by the introduction of a pessary.

Suprapubic Cystopexy. — H. A. Slocum^ has devised an excellent
operation for the relief of cystocele and vesical prolapse (see Figs. 78, 79).
The technic is as follows: The intestines and omentum were walled off
with a gauze pad and the pelvis inspected. The uterus lay retroverted
upon the pelvic floor, the fundus being of normal size. The broad liga-
ments and oviducts were unusually long. The bladder was far below its
usual position, the whole organ being apparently below the level of the
urethra. The bladder symptoms had been severe and it was necessary

1 Am. Jour. Obstet., Dec, 1902. ^ ^j^ j^^j. ^f g^j-g g^nd Gyn., Aug., 1903.

THE URINARY ORGANS.

447

to do what could be done to relieve the condition. Holding the fundus
with two fingers and thumb, it was lifted to the position it would'occupy
when the fundal sutures were tied, and the parts inspected. Owing to the
stretching the tissues had undergone, this maneuver had no effect upon the
bladder, which still lay deeply in the pelvis. Traction was then made upon

Fig. 78. — Slociim's caao. Condition on adniisslon
(Am. Jour, of Surg, and Gyn., Aug., 1903).

Fig. 79. — Slociim's case. Condition after tubes
and ovaries were removed (Am. Jour, of Surg,
and Gyn., Aug., 1903).

'sutii-redL to
a.bd.-u)a.lL.

the peritoneal lining of the anterior abdominal wall. This was successful,
and brought the bladder up to its normal position behind the symphysis,
where it was kept in place by a running catgut ligature for 2 inches, 1
inch on either side of the median line, thereby counteracting the effect
of the insufficient connective-tissue fibers. In the course of this opera-
tion both tubes and ovaries were removed, the broad ligaments shortened,
and two silk sutures secured the
fundus to the abdominal wall. For
several days after the operation
there was some discomfort upon
voiding the urine, referred to the
postpubic region; after that the
urine was voided without discom-
fort of any kind, and the patient
has gone on to thorough recovery.

Ureteritis in the Female. —
Garceau^ points out that in its
acute form simple ureteritis especi-
ally affects primiparas. Commenc-
ing with rigors, there is pelvic pain and vesical irritation, the affected ureter
being sensitive to pressure through the vagina, considerable quantities of
pus appearing in the urine in a few days. Usually part of a pyelitis or
cystitis, the symptoms of ureteritis are often overshadowed by these ac-
companying affections. In its chronic form simple ureteritis is generally
associated with chronic cystitis, though it may follow either a vesical or
renal inflammation, and it most probably arises from direct extension
» Am. Jour. Med. Sci., Feb., 1903.

Vagina ,

Fig. 80. — Slocum's case. Condition after cy.sto-
pexy (Am. Jour, of Surg, and Gyn., Aug., 1903).

448 GYNECOLOGY.

along the mucous membrane. Gonorrhea, calculous pyelitis, pelvic
cellulitis, and inflamed lymph-glands are among other causes of the con-
dition. Frequency of micturition is the chief and most troublesome
symptom, which, though usually painless, is so constantly present as to
cause considerable neurasthenia from loss of sleep, etc. Increased ten-
derness, and possibly some enlargement of the affected ureter, pressure
upon which vaginally causes an almost uncontrollable desire to micturate,
is the most important physical sign. Cystoscopically the trigone and
vesical neck may be congested, with swelling of the ureteral eminence on
the affected side, and there is an excess of desquamated epithelium in the
urine with diminution of urea in that collected from the affected ureter.
Preliminary to treatment any concurrent pelvic disease should be rec-
tified and a simple farinaceous diet ordered, with regulated daily exer-
cise alternating with rest. Among drugs potassium acetate, sandal-
wood oil, urotropin, and sodium bicarbonate are often of value, and
trional should be given for sleeplessness in preference to morjohin. Ap-
plications of silver nitrate solution to the trigone and ureteral eminence,
or vesical injections of protargol or ichthyol, may do good, but Garceau
has found that direct applications of boracic acid or silver nitrate solu-
tions to the ureteral canal, by means of a special injector he has devised,
have given great relief. Failing everything else a vesicovaginal fistula
is the only remedy left. Gonorrheal stricture and calculus are the prin-
cipal causes of ureteritis with obstruction, which may be partial or com-
plete. The symptoms are those of simple ureteritis, and, should gradual
dilation fail, cutting the stricture or transplantation of the ureter, and,
if high up, nephrectomy or the establishment of a low fistula may be
necessary. In one case of calculous obstruction small punctate ulcers
were seen around the ureteral orifice, and there was marked bladder-
inflammation, although the pelvis of the kidney containing the calculi was
normal in appearance. In complete obstruction due to fibrous stricture
the symptoms may be obscure, the kidneys becoming completely dis-
organized without any pronounced signs. Above the stricture dilation
with considerable fibrous thickening of the ureter are secondary changes,
while below an inflammatory condition exists extending into the blad-
der. The symptoms are usually referable to a cystitis with occasional
acute attacks of kidney-pain and the malaise generally accompanying
renal affections. Cystoscopically ulceration of the ureteral orifice is
found, and the urine collected separately from the ureters gives an ex-
cessive deposit of pus on the affected side diagnostic of pyelitic affections.
Nephrectomy, gradual dilation, cystotomy, or the establishment of an
artificial fistula are the courses open according to circumstances, and the
method of dilating and catheterizing the ureter and washing out the renal
pelvis with antiseptic solutions has afforded relief in some instances.
The symptoms of complete obstruction due to an impacted stone are
frequently obscure, surgical treatment depending upon the position. In
tuberculous ureteritis the symptoms are overshadowed by the renal and
vesical accompaniments, but colic due to the passage of a shred of tissue
may point to involvement of the ureter. On vaginal examination

THE URINARY ORGANS. 449

thickening of the ureter, which is felt as a solid tender cord, is characteristic
in cases of any duration, and pressure causes an urgent desire to micturate.
The history,' cystoscopic examination, and focal kidney-symptoms with
the finding of the bacilli confirm the diagnosis. Total nephroureter-
ectomy appears to afford the best permanent results, as partial resec-
tions may allow the remnant to act as an infecting center.

Ureteroureteral Anastomosis. — The unintentional division of
the ureter in operations in the abdominal and pelvic cavities is not of
frequent occurrence. Nevertheless, remarks George Ben Johnson,^
this accident is apt to occur in cases in which numerous adhesions exist,
and the anatomic relations are much disturbed. The ureter may be so
displaced from its normal position, and be so completely embedded in a
mass of adhesions, as to make its identification practically an impos-
sibility. In the event of such an accident a decision as to the best pro-
cedure to follow is of paramount importance. Several methods of deal-
ing with the condition are at hand: (1) The kidney on the injured
side may be removed; (2) the ureter may be passed into the intestine,
colon, or rectum, into the vagina, or through the abdominal wall ; (3) the
kidney may be brought down, and the extremity of the ureter sutured into
the wall of the bladder; (4) an anastomosis may be made between the
extremities of the divided ureter. This classification, while not ex-
haustive, covers the most important procedures so far devised. Of
these methods, the last two are the most worthy of consideration.
Ureteroureteral anastomosis would seem to be the operation of choice,
Ureteroureteral anastomosis, or ureteroureterostomy, as the operation is
designated by Kelly, may be performed in various ways. Henry Morris
gives the following classifications: (a) End-to-end anastomosis by
suturing the ends together in a transverse line; (b) end-to-end anasto-
mosis; (c) lateral implantation; (d) end-to-end anastomosis by suturing
the ends together in an oblique line. The transverse end-to-end method
was used by Schopf (1886) in the first recorded cases of ureteroureteral
anastomosis. The objections to the operation were so serious that the
operation has been almost discarded to-day. Poggi originated the end-
to-end anastomosis. Lateral implantation was devised and described by
Van Hook in 1893. Kelly was the first to apply this method to the human
subject. The obUque end-to-end anastomosis was first used by Bov^e.
Johnson reports two successful cases in which the Van Hook method
was employed.

Complete Nephroureterectomy. — J, Wesley Bovee^ defines this
term as the complete removal of the kidney and the ureter at one attempt.
It may be called an American operation, since the first four were performed
by American surgeons, Kelly probably doing the first in December, 1895.
Of the 17 cases on record, only 2 were done outside the United States.
But 4 of these were males, and only 2 ended fatally. Tuberculosis of
the kidney and ureter was the indication in 14 of these cases. Complete
nephroureterectomy may be done by the extraperitoneal and the trans-
peritoneal routes, Bov6e seems to prefer the loin extraperitoneal with

* Am. Gyn,, Jan. 19, 1903. ^ Amer. Med., June'6, 1903.

450 GYNECOLOGY.

a vaginal incision to remove the lower part of the ureter, and thinks it
best to begin with the vaginal incision. He gives a full history of his
second case, with the technic of the operation and its results. In tuber-
culosis of the kidney and ureter the strictest care to prevent contamina-
tion of normal structures is necessary. That virulent organisms other
than the bacillus of tuberculosis may be in the pus should be remem-
bered. It is well to remove the kidney and ureter en masse when pos-
sible, liberating the kidney first, care being taken that leakage from the
cut end of the ureter does not occur. In favorable cases, if thought
advisable, the ureter may be divided between clamps at any point where
the distention is not marked. Wliether pus be present or not, drainage
should be employed, as not to do so is to invite at least the accumulation
of a large amount of serum in the extraperitoneal space made in the
operation.

Renal Tumors. — C. P. Noble ^ reports 2 rare and interesting cases
of renal tumors (see Plates 6, 7). One was a hypernephroma (Plate 6)
which, until recent years, was imperfectly understood and variously
described as adenoma, lipoma, angioma, carcinoma, and endothehoma
of the Iddney. In 1883 Grawitz asserted that these growths originated
from misplaced portions of adrenal tissue included in the kidney-sub-
stance during the developmental process. This view has been \ddely
accepted, and only a few observers remain who consider them as originat-
ing from the uriniferous tubules or from the proliferation of the endo-
thelium of the bloodvessels and lymph-spaces. Therefore, for the most
part these growths are now called struma lipomatodes aherraUi renis, strumn
suprarenalis or hypernephromas. For the different views concerning the
origin of the growths one is referred to the critical re\aew by A. 0. J. Kelly. ^
Clinically the growths are soft and "marrow "-like, are well capsulated and
rarely invade the pelvis of the kidney and, therefore, rarely produce hem-
aturia. They are very vascular and there is a pronounced tendency to
marked interstitial hemorrhages leading to cyst-formation. They may
attain a large size and at times show maHgnant properties by giving
rise to metastasis through the bloodvessels, especially to the lungs, hver,
and bones. Most of the reported cases have occurred in men and women
between 40 and 50 years of age. In general they distinctly resemble ad-
renal tissue. The second tumor was a very rare papillary carcinoma
springing from the pelvis of the kidney and invading the renal substance
(Plate 7).

MENSTRUATION AND ITS DISORDERS.

Precocious Sexual Development. — Roger Williams^ reports over

100 authentic cases of precocious sexual development collected from the

literature of the nineteenth century, the large majority of which belong

to the earlier part of the century. This anomaly is of much commoner

occurrence in females than in males, the proportion in this series being

80 females to 20 males. All nationalities in civilized communities are

Am. Gynec, July, 1902. ^ Phila. Med. Jour., July 30 and Aug. 6, 1898.

3 Brit. Gyn. Jour., May, 1902.

Plate 6.

Plate 7.

Noble's case of pipillary carcinoma of the kidney (Am. Gynec, July, 1902).

MENSTRUATION AND ITS DISORDERS. 451

prone to this anomaly, but there is no evidence of its occurrence kmong
savages. The different types of sexual precocity in females are classified
as follows : Menstruation appearing prior to other signs of sexual evolu-
tion; precocious menstruation with the early appearance of other signs
of puberty; precocious sex-manifestations without menstruation; early
conception and pregnancy ; sexual precocity with intraabdominal tumor.
Transitory vaginal hemorrhages in newly born children, lasting for a few
hours or for several days, are of such frequent occurrence that they may
be -regarded as physiologic and as the prototype of the menstrual flux.
In the cases reported the time of menstruation varied from birth to 6
years. At later periods so many examples are mentioned that it is
unnecessary to cite individual cases. There were 13 cases of precocious
sexual development associated vdih intraabdominal tumors, and 15
instances of precocious pregnancy, the age varying from 8 to 12 years.
Sexual precocity is not incompatible with healthiness, yet most of those
afflicted have poor health and are generally short-lived. A large propor-
tion are rachitic, especially the females, and their dentition and skeletal
development are generally backward. The mental quaUties of these
anomalous children never corresponds to their sexual development;
either they are psychically childhke or they are unusually dull, mentally
defective, or even idiotic, and seldom manifest any passion for the oppo-
site sex. They generally come of large families, but rarely more than
one in the family is affected. Female precocity of the less extreme kind,
as menstruation between the normal period and the tenth year, is gener-
ally indicative of vigor and vitality above the ordinary. Such females
generally marry early and have more children than the average. Among
the different races of manldnd the lower ones are more precocious than
the higher; with the advance of civilization, precociousness tends to
become less and less, and there can be no doubt as to the correctness of
Delaunay's dictum, that "precocity is a sign of biologic inferiority."
The higher tissues and organs also are much more slowly evolved, and
much less prone to precocity, than the lower ones. This is especially
true of the human brain, which appears not to attain its developmental
maximum until very- late in life — even up to the fiftieth year; and it is
noteworthy that this organ is hardly ever affected in cases of precocity.
The Weight-wave of Menstruation. — W. T. Belfield^ offers the
following conclusions: (1) During several days preceding the menstrual
flow there occurs a progressive increase in the weight of a healthy young
woman, often comprising from 2A to 5 pounds, which may be from 1.5 %
to 5 % of her usual weight. The climax of this gain is immediately
followed by a rapid loss of a large part (perhaps half) of this increase, and
then a more gradual loss, extending over several days, of the remainder.
(2) The menstrual flow begins during the rapid loss of weight mentioned,
its appearance often, though not always, coinciding with the beginning
of the loss in weight. The flow continues with the less rapid loss which
follows during the next few days, terminating about when the woman's
weight regains its premenstrual level. (3) The premenstrual gain in
' Jour. Am. Med. Assoc, June 13, 1903.

452

GYNECOLOGY.

weight is due to diminished excretion, especially of water. The rapid
loss of weight which accompanies the flow is due to rapid excretion,
notably of water. (4) This menstrual weight-wave was absent in a
woman 59 years old, who had not menstruated for 12 years. (5) The
menstrual weight- wave was observed in two subjects of irregular men-
struation, at periods when the flow was scanty or absent. (See Fig. 81.)
The Influence of Menstruation on Gastric Activity. — [Both gyne-
cologists and therapeutists (Miiller, Eisenhardt, Freund, Jaworski and
others) have long made the subject of their studies the influence of dis-
eases of the sexual organs of the woman on disturbances of the gastro-

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intestinal system.] Liembick,^ after a series of experiments on the con-
nection between menstruation and gastric activity in the healthy woman,
reaches the following conclusions: (1) There is an undoubted connection
between the two ; (2) during the menstrual period there occurs an increase
in the acidity of the gastric secretions — the so-called hyperaciditas men-
strualis; (3) there is at the same time a hypersecretion of the gastric
juice; (4) the motor activity of the stomach is considerably lowered
during menstruation; (5) all these phenomena are of reflex origin. The
practical value of these phenomena, even though not so great, is never-
theless important enough to attract our attention; (a) the stomach-
' Pezeglad lekarski, No. 43, 1902.

MENSTRUATION AND ITS DISORDERS. 453

contents should not be examined during menstruation, as the results
obtained are not to be relied upon as a true indication of the individual's
gastric activity; (b) in case there appear any gastric disturbances in a
menstruating woman, we should rather resort to alkaHes than acids; (c)
women who suffer from ulcers of the stomach should observe an especially
strict diet and rest during their menstrual periods, for it is at this time
that the morbid process is liable to become worse, and even hemorrhage
may appear. In some cases the author observed increase of the acidity
and hypersecretion of the gastric contents during the interv^al between
two menstrual periods, a condition analogous to what the Germans call
Mittelschmerz. Under this term we are to understand the appearance in
the interval between two menstrual periods of various painful sensations,
such as gastric, abdominal, and lumbar pains, a sensation of weight in
the pelvis, sometimes an increase in the vaginal secretions, etc., announc-
ing the approach of the menstruation. FUess asserts that the majority
of women know of these " intermenstruating" symptoms. It seems that
the heightened irritability of the nervous system in the woman at this
period is reflected not only on the whole system, but also locally on the
activity of the stomach.

The Tube and Uterus in Menstruation. — Moltzer^ in an inaugural
thesis (Utrecht, 1902) examined healthy tubes removed from 2 patients
during the menstrual period. In one case there was an ovarian cyst.
Before the parts were disturbed a drop of blood was seen issuing from
each ostium, and the tubes were markedly hyjjeremic. The vessels were
found on microscopic examination to be dilated, the lymphatics contained
many multinuclear leukocytes, which also lay in quantities under the
epithelium. The epithelial cells showed vacuolation. In no part of the
tube were they seen to be broken down or deficient. Toward the ostiimi
hemorrhagic infarcts and hyperemia were more marked than the pro-
liferation of leukocytes. There was no true submucous hematoma. As
the inner half of the tubal canal was quite free from blood, the hemor-
rhage could not have originated from the uterus. There was no evidence
of catarrh or other inflammatory changes, and as the veins in the tube
were not more engorged than the arteries, the appearance actually de-
tected could hardly be due to venous stasis caused by the ovarian tumor.
In the second case the fimbriae were stained by free blood, and the micro-
scopic appearances of the tube were substantially the same as in the
first. Moltzer concludes that the tube naturally has a share in menstrua-
tion. Blood manages to escape into the lumen without breaking down
the epithelium, which is just what De Sinety observed in the menstruating
uterus. [Most recent researches into the histology of menstruation have
been made under favorable circumstances, as in winter when decompo-
sition is least hkely to set up misleading changes ; it at least seems certain
that the epithelium does not break down. The hematomas and defects
in the epithelium of a large area of endometrium are always of doubtful
import, and most probably signify not menstrual changes, but damage
during operation, clumsy section-cutting, or portmortem changes.]
' Monats. f. Geb. u. Gyn., Jan., 1903.

454 GYNECOLOGY,

Adrenalin in Metrorrhagia. — Debrand^ reports 2 cases of metror-
rhagia of the menopause, in the treatment of which condition he gave
adrenalin internally with great success, stopping the hemorrhages imme-
diately and permanently. He believes it to be an excellent hemostatic,
but still advises the ordinary hemostatics besides. Very small doses
should be given at first, since it may cause injurious results. Iron should
not be administered in this condition, but a change of air and bathing
are of service. CampbelP (Philadelphia) reports 3 cases of uterine
hemorrhage from polyps or fibroids which were promptly relieved, after
other remedies failed, by the administration of 15 drops, internally, 3
times a day of a 1 : 1000 solution of adrenahn chlorid.

Some time ago Lafond-Grellety obtained excellent results in bleeding
from the uterus by the internal use of calcium chlorid. G. Gross,^ act-
ing on this suggestion, has also obtained a very satisfactory outcome in 4
women who were suffering from bleeding from the uterus. The degree
of cure was such that the women, who were very anemic and emaciated,
gained flesh and strength and soon resumed their ordinary occupations.
His method is, briefly, that the patient shall take daily a douche contain-
ing 10 parts of calcium chlorid and 200 parts of distilled water, preceded
always by a cleansing douche. He at the same time considers it advis-
able to administer by mouth the following prescription : Calcium chlorid,
4 parts ; peppermint-water, 30 parts; distilled water, 90 parts; to be given
in teaspoonful doses every 2 hours. He states that this combination of
douche and internal medication is exceedingly satisfactory. The treat-
ment may be maintained for a long time provided the kidneys are in good
condition, as the calcium chlorid is readily eliminated.

Dysmenorrhea. — The Etiology of Dysmenorrhea. — Some cases
of menstrual pain are cured by dilation of the cervix, and others are not.
It is plain that the former cases have at least one feature in common.
The latter may be of the most diverse kind. Although this disease is
most common, say G. E. Herman and H. R. Andrews,* few text-book
authors consider it worth while to treat of it in their books. One theo-
retic statement as to the causation of dysmenorrhea, given by so many
writers, is that the uterus is anteflexed. Anteflexion is present in pre-
cisely the same proportion of women who menstruate without pain as
in those women who have straight uteri. Sir J. Williams has reached
the conclusion that the uterus is imperfectly developed, but that this
does not retard the onset of menstruation. Primary dysmenorrhea, or
dysmenorrhea which starts with the onset of the puberty, is more likely
to be cured by dilation than that which is acquired. Especially is this
true when the pain begins before the twenty-flfth year. Menstrual pain
may be acquired at almost any time during the first half of menstrual
life. The pain of menstruation may be of two kinds — ^general aching due
to congestion of the pelvic organs which precedes menstruation, which
is reheved by bleeding from the uterus, and the sharp uterine colic.
The former is not relieved by dilation, the latter is often cured by it.

1 La Tribune M6d., Julv 23, 1902. = Clin. Rev., Jan., 1903.

' La Sem. Med., 1902, No. 22. ^ Brit. Jour. Obstet., Jan., 1903.

MENSTRUATION AND ITS DISORDERS. 455

The pain of pelvic congestion not only begins earlier, but lasts longer
than that of uterine spasm. Spasmodic pain does not permit the patient
to he down; pelvic congestion is relieved by quiet recumbrance. Spas-
modic pain is severe and is usually accompanied by nausea and vomiting.
In most cases of dysmenorrhea there is no sign of organic disease of the
uterus. The most obvious explanation of the cure of the menstrual
pain by dilation of the cervical canal is that the pain is caused by the
narrowness of the canal. The cervical canal of a young multipara has
never been seen so narrow as to prevent the flow of the menstrual blood.
Such stenosis only exists in diagrams. The writers have come to the
conclusion that the narrowness of the cervical canal is most often sufficient
to account for a condition underlying, and perhaps causing, the spas-
modic dysmenorrhea, acting not by causing mechanical obstruction, but
by preventing physiologic dilation. The treatment of these patients
consists in the dilation of the cervical canal by bougies.

The Treatment of Dysmenorrhea. — [The inefficacy of the treatment
of dysmenorrhea is shown by the multiplicity of remedies recommended.
The statement is made, however, that beneficial results have been
obtained from the administration of thyroid extract in dysmenorrhea
owing to the intimate relationship which exists between the utero-
ovarian zone and the thyroid gland. It is stated that Stimson, of San
Francisco, has been successful in 80 % of his cases. He administers a
grain of the dried extract 3 times a day for one or two days preceding
the menstruation and doubles the dose during the period.] Fisher^
calls attention to the intimate association between the genital apparatus
and the thyroid gland. He states that occurrences which influence the
genital tract, such as puberty, pregnancy, and uterine fibroids, very
frequently cause enlargement of the thyroid gland. He also notes that
deficiency of the normal thyroid secretion is often accompanied by
atrophic changes in the genital apparatus. Consequently, it seems from
the foregoing statements that thyroid extract is deserving of a place in
the treatment of dysmenorrhea.

An editorial in "American Medicine"^ says that the presence of pain-
ful menstruation indicates the necessity for careful physical examination
to ascertain its cause. These causes are varied. Any malposition of
the uterus or its appendages, a stenosis of its canal, or any inflamma-
tory condition along the genital tract, may be the causative factor of
dysmenorrhea. The position of the pain and its relation to the flow
of blood afford material aid in diagnosis; but very frequently the gyne-
cologist finds that severe dysmenorrhea occurs without any demonstrable
pathologic lesion in any part of the genital apparatus, and often this so-
called neuralgia or spasmodic dysmenorrhea is most difficult to treat.
As a rule, it is unwise and irrational to mask the symptoms by giving
opiates, although it may be necessary during a severe paroxysm; but the
satisfactory results which have been obtained by the use of nitroglycerin
lead us to emphasize its value for the relief of this condition. By de-
tailing a typical case its range of usefulness may be indicated. The

' Jour. Am. Med. Assoc, Dec. 6, 1902. ' June 6, 1903.

456 GYNECOLOGY.

patient is usually a nulliparous woman of sedentary occupation, often
anemic, who just a few hours prior to the establishment of the flow has
marked vasomotor constriction, as shown by facial pallor, blueness of the
lips, coldness of the extremities, and a sense of pelvic engorgement. By
the administration of j^-q grain of nitroglycerin every 3 or 4 hours until
the flow is satisfactorily established, the physician may often relieve his
patient in a thoroughly rational manner without resorting to opiates or
other anodynes. Be it understood that it is only when clear indications
exist for vasomotor dilation that this remedy will alleviate. Other cases
in which cervical angulation or stenosis is present are best treated by
rapid dilation under anesthesia; or if due to malposition or diseased
appendages, an appropriate surgical procedure must be employed.

Nasal Therapy for Dysmenorrhea, — [Five years ago Fliess pub-
lished a monograph on the connection between nasal and menstrual con-
ditions, the main thesis being that in the nose there are two "genital
spots," one the tuberculum septi and the other on the inferior turbi-
nate, which in many women show congestion and sensitiveness during
menstruation. In some cases of severe dysmenorrhea Fliess found he
was able to control the pain by applications of cocain to these "spots,"
and more rarely he permanently cured the menstrual difficulty by cau-
terization of the same region. The idea of relationship between the
upper respiratory tract and the genital organs in woman is much older
than the contribution by Fliess. Bleeding from the nose and pharynx
during menstruation has often been noted, and the same periodic phe-
nomenon has been recorded in cases of amenorrhea caused by pregnancy,
the menopause, or pathologic conditions. Since the publication by Fliess
of his findings the subject has been discussed at length in some Continen-
tal medical societies, and has been reported on by a number of clinicians,
all of whom seem to find a certain percentage of cases amenable to this
treatment. Schiff found cocain effective in 35 out of 41 cases, and con-
cluded that it was of service in those cases in which the pain persists after
the flow is well established. Koblanck, Ruge, Knorr and Kronig have
aU reported series of cases favorably affected.] More lately Ephraim^
has been successful in arresting the pain of intense dysmenorrhea in 18
out of 24 cases treated by cocain. In Amann's clinic Linder^ has been
studying this subject for the last two years on a series of 30 cases. The
relief from pain has been so marked that some of the patients have
returned to have other painful disorders treated. The influence of sug-
gestion in rendering this treatment effective has been discussed time and
again, and proves a difficult question to decide. Schiff carefully under-
took to rule out this factor and found that applications of water were
ineffective. Linder reports a special series of 16 cases selected with great
care in order to test more exactly this nasal therapy. In 10 of these cases
cocain caused cessation of pain, sometimes lasting 24 hours. When the
pain returned, Linder tried a second application, this time secretly
substituting plain water for the cocain solution. Two of the 10 were
again favorably affected. Repetition of the cocain treatment then proved

' AUg. med. Cent. Ztg., March 12, 1902. ^ Miinch. med. Woch., June 3, 1902.

UTERINE INFLAMMATION. 457

effective in all cases, Linder is forced to think that in some instances
suggestion is the strongest factor in the result, although it must be re-
membered that even water causes a physiologic effect on the nasal mucous
membrane. For him the question of a nasal dysmenorrhea remains in
suspensio, but the striking number of cases which are reheved by nasal
therapy, which is harmless whether or not it involves suggestion, recom-
mends a method which ought to be equally welcome to physician and
patient for the treatment of such an obstinate disorder. The cocain is
appHed on a pledget of cotton through a speculum, 2 or 3 drops of a
10 % to 20 % solution, and is carefully limited to the "genital spots,"
so that there is no danger of intoxication. To be effective it may have
to be repeated in 15 minutes. The cessation of pain, even if for only over-
night, is extremely grateful to the patient. Cauterization, in the ex-
perience of several men, permanently cures far fewer cases of dysmenor-
rhea than cocain temporarily relieves.

Menopause. — Jose Zunzunezui Echevarria^ states that cardiac
disturbances in the menopause are of two kinds; one being of organic
nature, brought on or increased by the menopause; the other, and most
frequent, being a purely functional disturbance, which manifests itself
in palpitation and tachycardia. The latter may be entirely reflex, and
due to the influence of the menopause upon the uterus, liver, stomach,
or nervous system. In other instances this symptom may be present
without organic affection of any kind. In Echevarria's opinion, arterial
overtension and excitation of the sympathetic nervous system enter into
the pathogenesis of this last form; and he advances the theory that the
arteriosclerosis, of which overtension is the first manifestation, may be
induced by the disturbances brought about in the organism through the
influence of the menopause. He holds, further, that tachycardia due
to excitation of the great sympathetic may be produced through
sanguineous plethora or ovarian insufficiency; and believes that the ad-
mission of the latter possibility may lead to the advantageous employ-
ment of opotherapy in such cases.

UTERINE INFLAMMATION.

Treatment of Endometritis. — Menge^ calls attention to the superior
excellence of formalin as an escharotic as compared with zinc chlorid.
He employs both the pure^drug and the 50 % solution. It is especially
valuable in cases of endometritis following abortion and labor at term, a
single application often being sufficient to stop hemorrhage and foul dis-
charges. The writer is strongly opposed to intrauterine injections of
caustic solutions. Kozlenko^ discusses the therapeutic applications of
thiol in gynecologic practice. He employs this drug, either in the form of
tampons saturated with a 20 % to 50 % watery or glycerin solution, intro-
duced daily or every other day, or in the form of rectal suppositories made

' Revista de Especialidades M^dicas, March 5, 1903.

2 Zent. fiir Gynak., 1902, No. 13.

3 Praktitchesky Vratch, vol. i, Nos. 45 and 46, 1902.
30 S

458 GYNECOLOGY.

of powdered thiol, 0.3 gm. in each. In acute and subacute inflammations
of the perimetrium he employs pure thiol, either in the form of direct
application or tampons. In endometritis and endocervicitis he uses pure
thiol in the form of intrauterine applications or external inunctions of
the abdominal walls.

The Present Status of the Use of Steam in Surgery and Gyne-
cology.— M. F. Kozlenko^ reviews the different uses of steam in diseases
of women and in surgery. The first application of steam was made 15
years ago, when Snegireff suggested its use in the arrest of uterine hemor-
rhage. Since then a number of new uses have been found for the method
in question. A number of authors recommend the use of steam in cases
of endometritis, and recently steam has been employed to obtain relief
in cases of metrorrhagia in the climacteric, or in profuse bleeding from
the uterine cavity depending upon senile catarrh. Such cases are often
resistant to every form of treatment, and frequently the question of
removing the uterus arises, though the patient's condition is very often
excellent. In such cases steaming the interior of the uterus for the
purpose of destroying the entire diseased mucous membrane has given
good results, inducing ultimately an artificial climacteric. Steam has
also found a number of applications in the treatment of diseases of the
eye, nose, and throat, but the most interesting use of it is in resections of
the liver, in which it is applied for the arrest of the bleeding. A steam
saw has been devised for this purpose by Snegireff, the purpose of which
is to arrest the bleeding as the liver is cut. The instrument looks like an
ordinary small surgical saw, but is hollow and its hollow handle is con-
nected with a steam apparatus. Small openings are provided on the cut-
ting surface between the teeth of the saw through which steam passes
directly into the tissues traversed by the instrument. Experiments on
animals show that this saw arrests bleeding when used in resections of the
liver. The steam is driven through the saw at a pressure of two atmos-
pheres. It arrests instantly bleeding from parenchymatous surfaces,
and the liver can even be kneaded mth the hand after having been cut
without inducing any more bleeding. The author believes that this saw
offers the best method of arresting bleeding in operations upon the liver
and spleen.

On Columnization of the Vagina in the Treatment of Metritis. —
F. Boukomsky^ recommends the use of a procedure called "columniza-
tion " in gynecologic practice. This procedure is a special form of tam-
poning of the vagina, which is applied in the knee-chest position. The
posterior wall of the vagina is pulled back with a Sims speculum, so that
the cervix and a part of the vaginal vault become easily accessible. A
strip of gauze, 1 yard wide and from 1 yard to 1^ yards long, sterihzed
or slightly impregnated with iodoform, is moistened in glycerin and
pressed out, so as to remove the excess of fluid. This piece of gauze is
then introduced firmly into the vaults of the vagina by the fingers, chiefly
into the posterior and lateral fornices, partly into the anterior, so that

1 Roussky Vratch, Jan. 18, 1903.

' Jour. Akousherstva i Gienskikh Boliesney, Feb., 1902.

UTERINE DISPLACEMENTS. 459

the cervix is evenly surrounded by a mass of gauze. The upper 'part of
the vagina is also packed in the same manner. Instead of gauze, tampons
of sterilized cotton may be used. This procedure was first employed in
America by TaUiafero, of Atlanta, in 1878. Coe, Tucker, Jackson, and
Potter have written reports on its value. The French gynecologists were
the next to take it up. The present author gives the results of 5 years'
experience "\vith this method of tamponing, which he has applied in over
1000 patients. He finds gauze to be the best material for this purpose,
and that ichthyol is the best medicinal agent for impregnating the tam-
pons. The patient is placed in the ordinary gynecologic position, her
external genitals are scrubbed with soft soap and irrigated with a solu-
tion of formalin (1 : 500). A Sims speculum is introduced, drawing
back the posterior vaginal wall, and the tampon applied as described
above. The best results "with this treatment are obtained in cases of
metritis, pure or complicated with retroflexions with adhesions, in exu-
dates in the cavity of the pelvis, and in salpingooophorectomies which
are suitable for nonoperative treatment.

UTERINE DISPLACEMENTS.

Intraabdominal Pressure. — Meyer ^ considers this expression erro-
neous, and affirms that there is no such thing as a constant pressure
which is the same at every point in the peritoneal cavity. The compari-
son between the difference in pressure in the pleural cavity and in the
external air and that within the peritoneum is not justified on account
of the elasticity of the abdominal walls. In the normal condition the
equilibrium between the abdominal cavity and its contents is maintained,
and when the air is allowed to enter at the operating-table the intestines,
even when not previously emptied, protrude only to a slight degree. If
they have been thoroughly evacuated, it is even possible to establish a
negative intraabdominal pressure artificially by drawing up the unopened
peritoneum, the muscular wall being thoroughly relaxed under anesthesia.
Normally it cannot exist. That the pressure is never constant at all
points is evident when one considers the variable conditions present in
the intestines and bladder, the peristaltic movements and those of the
diaphragm, the contractions of the voluntary muscles, etc. The supposed
variation in pressure due to different positions is also entirely theoretic.
Kossmann ^ rephes to Meyer's article. While agreeing with the latter in
his assertion that this pressure is constantly changing and that it is never
negative, he denies that it varies at every point in the ca\aty. The writer
claims that this pressure is ever}'where alike, and is only unequal when
gas or fluid is abnormally present in the free cavity. Intraabdominal
pressure becomes a disturbing factor, he believes, when it is sufficient to
overcome the normal power of resistance of the muscular wall.

Treatment of Congenital Anteflexion.— Alexandroff^ describes the
follo-wing operation for the relief of dysmenorrhea due to congenital ante-

1 Zent. f. Gynak., No. 22, 1902. ^ 2ent. f. Gynak., 1902, No. 27.

3 Frauenarzt, Heft 193, 1902.

460 GYNECOLOGY.

flexion: The os externum is drawn apart with two pairs of bullet-forceps,
while an incision is carried downward along the anterior vaginal wall,
beginning at the portio. The cervix is dissected off as in vaginal hyster-
ectomy as high as the os internum, is then split, and each half is sutured
to the edge of the vaginal wound on either side, in such a way that the
cervical endometrium is united to the submucous muscular layer of the
vagina. The flaps of mucous membrane are next allowed to slide over
the sutured edges, to which they are also sewn, thus covering all raw
surfaces. A strip of iodoform gauze is introduced into the canal and the
vagina is tamponed. The stitches are removed on the tenth day and the
patient may leave her bed 2 days later.

Operative Treatment of Prolapsus Uteri. — Berry Hart,^ after a
careful review of cases and operations, sums up as follows: Prolapsus
uteri may be regarded as a hernia of a definite part of the pelvic floor.
After replacement the hernia is reproduced by the patient's straining.
The most useful operations are the combined cervical amputation, elytror-
rhaphy and perineorrhaphy in medium cases, and ventrofixation in
selected cases. In advanced cases in widows vaginal resection and
hysterectomy have to be considered. Baumm^ refers to the anatomic
and static elements in the causation of prolapse, and discusses the rela-
tion of retroversion and flexion to uterine prolapse. He considers pro-
lapse of the vagina alone to be very rare and slight. Kiistner and others
have maintained that, when the uterus is retroverted, its axis is in line
with that of the vagina, instead of making a sharp angle with it; in this
position abdominal pressure does not force the anterior uterine wall
against the anterior vaginal wall, but carries the uterus like a plug into
the vagina, folding the anterior vaginal wall on itself, and causing it to
appear at the introitus vaginae. This belief determines the action of
those who consider a fastening of the uterus in a position of anteversion
to be an essential part of any operation for prolapse. Some, however,
consider retroversion to be secondary to the descent of the anterior
vaginal wall, or hold, like Hegar, that any considerable retroflexion tends
to hinder the development of prolapse. They, naturally, will not com-
plicate their operations by any attempt to antevert the uterus. The
writer holds that clinical observation cannot settle the point, which can
only be determined by operative experience. He himself for some time
combined vaginal fixation with anterior and posterior kolporrhaphy and
reported his results in 1897. There was recurrence in 30.7 % of his
operations. Whether these results were worse than those obtained by
him before using vaginal fixation he has no figures to show. He has sub-
sequently, however, operated for prolapse 95 times without any attempt
to fix the uterus forward, and has followed 86 of the cases. In 8 the imme-
diate result was not satisfactory, and recurrence of the prolapse quickly
followed. Of the total, there was recurrence in 26 cases (30.2 %) and
permanent; good results in 60 (69.8 %). Comparing this with his pre-
vious figures, he concludes that in operation for prolapse it is a matter

1 Brit. Med. Jour., Oct. 11, 1902.

^ Jour. Obstet. and Gynec. of Brit. Emp., May, 1902.

UTERINE DISPLACEMENTS. 461

of indifference whether the uterus be fixed forward or left in a. faulty
position. The results of other operators when employing vaginal fixa-
tion for rehef of prolapse are reviewed. Herff claims permanent cure in
78 %; Schmidt obtained the same. Schultze operated in 10 cases, in 8
of which prolapse quickly followed. He gives a table in which are com-
pared the results obtained by ventrofixation, the Alexander-Adams
operation, fixation of the round hgaments in the vagina, and shortening
by the Wertheim method. The results are variable. The Alexander-
Adams operation comes out with only 33.3 % of cures. Other methods
gave permanent rehef in about 70 %. Another table gives the results ob-
tained by other operators without any attempt at fixation of the uterus.
In simple cases 71.1 % were cured by kolporrhaphy and kolpoperineor-
rhaphy. In severe cases 75 % of cures followed the same measures with
the addition of amputation of the cervix. The causes of failure are next
discussed. The more complete the prolapse, the more likely it is to
occur. Parturition following operation is a common but by no means
universal cause of recurrence. The effect of the age of the patient is a
point not yet sufficiently observed.

E. Stanmore Bishop^ claims that the true ligaments of the uterus
which preserve it at its normal level and prevent prolapse are the fundo-
pubic or round ligaments in front and the sacrouterine or retrosacral
ligaments behind. Of these, the latter are by far the more important.
Their relative shortness, the position of their implantation below the
main bulk of the uterus, their coordinate action with the vesical attach-
ment in front, aU render them more effective in maintaining the uterus
in its normal position than the comparatively longer round ligaments
which act upon the fundus. To ventrofixation, which he has many times
performed. Bishop sees many objections, and mentions vaginofixation
only to condemn it. He states the anatomic and physiologic objections
to these procedures and contends that the true remedy for any severe
prolapse is the reproduction of the sacrouterine ligaments, since in those
cases in which they are absolutely torn through no amount of rest will
reunite them. Torn fibers retract and atrophy from disuse. In the
upper extremity of the posterior fornix a sufficiently firm resistant mate-
rial is available which, while firmly attached to the cervix, yet is of suffi-
cient length between its most superior point and that blended with the
latter to permit of normal freedom of movement. It is this which is
utilized as the new sacrouterine ligament. Its superior surface is covered
with peritoneum. If this is denuded by removal of a short, narrow strip,
its connective-tissue surface is bared for attachment to the parietal peri-
toneum behind; the best point of attachment is between the rectum on
the inner side and the ureter on the outer, its height on the sacrum vary-
ing with each case. The technic of the operation is as follows: After
opening the abdomen a thread is passed through each broad ligament,
inclosing tube and round ligament. These are used as tractors to draw
the fundus forward. A sound in the posterior fornix renders the latter
prominent. A thick thread is passed vertically through each side, avoid-

1 Lancet, March 14, 1903.

462 GYNECOLOGY.

ing the mucous lining, so that each protruding end is ^ inch distant from
the other, and the whole loop i to f inch from the cervix. The fornix
is now applied to the sacrum, and a spot chosen directly opposite, free
from vessels, nerves, and ureter, and well outside the rectum, where the
needle carrying the suture is entered deeply so as to embrace the perios-
teum, and brought out J inch above. Before tying this suture a narrow
strip of peritoneum is removed, both from the fornix and the wall oppo-
site. The round ligaments are then shortened by Olshausen's method.

Hysterokataphraxis. — The meaning of this new word is the inclu-
sion of any viscus, for example, the uterus, within supporting metal
sutures as a medium of replacement. A. Catterino^ (Camerino, Italy)
has devised the following operation, which he denominates by this term,
as a substitute for ventrosuspension or ventrofixation or as a more secure
type of these operations. After the usual method of opening the abdo-
men, exposing and bringing the uterus into the wound, a gold or pure
silver-wire suture is passed through all the layers of the abdominal wall
except the skin, thence through the broad ligament close to the uterus
opposite the juncture of its lowest and middle third, and from this point
in reversed order through the broad ligament and parietes on the opposite
side. A second suture is passed in the same manner above this, around
the organ just below the insertions of the round ligaments. Either before
or after the abdominal layers are apposed the wires are twisted together
and then the skin is sutured. Instead of two sutures, only the upper
may be used. Again, both may be passed like Halstead's intestinal
mattress-suture — namely, after passing the lower suture, instead of
cutting the wire, it is carried along between the aponeurosis and the skin
of the side of its emergence and then entered as before on that same side
at the level for the upper sling. In this manner on one side both free
ends will be twisted together, while on the opposite the continuous line
of wire will be seen passing from above downward. Catterino states
that its results are good as a means of support, but does not discuss its
attrition upon the structures concerned.

RETRODISPLACEMENT OF THE UTERUS.

The Present Status of the Pessary in the Treatment of Retro-
displacement. — [Twenty-five years ago the pessary was the sole method
of treating uterine displacements. This instrument has been neglected
in the rapid development of surgical technic, which offers more certain
relief. The pessary is now regaining its position to some extent, and
the indications for its use are better understood. In uncomplicated
displacements in young women who have not had treatment, operation
should be advised. It is also the only method that holds out a prospect
of cure in cases which are complicated by lacerations, or in which the
uterus is enlarged or very much prolapsed. In the cases in which the
uterus is small, and in which symptoms have been present but a short
time, and especially if they are associated with neurasthenia, treatment
> Z'blatt f. Gyniik., 1902, No. 26.

RETRODISPLACEMENT OF THE UTERUS.

463

by the pessary will often cure.] Davenport^ gives a few general prin-
ciples, which, if adhered to, will make the treatment of displacements
by pessary a success in the greatest number of cases possible: (1) Study
the cases. Determine the probable length of time that the displacement
has lasted, its possible cause, the symptoms it has caused, their order of
occurrence, and the relative importance of the general and local manifes-
tations, and from these data form a careful opinion as to the chances of
cure by one or the other method of treatment. (2) In a case of retrover-
sion or retroflexion, always replace the uterus before adjusting the support.

Fig. 82.— Slocum's operation for retroversion of uterus: A, Line for removing oviduct; B, cuneiform
piece removed from broad ligament (Am. Gyn., July, 1903).

Fig. 83. — Slocum's operation for retroversion of uterus : C, Incision closed ; D, sutures in cornua ; E,
overlapping flaps (Am. Gyn., July, 1903).

The pessary should not be relied upon to do this, as only in the rarest
cases will it be possible. (3) In choosing a support, choose one which
fits exactly if possible ; but, if not, have it rather too small than too large.
(4) The ideal pessary is one which supports the uterus perfectly and
without the patient being conscious of its presence. (5) The patient
should be kept under observation while she is wearing the pessary and
seen at regular intervals, preferably after each monthly period, for the
cleansing of the support and its replacement. (6) When it is deemed

» Boston M. and S. Jour., Aug. 7, 1902.

464

GYNECOLOGY.

wise to make an attempt to go without it, it should not be removed at
once, but a smaller one substituted to be worn a month, and then a still
smaller one, which may then finally be removed.

The Operative Treatment of Retrodisplacements. — New methods
employing the round hgaments, the uterosacral ligaments, and the broad
ligaments as suspension points have been suggested during the year.
Probably the most unique and suggestive operation recently devised for
uterine retrodisplacement is that proposed by H. A. Slocum,^ which he
terms " cuneiform shortening of the broad ligaments," and which
depends entirely upon these structures to hold the uterus in place. The
original technic consisted in the removal of a V-shaped portion of the
broad ligament (see Figs. 82 and 83) and bringing the edges together
after securing the bloodvessels. Modifications are suggested as follows:
When the object is simply to correct a backward displacement, after
adhesions are broken up, and the fundus drawn forward by making

Fig. 84. — Slocum's operation for retroversion of uterus: F, Buttonhole through parovarium; G, but-
tonhole through broad ligament (Am. Gyn., July, 1903).

traction on the broad hgaments, it might suffice to shorten the latter by
simply making a fold on either side, and securing it by several mattress
sutures. Prolapsus could also be rectified by drawing the uterus up to
the proper height and modifying the shape of the fold as well as its site.
If it is simply desired to raise the fundus, a V-shaped fold should be used.
If it is desirable to raise the uterus as well, an inverted A should be made,
gathering in more at the base than at the top. If the tubes and ovaries
are to be removed, Slocum suggests first tying the ovarian arteries at the
pelvic wall; this would allow quicker work and less hemorrhage. Next,
with scissors remove the oviduct by cutting directly beneath and parallel
with it, to the uterus. With a knife two converging incisions into the
comu would separate the tube entirely, while the wedge-shaped wound
in the comu could be brought together with catgut. If the broad hga-
ment was voluminous, a V-shaped incision could be made which would
include the attachment of the ovary at its apex. Should the tissues not

' Am. Gyn,, July, 1903.

RETRODISPLACEMENT OF THE UTERUS.

465

be sufficiently abundant for this method, a simple fold would. suffice,
suturing it in place, or a vertical incision, making two flaps, the edges
drawTi past each other and sutured, either with a mattress-suture or by
uniting the raw edge to the peritoneum it was lying against, or both.
If the tissues are too scant to make a V of sufficient size to remove the
ovary with the excised portion, two curved incisions at the base of the
ovary would allow of its being dissected free and the oval wound closed

Fig. 85.— Slocum's operation for retroversion of uterus : Flaps drawn past each other and sutured, lift-
ing that side higher (Aiu. Gyu., July, 1903).

Fig. 86. — Slocum's operation for retroversion of uterus: Both buttonholes sutured, lifting whole uterus

higher (Am. Gyn., July, 1903).

with catgut. If desirable, the ovaries may be allowed to remain. An-
other modification is to make a buttonhole incision of varying length
through one or both layers of the broad ligament, and carrying the edges
of the buttonholes past each other, suture in place (Figs. 84 and 86).
The direction of the buttonhole will be governed by the judgment of the
operator after making traction in various directions to determine just
the point where the shortening is needed. This method Avill be found
to answer requirements when the other method is unsuitable. When it
is desirable that both tube and ovar\' shall remain intact, the following

466

GYNECOLOGY.

Fig. 87. — Slocum's operation for retroversiou of uterus: H, Incision separating outer part of oviduct,
and into broad ligament (Am. Gyn., July, 1903).

Fig. 88. — Slocum's operation for retroversion of uterus. Anterior view of left broad ligament at
completion of operation : K, Anterior flap; L, outer part of oviduct refastened to top of broad liga-
ment (Am. Gyn., July, 1903).

Fig. 89. — Slocum's operal.ion for retro-
version of uterus. Posterior view of left
broad ligament, showing angle and button-
hole incision (Am. Gyn., July, 1903).

1" ig. 90. — Slocum's operation for retroversion
ol uterus. The distal flap is brought over the
ovary, the latter pulled through the buttonhole,
and the edges of the flap sutured, under proper
tension, to hold the fundus in normal position
(Am. Gyn., July, 1903).

RETRODISPLACEMENT OF THE UTERUS.

467

modification will answer: Raising the fimbriated extremity, separate the
oviduct from the broad ligament with scissors for the distance necessan,-
to make the requisite flap, probably ^ to 1 inch ; then cut at right angles
to this down into the broad ligament to the desired length, and carry^
the outer flap behind the inner one and suture (Fig. 87). In each case
it is better to carry the inner or uterine flap anterior to the other, as it
gives one the advantage of the thickness of the broad ligament in advanc-
ing the fundus. If the operator fears to leave the tube separated, it could
be refastened to the upper edge of the broad hgament without causing
constriction or distortion (Fig. 88). In any given case should the
mechanical requirement call for such a line of incision, Slocum would not
hesitate to cut across the round ligaments or even split them, and make
their^respective halves the fronts of the advancing flaps. In the method

Fig. 91. — Ferguson's operation of anterior transplantation of the round ligaments for displacements
of the uterus : a, Suture to prevent bowel slipping between uterus and bladder (K. Y. Med. Jour., Jan.
17, 1903).

pursued when both ovaries and tubes are to be saved, if it is found neces-
sary to make the vertical incision close to the attachment of the ovary,
the posterior flap should either be split, the upper part being attached
above the ovary, and the lower part below it, or a buttonhole cut in the
outer posterior flap, the ovary brought through the buttonhole, and the
flap then secured at its edges, and several mattress sutures introduced
over its area, if necessary (Figs. 89 and 90). If the broad ligament
widens too rapidly, from above downward, it may be feasible to divide
only the anterior layer with the vertical incision, and attach the inner
flap to the outer one, at a site nearer the pelvic wall.

Anterior Transplantation of the Round Ligaments. — In order to
leave the uterus free in the abdominal cavity with no stitches or bands
attached to it an operation was devised several years ago by A. H. Fer-
guson* in which a transplantation of the round ligaments is performed
» N. Y. Med. Jour., Jan. 17, 1903.

468

GYNECOLOGY,

for the purpose of replacing an abnormally situated uterus. Over 200

such operations have now been done
by him without a death or complica-
tion except suppuration in the ex-
ternal wound in 3 cases. The Tren-
delenburg position is used and a
median incision 3 inches in length
is made through the abdominal wall,
the lower angle reaching the supra-
pubic fold. The skin and fat are
dissected from the anterior sheath of
the rectus on either side. Two fin-
gers are passed into the abdomen to
protect the bladder and a stab-
wound is made through the rectus
between the two fingers, 1 inch from
the median line and 1^ inches from
the pubes. Before withdrawing the
knife pass a pair of forceps beside
it through the wound and seize the
round ligament and a portion of the
broad ligament near the uterus. In
order to prevent the bowel or omen-
tum subsequently slipping between

the ligaments and bladder and causing strangulation, a suture is now in-

Fig. 92. — Ferguson's operation of anterior
transplantation of the round ligaments for dis-
placements of the uterus: a, Round ligaments
coming through recti muscles (N. Y. Med. Jour.,
Jan. 17, 1903).

Fig. 93.— Ferguson's operation of anterior transplantation of the round ligaments for displacements
of the uterus: a, Round ligament in its new position; b, suture shutting iliac and bladder regions oflF
from each other (N. Y. Med. Jour., Jan. 17, 1903).

serted running along the parietal peritoneum from the puncture in it

FIBROID TUMOR OF THE UTERUS. _ 469

dowTiward to the bladder and backward to the round hgament riear the
uterus (Fig. 91). In this circular sweep the peritoneum is caught up about
every third of an inch, and when the suture is tied on both sides an antero-
posterior partition of folded peritoneum is thrown between the iliac and
bladder regions on either side. The proximal end of the round hgament is
then withdrawn through the rectus with the forceps and sewed with the
subjacent broad ligament to the anterior sheath of the rectus muscle,
leaving a stump about half an inch long between the uterus and the an-
terior abdominal wall (see Figs. 92 and 93). The other side is dealt with
in the same manner. The operation is easy to perform because all the
structures are seen as well as handled, there is no subsequent interference
Avith the physiologic functions of the uterus, and the range of application
is much wider than in any other similar operation.

Vaginal Shortening of the Uterosacral Ligaments. — Bovee^ gives
the folloAving technic for shortening the uterosacral ligaments to correct
retrodisplacements of the uterus: The patient is placed in the extreme
lithotomy position, the perineum is well retracted, and the cervix is grasped
with a volsellum forceps and drawn forward. A longitudinal incision,
starting at the cervicovaginal junction, is made through the structures
of the posterior vaginal fornix down to the perineum. By careful dis-
section the hgaments are brought into view. The amount of shortening
needed is decided upon, and one of the hgaments is grasped with forceps
midway between the points to be united ; the traction on the cer\'ix is
lessened and the ligament brought into the vagina. A curved needle
armed with kangaroo tendon is then passed through the extreme points
of shortening ; another is passed through the loop thus formed and through
the posterior portion of the cervix below the insertion of the ligament.
The opposite ligament is similarly treated. The sutures are tied after
they are all in place. The vaginal wound is spread well open, and the
two ends of the longitudinal incision are approximated by suture, the
remainder of the wound being closed as though originally a transverse
incision.

FIBROID TUMOR OF THE UTERUS.

Fibroids and Heart-disease. — [Bleeding uterine fibroids may cause
more or less acute anemia, but hemorrhage, as Brosin has shown, does
not necessarily cause heart-disease. In bleeding cancers it was found
that the heart often remained remarkably strong. In any case of fibroid
with cardiac symptoms we must make allowance for, possibly, coincident
heart-disease, for medication, and also for bulkiness of the tumor embar-
rassing the circulation. Pressure on the ureters may indirectly affect
the heart by causing renal disease.] Alban Doran^ states that deaths
which may occur suddenly after the removal of a fibroid of large propor-
tions have occasionally been traced on postrriortem evidence to cardiac
degeneration. It is known that the heart may fail on occasion, following
the removal of any large tumor. To counteract the danger of heart-
» Am. Gyn., vol. i, No. 1, 1902. ^ Brit. Jour. Obstet., Jan., 1903.

470 GYNECOLOGY.

failure spartein answers in some cases in which the kidneys are involved,
but strychnin is universally acknowledged to be the best drug for this
purpose. This latter, however, is useless, if sepsis establishes itself.
The practical value of considering the heart in relation to fibroids and
hysterectomy is that we are often called upon to distinguish shock, both
from hemorrhage and sepsis. The author does think that it is well to
attribute all bad pulse conditions to heart-disease due to fibroids. After
the removal of a large tumor a patient may have palpitations. Circu-
latory troubles are certainly observed in cases of fibroids in which only
moderate hemorrhage or no bleeding at all exists. Syncope during the
period (which was free though never severe) occurred in a case in which
the author removed a fibroid uterus. Pain must be taken into account
as w^ell as free bleeding when the patient with fibroids has fainting fits
during the period. It has been the author's experience that irregular
pulses and attacks of syncope do not in themselves contraindicate opera-
tion; indeed, the patient is all the better for the removal of the tumor.
Other forms of heart-disease may complicate fibroids. The common
valvular changes when compensation has failed do not entail much extra
danger, and the removal of a bulky fibroid proves rather beneficial under
the circumstances. On the other hand, chronic Bright's disease, with a
dilated heart, greatly increases the risk of hysterectomy.

Degenerations and Complications of Fibroid Tumors. — C, P.
Noble, ^ after making a statistical study of 258 cases of fibroid tumors in
his own experience, with their degenerations and complications, and
reviewing the reports of C. J, Cullingworth, C. C. Frederick, and A. Martin,
upon a series of numerous cases, concludes that it is a conservative state-
ment that upward of two-thirds of women having fibroid tumors will die
if not subjected to operation. The contrast with the results which can
be secured by operation is very striking. It probably will not be disputed
that the mortahty of myomectomy and hysterectomy is between 2 % and
10 %, depending upon the gravity of the case, upon the operator, and
upon the enviroment in which the operations are done. It seems a fair
conclusion that the resort to early operation will effect a saving of from
25 % to 30 % in mortality, in addition to the perhaps greater saving in
the morbidity which follows operation, as compared with that which is
incident to the history of fibroid tumors. Early operation in the case
of young women having one fibroid or a few small fibroids affords the
truest opportunity for conservatism by curing these women of their dis-
ease and at the same time retaining their organs of reproduction. It
seems to him that the attitude of the text-books should be reversed, and
that the rule of practice should be to remove all fibroids which come
under observation, unless in a particular case there seems to be some good
reason for temporizing, due either to the small size of the tumor, or to
the advanced age, or to the general health of the patient. Cullingworth^
reports 100 cases of operations for uterine fibromyomas, in 52 of which
the specimens showed more or less evidence of degenerative changes.
Of these, 27 were myomatous, 5 fibrocystic, 18 necrotic, 1 sarcomatous,
1 Am. Gyn., April, 1903. ^ Jour. Obstet. and Gyn. of Brit. Emp., 1902, No. 1.

FIBROID TUMOR OF THE UTERUS. 471

and 1 calcareous. The writer lays especial stress upon the age- of the
patient , myxomatous degeneration being most common between 42 and
52, while necrosis was noted in patients between 36 and 46 years of age.
Pain was a marked symptom in 38 cases, especially in connection with
necrosis and cystic degeneration.

Malignant Uterine Fibroids. — Ulesko-Stroganowa ^ claims to have
established the fact that there is a true malignant fibroid, the leiomyoma
mahgnum of several authors, and that it is commoner than has hitherto
been supposed. The changes originate in the smooth-muscle cells, the
essential part of the tumor. On the other hand, sarcomatous degenera-
tion of a myoma is very rare, and the author has never detected this
condition in any malignant fibroid. As a malignant myoma advances
it assumes the appearance of a mixed sarcoma, yet in every case the tran-
sition from a muscle-cell to a round or spindle cell can be traced. The
walls of the bloodvessels share in the malignant degeneration. In
discussing the subject, Massen believes that this malignant change
accounts for the sudden growth which a fibroid sometimes undergoes at
the menopause. Litschkus insists that this malignant degeneration must
force us to practise hysterectomy and abandon the supracervical opera-
tion. Fenomenoff asks Ulesko-Stroganowa if malignancy can be recog-
nized at an operation. In reply it is stated that it cannot be recog-
nized without the aid of the microscope : 100 cases of fibroid examined
by the author included 10 in which malignant degeneration was detected.

The Cases of Uterine Fibroids treated at the Gynecologic Clinic
in Zurich in the Last 13 Years. — Schwarzenbach^ analyzes the 393
cases which entered the gynecologic clinic of the University of Zurich
during the last 13 years. Flowing and pain were complained of in 345
cases, flowing alone in 116, and pain alone in 86. Urinary symptoms
were present in 108 cases. Sterility was a frequent cause of the patients
applying for treatment. Among 297 married women, 80 were sterile, or
26.9 %. A majority of the women were between 35 and 55 years of age;
261 cases were treated by laparotomy. Castration was practised in 19
cases, with 3 deaths. In 5 of the successful cases who were traced for
from 6 to 12 years, the results were satisfactory, that is, the patients
were relieved of flowing and the tumors diminished in size. Myomec-
tomy was practised on 87, with 13 deaths. Of these, 35 were castrated
at the same time the myomectomy was done and 52 were not. In 18 the
uterine cavity was opened. In one case of myomectomy -with castra-
tion it was necessary to do a supravaginal amputation 7 years later,
because of the development of another fibroid. In those treated by
myomectomy ^vithout castration the flowing was lessened, especially in
the two years following operation, and all the patients traced expressed
themselves as pleased with the results, and in every case the uterus was
found either of the same size or smaller than immediately after the
operation. One of the patients who had a fibroid the size of a man's
fist in the fundus uteri gave birth to a healthy child 15 months after

' Monats. f. Geb. u. Gyn., Sept., 1902.

^ Beitriige Zur. Geb. u. Gynak., Bd. vi, H. 1, 1902.

472 GYNECOLOGY.

operation. Previous to the operation she had had one child, and one
abortion at 3 months. Supravaginal amputation was practised on 109
cases. Up to 1892 the extraperitoneal method of treating the stump was
used, with a mortality of 37.5 %. After 1892 the intraperitoneal method
was used, with a mortality of 7.8 %. Total hysterectomy was done only
when supravaginal amputation was not practicable. There were 46
cases, with a mortality of 23.9 %. It is to be said, however, that of these
46 cases, 31 were done in the year 1900 by improved methods, with a mor-
tahty of 12.6 % only. The author concludes that the supravaginal
amputation is the operation of choice when myomectomy without castra-
tion cannot be done. He thinks that a majority of the patients came
to operation too late; that on account of anemia, weak or fatty heart,
the system is often unable to successfully combat infection, when \Yiih. a
sound heart and the blood in good condition the result is very different.

lodipin in Cases of Uterine Fibroid. — J. A. Shaw-Mackenzie^
has tested the value of iodipin as a remedy for uterine fibroids in 2 cases,
and reports the results, hoping to lead others to similar experiments.
Both were instances of large movable fibroids reaching to the umbilicus.
The treatment in the second case was by hypodermic injection of 2 cc.
of iodipin (25 % in strength) into the cellular tissue of the buttock and
continued injection daily for 10 days on alternate sides, doubling the
dose on the fifth day. On the sixth day the tumor was 2 fingerbreadths
below the umbilicus, and the right lobe was easily defined. On the tenth
day the patient went out of town feeling very well ; but returned on the
nineteenth day, the tumor being much swollen again. The treatment
was renewed, the dose increased in amount, and continued for several
weeks with marked improvement, and in about 2 months' time she
appeared restored to excellent health. The tumor and lobe could still
be felt, but deep palpation was required to make them out. Although
the reduction in the size of the tumor in the first case was not as re-
markable as in the second, still there was a very decided improve-
ment. This treatment does not confine the patient to bed or the house,
nor is there apparently any disagreeable effect.

Myomectomy Versus Hysterectomy. — A. McCosh^ remarks that
in fibromas of the uterus less progress has been made in the direction of
preservation of organs than in other lesions of the pelvis. There is no
question as to the advisability of conservative surgery in those cases in
which the fibroids are small and the organ is not extensively involved;
but when there is severe hemorrhage and pain, and the fibroids are large,
hysterectomy is commonly advised. The writer's judgment is toward
conservatism in these operations. If. an operation for the removal of a
uterine fibroid involved the extirpation of the organ, extreme conserv^-
atism should govern the operator. In cases, however, in which the organ
can be left, operation may be entered upon with more assurance. For
the removal of uterine fibroids the vaginal route offers in a certain num-
ber of cases a suitable approach. If the tumors are subserous, small, and
not very numerous, the uterine body can without much difficulty be
1 Lancet, April 4, 1903. ' Med. News, Sept. 27, 1902, p. 577.

FIBROID TUMOR OF THE UTERUS.

473

turned into the vagina through an incision anterior or posterior .to the
cervix and the tumors extirpated. A disadvantage of the vaginal route
is that there is less opportunity offered for thorough inspection of the
pelvic organs and less facility in performing the operation. The usual
method of reaching these tumors is through the abdomen. The uterus
is brought inio the wound and a careful examination made to demonstrate
whether it is possible to remove all the tumors, and yet leave sufficient
uterine tissue to form a useful organ. The mere fact that the tumor is
interstitial or submucous should not have weight in favor of hysterectomy.
The size and number of the tumors, may also be more or less disregarded.

Fig. 94. — Showing suture of uterus after removal of fibroids (McCosh, in Med. News, Sept. 27, 1902).

The cases in which myomectomy is impracticable are those in which the
uterus is infiltrated with scores of small fibroids extending into the broad
ligament. There are cases in which the tumors are of very large size,
in which hysterectomy must be the operation of choice. In McCosh's
experience, tumors weighing 6, 8, and 10 pounds have been removed,
and frequently their number has exceeded 20, without sacrificing the
body of the uterus. He gives illustrations showing the method of sutur-
ing the uterus after the operation of myomectomy (Figs. 94 and 95).
In conclusion McCosh says that in young women with uterine fibroids
demanding removal, myomectomy should always be the operation of
31 S

474

GYNECOLOGY

choice. This operation is possible in the great majority of cases of
fibroids. The operation is one that requires the strictest asepsis, and
there is about the same danger to life that there is in hysterectomy.
The ultimate results in relation to pain and pregnancy are satisfactory.
Martin^ emphasizes the fact that since the indications for myomectomy
have been so much extended it is important to select a method of opera-
tion which gives the best remote as well as immediate results. He is
strongly in favor of the vaginal route. The size of the tumor is not in
itself a contraindication, since growi^hs of large size can readily be re-
moved through the vagina by morcellation. On the other hand, in the

Fig. 95.— Uterus divided as far as internal os. Coiiiinencement of suture after triniuiing of uterine
walls (McCosh, in Med. News, Sept. 27, 1902).

presence of firm suprapelvic adhesions, especially intestinal, the abdom-
inal route is preferable ; but deep pelvic adhesions and intraligamentary
tumors are best handled from below. Martin fears injuries to the blad-
der and ureter more than he does hemorrhage, especially the former.
He has never injured the ureters during vaginal myomectomy, though
this accident has frequently occurred in his abdominal operations. When
it is possible, he enucleates tumors without removing the uterus. In
young women he tries to leave one ovary. The writer reports the re-
sults of his work during 3 years at the Greifswald chnic — 87 vaginal and
31 abdominal myomectomies. The latter were all complicated, and 6

» Zent. f. Gynak., 1902, No. 14,

FIBROID TUMOR OF THE UTERUS. 475

terminated fatally. Of the vaginal operations, 35 were total hysterec-
tomies, with no deaths, and 52 were enucleations, with 2 deaths.

Hysterectomy for Fibroids. — The operative records of 50 cases of
abdominal hysterectomy for fibroids is given by C. J. Pond,^ from which
he draws the following deductions: The position as to operation de-
pends on the danger to life and the degree of displacement, of ill health
and of suffering caused by the disease. The social condition of the
patient is a factor. Comfortable invalid life is incompatible with poverty ;
therefore the disease must be removed among the poor, in order to return
them to a working capacity. Among the more wealthy classes, moral,
mental, and physical degeneration follow long-continued invalidism,
which would be good grounds for operation, when other conditions per-
mit. Whenever the disease causes displacement, hemorrhage, pain, and
pressure sufficiently severe to threaten damage to the general health, to
the nervous system, or to the pelvic organs, the operation should be ad-
vised. Cervical hysterectomy has a lower mortality (about 4 %) and is
preferable to ovariotomy in this particular. The uterus may safely be
impacted at this level, and the absence of recurrence in the cervix is an
argument for this form as against panhysterectomy. In the former the
pelvic floor is left intact; in the latter it is damaged. Myomectomy is
a valuable operation, and applicable for certain accessible tumors. In all
possible cases one or both ovaries should be left intact and not removed.
Convalescence is more complete and the patient has no artificial meno-
pause.

Superperitoneal Hysterectomy. — MoulUn,^ having secured the
ovarian arteries with a double ligature, cuts between them and extends
the incision as far down as need be through that portion of the broad
ligament which is free from vessels, and then carries it across the face of
the tumor to the opposite side above the bladder, which is stripped down
out of the way. The uterine artery is ligated as close as possible
to the cervix and a clamp placed over the ligature. The amputation
should be at the lowest possible level, the artery being cut below the point
at which it divides. There is no necessity to strip the peritoneum from
the back of the uterus in order to make a posterior flap. After suturing
the stump with chromicized catgut he draws the anterior flap and the blad-
der completely over its face and fastens it with a continuous suture from
one side of the pelvis to the other. The strength of the parietes depends
entirely on the fascia. There must be accurate adaptation and firm
union. The aponeurosis splits to form the sheath of the rectus on each
side. In the lower two-thirds the strongest layer lies in front, the upper
third behind the muscle. The former is separated from the peritoneum
by cellular tissue and fat, the latter is closely attached. In the lower part
he sutures peritoneum, fascia, and skin separately ; above he makes only
two layers of sutures. In hernia the edges of the aponeurosis must be
sought by carrying the incision above and below, the scar-tissue removed,
and the edges approximated.

' Lancet, Jan. 17, 1903. ^ Med. Press and Circ, Jan. 29, 1903.

476 GYNECOLOGY.

SARCOMA OF THE UTERUS.

Sarcoma of the Uterine Parenchyma. — [Sarcoma arising in and de-
veloping from the myometrium as a multinodular newgrowth of the uterus
is a very rare and, from a clinical and pathologic standpoint, one of
the most interesting diseases of the female genital tract.] Henry D.
Beyea^ was unable to find more than 70 or 80 such cases in the literature.
It would seem that no accurate clinical study of this class of uterine sar-
comas had been made. Their histogenesis is undetermined and is a
question which has led to much discussion. Some investigators believe
that they arise through a metaplasia of the muscle-cells of a preexisting
myoma of the uterus and are myosarcoma; others, that they arise in
the connective-tissue cell of such a tumor; still others, that they are pri-
mary sarcomas of the myometrium. It would seem probable that the first
theory was the correct one; possibly some arise from the connective
tissue and others from the myometrium. The author reports a case in
which the histogenesis was most doubtful and impossible to determine.
Knott^ has collected 118 cases, the average age of the patients being
37 years. In 40 cases the disease developed in the muscular wall of the
uterus, in 33 in the endometrium, and in 29 the cervix was primarily
affected. Attention is called to the frequency of sarcomatous degenera-
tion of fibromyomas, especially cervical polypi. Pain, hemorrhage, and
a watery discharge are the initial symptoms, cachexia being a late mani-
festation. The prognosis is bad. The mortality in 86 cases after total
extirpation of the uterus was over 60 %. Pulmonary metastases are
most to be feared.

MALIGNANT DISEASE OF THE UTERUS.

Adenomyoma of the Uterus. — An editorial in "American Medi-
cine"^ remarks that in that department the journal has repeatedly called
attention to the importance and difficulty of early diagnosis of uterine
carcinoma, and emphasized the necessity for more careful clinical study
of the symptoms of this insidious disease. Hemorrhage from the genital
tract after the menopause is almost invariably indicative of incipient
malignant disease and demands careful investigation. The recognition
of malignant disease of the body of the uterus presents unusual difficulty:
it is only by a dilation and intrauterine exploration that we can be certain
of our diagnosis, and often the clinical examination must be followed by a
microscopic test. Operators have frequently seen advanced adenocarci-
noma of the body of the uterus without any change in the size or symmetry
of the organ, or any evidence apparent on the ordinary bimanual examin-
ation. And there has recently been reported one case in which the presence
of a small adenomyoma presented the same perplexing problem in dif-
ferential diagnosis. One of the most interesting additions to gynecologic
pathology during the past year was a contribution to the Philadelphia

' Am. Jour. Obstet., Feb., 1903. ^ Ann. of Surg., 1901, No. 2. = July 5, 1902.

MALIGNANT DISEASE OF THE UTERUS. 477

Obstetric Society by T. S. Cullen, of Baltimore. In the examination
of over 700 cases of uterine myoma at the Johns Hopkins Hospital,
he found 19 specimens of adenomyoma. Many of these were detected
in the early stages, and hence the very beginnings could be followed.
Cullen divides these growths into 3 main groups: (1) Those in which
the uterus preserves a relatively normal contour: (2) subperitoneal or
intraligamentary adenomyomas; (3) submucous adenomyomas. In dis-
cussing the origin of these neoplasms, he observed that formerly the major-
ity of writers thought that they were due to remnants of the wolffian
duct, but now the consensus of opinion is that the greater number at
least are derived either from the uterine mucosa or from a portion of
Miiller's duct. In over half of his cases the uterine mucosa could be
seen extending by continuity into the adenomyoma, demonstrating
beyond peradventure their origin from the mucosa. In the second
place, in no other part of the body, either in the embryo or in the adult,
do we find glands resembling uterine glands and surrounded by charac-
teristic stroma, and, furthermore, the wolffian body contains no struc-
tures that can be mistaken for uterine glands. The uterine mucosa is,
as Sanger taught his students, a definite organ and has a well-defined
function to fulfil. This function is seen in practically every case of
adenomyoma. Adenomyomas are usually detected during the child-
bearing period and give rise to menstrual disturbance varying from a
few months to 10 years or more. The periods are usually more profuse
and painful, but between periods there is, as a rule, little or no discharge.
In 15 cases reported by Cullen the patients were married, and of this
number 9 had had children. In the first group the uterus may be normal
in size, but as a rule is 2 or 3 times as large as normal. It is globular in
form, and often slightly irregular in outline, due to small discrete myo-
mas which are often present. The appendages show a peculiar tendency
to become adherent, and the uterus is often fixed by dense bands of
inflammatory tissue. A sound introduced into the uterus will give no
clue, and curettings will invariably yield nothing but normal mucosa.
We thus see that while we have some clue from the slow increase in size
of the organ and the profuse menstrual period, yet no diagnosis can be
made until the organ is removed. The subperitoneal and intraliga-
mentary adenomyomas cannot possibly be differentiated from ordinary
myomas, sarcomas, or obscure cysts until removal, and the submucous
variety offers no points of clinical variation from submucous myomas.
The prognosis in these cases is very favorable, provided the uterus is
removed before pressure-symptoms have developed. [It is particularly
between the first group of cases and uterine carcinoma of the body of
the uterus that there will be difficulty in the diagnosis, and we use this
contribution as an additional argument in favor of more frequent vaginal
examinations during the fourth decade, and a more rigid determination to
know the cause for all unusual bleeding or menstrual disturbance, even
if in doubtful cases it requires intrauterine and microscopic investigation.]
The Statistics of Cervical Carcinoma. — Borland^ claims that the
1 Phila. Med. Jour., Oct. 4, 1902.

478 GYNECOLOGY.

recently published statements of men of such national repute as Frederick,
of Buffalo; Baldy, of Philadelphia; McMonigle, of San Francisco, and
others, concerning the results of their operations upon cervical cancer
must command the close attention of all gynecologists. Our knowledge
of the extreme fatality attendant upon this condition has been a matter
of gradual development. Twenty years ago it was taught in the medical
schools that of the patients suffering from cancer of the cervix, if seen
early enough, a cure could be wrought by high amputation of the cervix.
The constant and almost inevitable recurrence after this method of
treatment led to an abandoning of the operation, and resulted in the
general adoption of the operation of total extirpation of the uterus.
While with this advance there followed a diminished frequency of early
recurrence, sooner or later the disease reappeared, and other steps were
required to insure, if possible, a nonrecurrence of the growth. Then arose
the school of theorists who claimed that the recurrence was due to an
invasion of the lymph-glands of the pelvis, and that, in order to arrest
the progress of the disease absolutely, these glands must be totally
eradicated. In prolonged operations efforts were made to trace the
lymph-channels to their jEinest radicles, and the broad ligaments and
pelvic contents were, as far as possible, removed in toto. It required but
a couple of years to prove the futility of these methods. The disease
still recurred, and it dawned upon the minds of the theorists, as it had
already been clearly evident to the more practical, that no one could say
when the glands had all been removed. The final surrender of the opera-
tors followed 2 years ago. At the St. Paul meeting of the American
Medical Association, Baldy stated that all of his cervical cancer patients
were dead. Following this bold leader the others fell into line and ad-
mitted that their results had not been as satisfactory as they would wish
them to be. At Saratoga, Frederick made the alarming but probably
correct statement that the condition was a fatal one, and supported his
avowal by the statistics of McMonigle, of San Francisco, who, in 481
hysterectomies for carcinoma, had had 479 deaths from the primary
operation or from recurrence. Such is the present status of affairs.
To all intents cancer of the uterine cervix is, -with the exception of an
extremely small percentage of doubtful cases, an incurable and rapidly
fatal condition.

Age-limit in Uterine Carcinoma. — An editorial in "American
Medicine"^ remarks that although the maximum incidence for the oc-
currence of carcinoma of the uterus is between the fortieth and fiftieth
years, yet the possibility of its development earlier should not be over-
looked, and probably should be more frequently emphasized. This fact
has been brought strongly to our notice recently by the observation with-
in 3 months of 3 patients suffering from well-advanced cervical cancer
before 30 years of age. In two of them the disease was so extensive
as to contraindicate surgical interference. As we have repeatedly said,
eternal vigilance is required for the early diagnosis of this insidious
disease; and these cases in point indicate the necessity for careful exam-

1 June 20, 1903.

MALIGNANT DISEASE OF THE UTERUS. 479

ination and early operation in bad lacerations of the cervix; for it is
extremely rare for a nulliparous woman to suffer from cervical cancer
unless she has been subjected to some operation or instrumental treat-
ment. When the disease occurs early during the period of sexual
activity, its extension is very rapid and recurrence almost inevitable,
so that we are confronted by the melancholy truism that we know little
about, and can do little for, well-defined cases of uterine carcinoma. The
chief prophylactic measure is the repair of lacerations of the cervix which
are extensive enough to produce an eversion of the cervical mucous
membrane, whether they are symptom-producing or not.

The Condition of the Pelvic Lymphatics in Uterine Carcinoma.
— Borland,^ says that to one who has studied the pelvic lymphatic
system, its complexity and enormous ramification must appeal as most
important elements in the prognosis of pelvic malignant disease. The
immense numbers of individual glands, their frequent groupings and close
intercommunication, must act as a rapid means of infection when there
has been once established a focus of carcinomatous change in the cervix
iiteri. That this glandular extension is rapid and ineradicable is amply
proved by the published statements of such eminent pelvic surgeons as
Baldy, McMonigle, and others. These men claim that sooner or later
after hysterectomy for cervical carcinoma a recurrence will inevitably
take place, and they regard the condition as a fatal one. McMonigle
publishes a remarkable record of 481 vaginal hysterectomies with 478
deaths occurring either primarily or, for the most part, from recurrence
in the pelvic glandular structures. A noteworthy feature of the re-
currence is that in the vast majority of cases it takes place below the
cervix, thus showing the inefficacy of the attempt at eradication of the
pelvic glands. To the magnificent work of Emil Ries, of Chicago, must
be attributed most of our present knowledge of the changes that occur
in the pelvic glands in uterine carcinoma. He has made this field of the
pelvic morbid anatomy his special domain, and has elicited much valu-
able information for general use. During the past 8 years he has
endeavored to remove the pelvic glands in carcinomatous cases, and has
always subjected the extirpated glands to careful microscopic examina-
tion. His investigations have covered 10 cases of cervical carcinoma
and over 20,000 sections, the work having been a personal one. He
concludes that invasion of the glands occurs early and inevitably. An
interesting discovery is that the invasion does not proceed from gland to
gland consecutively, but that the carcinomatous emboli overleap some
of the glandular links and lodge in glands well beyond the primary seat
of the disease. There may accordingly exist a number of absolutely
healthy glands between the primary and the secondary foci of the disease.
Again, it has been found that glandular enlargement does not necessarily
indicate a cancerous change. The enlargement may be purely irritative
in origin. Another feature discovered by Ries, and one that has not
been adequately explained, is the frequent presence of a large-cell hyper-
plasia. Large, clear cells with distinct and prominent nuclei may be
1 Phila. Med. Jour., June 6, 1903.

480 GYNECOLOGY.

noted among the thickly crowded leukocytes in the glandular tissue.
The same condition has been observed in tuberculosis, and is not, there-
fore, pathognomonic of carcinoma. Ries has also concluded from his
studies that a constant fluctuation is taking place in the lymphatic system
during pathologic processes. As certain of the glands lose their function
because of the development in them of pathogenic changes, new glands
are formed at any point in the connective tissue. The logical deduction
of these investigations is that in all cases of cervical carcinoma the pelvic
glands should be totally extirpated. The practical conclusion of most
gynecologists is that this much-to-be-desired result is impossible. It is
futile to endeavor to remove the glands in toto; some more or less remote
will be left behind, and in these glandular vestiges sooner or later re-
currence is bound to take place. In a Vienna hospital a histologic and
pathologic study was made of the lymph-glands removed in 141 cases
of uterine carcinoma. Wertheim^ states that in 35 % of these cases the
glands had been attacked by the cancer. In nearly all of these they were
more or less enlarged; but the long, spindle-formed, very thin glands
which lie between and near the large vessels showed no signs of carci-
noma. About 30 % of the cases showed enlarged glands, although no
evidences of carcinoma could be detected, the enlargement being due
to hyperplasia and infiltration. The region most frequently affected
was that between the external and internal iliac arteries and the inguinal
region, toward the obturator foramen. In the other third of the cases
there was not the polymorphic, alveolar formation of the others, but
tubular, cylindric, often cystic cells with mucus-filled spaces. Wertheim
describes in detail the formation of these glands; and in order to answer
the question whether there was any causal connection between their
formation and the presence of uterine cancer, be had two of his pupils
examine the lymph-glands taken from 80 corpses without any cancer,
and in none of these was there a like condition found. Hence he con-
cludes that where the peculiar cell-structure described occurs in the
lymph-glands we have to do, not with anything caused by disturbance
of development, but with metastases of uterine cancer.

Clinical Aspects of Carcinoma in Women. — W. J. Sinclair,^ in his
address in obstetrics at the annual meeting of the British Medical
Association, draws a contrast between pathologic and clinical work which
is not particularly flattering to the former, stating, however, that path-
ology has not been misleading to the gynecologist, for he has never trusted
to its guidance He reviews the older pathology, particularly the work
of Hegar, and lays especial stress upon the necessity for preventing
irritation, maintaining nutrition, studying individual characteristics,
occupation and time of life, and avoidance of infection, as far as possible,
from such diseases as lues and gonorrhea. He considers that recent in-
vestigations have shaken, if not shattered, the whole blastodermic theor\^
He refers to the parasitic theor}^, calling attention to the work of Gaylord,
on the one hand, and the report of the Cancer Commission of the Har-
vard Medical School on the other, the latter body concluding that the

> Zent. f. Gynak., Jan. 24, 1903, ^ Lancet, Aug. 9, 1902.

MALIGNANT DISEASE OF THE UTERUS. 481

work done during the past two years in the study of the etiology of -cancer
has been wholly negative in its results in the sense that an increasing
doubt has been thrown upon the parasitic origin of the disease and upon
the pathologic significance of the so-called cell-inclusion. Sinclair be-
lieves that we have heard too much of cancer as a neoplasm and too
little of it as a disease. If we set aside all consideration of etiology and
pathology and keep in mind only the clinical aspects of the disease,
much has been achieved in the last quarter of a centur}^ The clinical
work has been wholly surgical; what is not surgical is futile; it is hardly
knowledge. So far from the pessimistic view being the true view, the
results obtained by many of the best knoAvn operators continue to
improve and to give the greatest encouragement for continued effort in
the future. They are obtaining better immediate results and the num-
ber of "cures" increases — that is, the percentage of immunity for at
least 5 years after operation becomes greater. The percentage of cases
operable when first seen also increases, because the patients come earlier
for treatment, and improvements in technic have extended the indica-
tions. The proof of all this lies in the statistics of carefully reported
work done under circumstances in w^hich the sources of error are reduced
to the minimum. Sinclair has no hesitation in saying that a large
number of the extended, radical abdominal hysterectomies for cancer are
murderous vivisection which nothing hitherto advanced in their support
appears to palliate, much less to justify. Most of the cases recorded
have been too far advanced for any operation, however radical. The
immediate mortality is terrific and the proceeding unjustifiable, as the
experience of remoter results shows that the patients who escape with
their lives from the operation are no better off in relation to recurrence
than those who have undergone the comparatively safe operation of
vaginal extirpation. Cancer of the cervix occurs almost exclusively
among the prolific poor, the chronically overworked and underfed,
harassed, drained women, who have fissures of the cervix, neglected
lacerations, venereal diseases, and remnants of puerperal sepsis. It is a
different disease from cancer of the body and is bound to decrease as
the social condition, the physical well-being, and the consequent com-
parative happiness of the people improve. Hope of immediate amelio-
ration must rest upon surgery. The general practitioner must be trained
to make an early diagnosis of the disease. He asserts that the presence
of friable tissue in the cervix uteri indicates the existence of disease
which is clinically malignant whatever the microscope may say, and con-
cludes with the statement that if we are ever to arrive at the causation
of carcinoma of the uterus we must reach it by the rigid application of
logical methods of induction to clinical work. [This scholarly address
is convincing that in the present nebulous state of knowledge upon the
etiology of carcinoma the first practical and active duty is to make an
early diagnosis of the disease; and Knowsley Thornton, in an address
given before this same association in 1895, states that an early diagnosis
of malignant disease of the uterus can only be made by clearly neglecting
no menstrual departure from the nonual, however trivial it may be at

482 GYNECOLOGY.

first appearance, by encouraging the patient to describe accurately her
symptoms, and, above all, by insisting in the most determined manner
upon a local examination.]

Mortality from Cancer. — J. M. Baldy^ remarks that but 5 % or less
of all cases of cancer of the cervix uteri presenting themselves for treat-
ment were cured, and that some of these cures were doubtful. For this
analysis he used the statistics of the Johns Hopkins Hospital, the most
reliable and complete as yet presented in this country. Of 141 cases
presenting themselves for treatment, but 15 remained alive after 6 years,
some of the patients having died as late as 5 years after operation. The
time was when Volkmann laid down the dictum that after removal, after
2 years of freedom from recurrence or metastases, a permanent cure was
usual, and that after 3 years, without exception, such a cure was certain
to be the case. This became the universal belief, and is to-day the
cause of the claim of from 20 % to 50 % of cures. We now know this to
be untrue. Labhardt collected 112 cases of late recurrence, i. e., after
the third year. He found that the majority of these occurred in the
fourth to the sixth year after the operation, and he even cites cases of
recurrence in the fourteenth to the twentieth year. He substantiates
the fact that these were cases of recurrence by showing that they all
developed as local growths in the scar from the operation. Not only is
there an indefinite period in which recurrence may take place, as stated
by Duplay, but Labhardt states that there was a late period of metas-
tasis as well in his collected cases. Certainly, in view of all these facts,
we cannot consider a patient cured under 6 years.

Treatment of Inoperable Cancer of the Uterus. — Cucca and Un-
garo^ use the following solution: Methyl-blue, 90 grains; 90 % alcohol
and glycerin, aa 3 drams ; water, 7 ounces. This is applied to the diseased
cervix on tampons after previous curetting. A weaker solution is used
for vaginal and intrauterine irrigation. The results have been quite
satisfactory, patients being kept comfortable and free from hemorrhage
and discharge for months, or even years. Pain was relieved so that morphin
could be dispensed with, and the progress of the disease was evidently re-
tarded. No unpleasant effects were noted after prolonged use of the remedy.
Bramon^ speaks highly of the following method of treating inoperable can-
cer of the uterus and vagina, adopted by Horwitz : A few days after curet-
ment and tamponade with gauze the spray of methylene-blue is applied to
the diseased surface for from 1 to 5 minutes, or until it has been handled
several times. The treatment is repeated in 3 days, and is continued
subsequently at longer intervals. Healthy granulations form, and in
time new epithelium develops. The patient's general condition improves
and menstruation becomes normal. Bramon has observed that under
this treatment a uterus which had previously been fixed may become
movable, probably due to the absorption of inflammatory exudate. At
the previous meeting of the Italian Surgical Society^ Mariani reported 2

1 Phila. Med. Jour., Oct. 4, 1902. * Zent. f. Gynak., No. 22, 1902.

^ Arch. de. M^d. et de Chir. Spec. ; La Gynakologie, April 15, 1902.
* II Policlinico Supplemento Settimanale, April 12, 1902.

MALIGNANT DISEASE OF THE UTERUS. 483

cases of inoperable uterine cancer cured by the endovenous injectibn of
quinin (Jaboulay's treatment). He began by injecting a dose of 25 cgr.
of quinin hydrochlorate, after a time giving hypodermatic injections of
50 cgr. To one woman he gave 35 injections, to the other 30 in 3 months ;
in the latter case the drug was given by the mouth for the last 5 days of
the treatment. A fortnight's interval was allowed in the middle of the
course. In one case pain and metrorrhagia ceased and the ulcer com-
pletely healed; in the other it healed to a large extent. Examination of
the blood before and after treatment showed that in one case leuko-
cytosis had entirely disappeared, and in the other had greatly dimin-
ished. Histologic examination of tissue removed 2^ months after the
conclusion of the treatment showed in one case not a trace of epithelioma ;
in the other epitheliomatous structure was apparent. With regard to
the action of the remedy, the author is inclined to believe that it is due
to the antiseptic properties of the drug, acting either directly on the
microorganisms or neutralizing the toxins produced in the cancerous
tissues. In the discussion Salomoin said he had used the method in 3
cases. In one — an adenoma-carcinoma of the kidney — the result was
good ; he thinks, however, that there was an error of diagnosis, although
the diagnosis was made after an exploratory incision. In the other two
cases — an epithelioma of the lower lip and an osteosarcoma of the lower
jaw — the result was negative. Durante said he believed that quinin
might act on the area of leukocytic infiltration which accompanies mahg-
nant tumors, especially if there is ulceration. But he does not think
there is any ground for looking upon the drug as a means of radical cure.
Tansini had used quinin in a case of inoperable cancer of the breast,
with the result that the evolution of the gro^\i}h proceeded more rapidly
than before.

The ligation of the hypogastric and ovarian arteries on both sides
is advocated by Kronig* in palliative treatment of uterine carcinoma.
In inoperable cancer the cauterization of the cancerous mass often fails
to check the bloody or putrid discharge, and the desired result is better
secured by such ligation, which can be best accomplished through a small
transperitoneal incision between the navel and symphysis. With this
method there is little loss of blood and a brief convalescence. It is best
to ligate the hypogastric artery at its point of departure from the common
iliac artery, and the ovarian at its entrance into the broad ligament. In
suitable cases this procedure may be combined with the cauterization of
the cancer. He thinks the ligation of these arteries is indicated in all
cases in which, after opening the abdomen, it is found inadvisable to per-
form a radical operation.

Operative Treatment of Carcinoma. — T, Wilson^ remarks that the
improved results that have been obtained by Halsted's method of opera-
tion in the treatment of cancer of the breast is stimulating gynecologists
to the endeavor to find a safe operation that shall be attended by similarly
improved results in cancer of the uterus. A, Mackenrddt^ states that at

1 Zent. f, Gynak., Oct. 11, 1902. * Canad. Jour, of Med. and Surg., Sept., 1902.

3 2eit. f. Geb. u, Gyn., Bd. xlvi, No. 1, 1901.

484 GYNECOLOGY.

the Giessen Congress it was shown that by vaginal hysterectomy a definite
cure can be obtained in about 32 % to 40 % of operable cases, and in 10 %
to 12 % of all patients seeking advice for carcinoma of the uterus. These
results, as regards cancer, must be considered relatively favorable, but
they do not appear satisfactory to many gynecologists. A more radical
operation must be based upon ascertained anatomic and pathologic facts.
As regards the pathology of uterine cancer, it is important to note that
the pelvic connective tissue is early implicated, and that often there is
early infection of the pelvic glands. The paravaginal connective tissue
can be almost completely removed through the vagina with the help in
certain cases of a vaginoperineal incision, or of a paravaginal incision, as
in Schuchardt's method. By the latter method Schuchardt has ob-
tained, in a material showing 62 % of operable cases, a definite cure in
24.5 %. Mackenrodt states that Schuchardt, in his operations, has paid
no attention to the danger of infection of the fresh vaginal wound by
cancer, and claims that he himself has obviated this danger by the use of
the actual cautery in making the incisions. Igniextirpation of the uterus
through the vagina has given, in Mackenrodt's hands, 42.8 % of lasting
cures in a material showing an operable ratio of 92.9 %. The difference
of 18 % of radical cures between his figures and those of Schuchardt,
Mackenrodt ascribes to the avoidance of implantation-metastasis in his
method. Preparatory cauterization of the central portion of the mass
does not suffice to prevent cancer-infection of the operation-wound,
because there is an equal likelihood of infection by pieces derived from
the peripheral portion of the growth. Mackenrodt^ believes that the
complete removal of the pelvic connective tissue through the vagina is a
practical impossibility, but he further asserts that in all the cases that
have been sufficiently investigated by him a complete operation was ana-
tomically possible and recurrence avoidable. The removal of the whole
of the glands, and not only of those that are already obviously diseased,
is necessary. Mackenrodt thinks that there is a possibility of obtaining
radical cures in more than 50 % of cases of cancer of the uterus, and as in
cancer there is everything to gain, and very little to lose by operating,
the end to be aimed at is not good statistics, but the definite cure of as
many patients as possible. Influenced by the above considerations, and
being assured that a complete removal of the pelvic glands is from their
anatomic relations feasible, Mackenrodt has sought for a suitable opera-
tive method. He found that the removal of the glands was not possible
through a median lower abdominal incision, and the method he has arrived
at after careful trial is a subperitoneal one carried out through a horse-
shoe-shaped incision. The cancerous growth is prepared 2 days before-
hand by curetting and packing with gauze soaked in 10 % formalin
solution. The operation is briefly as follows : A vertical incision is made
on each side along the lower part of the outer border of the rectus muscle.
The lower ends of these incisions are joined by a transverse cut just above
the pubes. The attachments of the recti to the pubes are divided. The
peritoneum is pushed off unopened from the large abdominal flap, and
1 Berl. klin. Woch., Sept. 11, 1902.

MALIGNANT DISEASE OF THE UTERUS. 485

is cut across above the bladder. The uterus is then drawn up through
the opening and its peritoneal attachment divided all round. The peri-
toneum separated from the anterior abdominal wall is next sutured to the
peritoneum on the posterior pelvic wall from one side to the other. The
peritoneal cavity is thus shut off above, while below the pelvis, with its
contents, lies widely open. The peritoneum is now pushed off the lateral
pelvic wall, and the glands are removed retroperitoneally as high as the
bifurcation of the aorta. Finally, the uterus, and as much of the vagina
as seems desirable, are removed. If the ureters are implicated in the
growth, it is claimed that portions of them can be easily removed, and the
ends implanted in the bladder. As regards the treatment of the wound
left after removal of the uterus, in the first 5 patients operated upon in
this way the whole enormous cavity was stuffed with iodoform gauze, and
the parietal wound closed by sutures. Out of the 5 patients, 4 died from
septic infection that undoubtedly arose from the vagina and the injured
rectum. In several other cases the wound was divided into 4, the bladder
being first sutured to the stump of the sacrouterine ligaments, and the
lower compartment of the wound thus fonned being drained into the
vagina. The upper compartment was then divided into 3 by suturing a
fold of peritoneum to each lateral border of the abdominal flap, and these
3 cavities were separately drained through the abdominal incision by
tubes with gauze. After this method of treatment of the wound, heal-
ing proceeded smoothly in 6 cases.

The studies of J. A. Sampson^ show that carcinoma of the cervix
may form metastases in the small lymph-nodes among the vessels, and
these nodes may have a diameter of not over 1 mm. to 1.5 mm. Owing to
this small size, it may be impossible to feel these either in the para-
metrium or along the pelvic vessels, and they may be discovered only
accidentally or by cutting serial sections. In every case of hysterectomy
for carcinoma of the cervix the lymphatics along the pelvic vessels and
also the parametrium should be removed en masse with the uterus,
because an enlarged gland is not necessarily an invaded gland, and
cancer may be present in very small l3'mph-nodes which cannot be pal-
pated; therefore clinically it is impossible always to diagnose cancerous
lymphatics. Should the ureter be adherent to the parametrium, the
lower portion of it should be sacrificed and all the tissues from cervix
to pelvic wall removed, for if the ureter is dissected free the disease will
probably return and a ureterovaginal fistula will probably occur from
injury to the blood-supply of the ureter. Following out these prin-
ciples, the steps of the operation recommended by the author are: (1)
A preliminary catheterization of the ureters with silk bougies before the
patient is narcotized. (2) After the patient is narcotized she is placed
in the perineal position and a long proctoscope is inserted into the rectum
in order to get rid of any gas or fecal matter. (3) A row of interlocking
sutures is now placed around the vagina 3 cm. below the growth. These
sutures are passed with a large, curved needle, include large masses of
tissue, and extend laterally as far as the needle will permit, while a
» Bull. Johns Hopkins Hosp., Dec, 1902.

486 GYNECOLOGY.

finger in the rectum prevents their being passed too deeply posteriorly.
After all these sutures have been passed, they are tied. (4) A retention-
catheter is placed in the bladder. (5) The patient is now placed in
the Trendelenburg posture and the abdomen opened from symphysis
to umbilicus. After packing back the intestines with gauze, the ovary
on the side on which the ureter is to be resected is grasped by a pair
of forceps and pulled downward and outward so as to make taut the
ovarian vessels and peritoneum covering the iliac vessels. The peri-
toneum is now split below and parallel to the ovarian vessels as high
up as the origin of the internal iliac artery. Beginning at the origin
of this, he dissects downward, removing the fat and lymphatic vessels
from along the iliac vessels, thus exposing the branches and removing
the tissue en masse. One should never dissect upward, for (a) the in-
strument may enter the angle between the branches of the iliac vessels
and may tear off one, (6) by dissecting downward the fat and lymphatics
can be removed en masse, (c) it is safer always to work from a more
dangerous to a less dangerous region. After exposing the vessels down
to the uterine artery, the ovarian vessels and round ligaments are cut.
The uterine artery is tied twice at its origin, taking care to include in
the ligature the vaginal artery, should it arise from the internal iliac,
but not the superior vesical. (6)- The other side is treated in a similar
manner, if both ureters are to be removed; if not, the exposure of the
vessels is the same and the removal of the lymphatics may be similar,
and the uterine vessels are tied and cut at their origin, and then lifted
up and dissected away from the ureter, taking care not to injure its
outer, vascular coat. (7) The uterus is now pulled upward and the blad-
der dissected free from the cervix and not the cervix from the bladder,
for in the former, while there is greater danger of injuring the bladder,
there is less danger of cutting into the diseased cervix. The dissection
is carried on down to the ureters, and, if thought best, one or both are
cut off close to the bladder. (8) The ureter should be amputated just
above the place where the uterine artery crosses it, and all the tissues
lateral to the cervix, including the lower portion of the excised ureter
may be dissected from the pelvic wall. If the lower end of the ureter
is not to be sacrificed, the parametrium is dissected free mesially to the
ureter. (9) The ureterosacral ligaments are next cut, and the rectum
is dissected from the cervix and vagina. (10) The dissection is now
carried on around the growth on all sides and down the vagina to the pre-
liminary catgut ligatures. The gaping opening of the large veins can
be seen in these cases, some thrombosed, and others empty, perfectly
controlled by the preliminary catgut sutures. Wertheim's clamps are
now applied to the vagina and the vagina is cut below them and the tissue
removed. (11) The ureterovesical implantation. The operation at
present takes 2^ to 3 hours, but is justifiable when one considers that
after the ordinary operation recurrences were noted in 87.7 %; with
greater experience no doubt the operation will be done more rapidly
and thus the mortality considerably reduced.

Electrothermic Hysterectomy. — [In the treatment of cancer of

MALIGNANT DISEASE OF THE UTERUS.

487

the uterus hemostasis has always been most important for those .cases
that do not stand the loss of blood well. Another important point
in this disease is that we should hemostase in the tissues as far removed
from the uterus as possible, with the view of going bej'ond the limits
of malignancy.] A. J. Downes^ insists that all malignant cells at the
line of section should be killed ; the lymphatics leading from this line should
be sealed and rendered nonabsorptive. Electrothermic hemostasis alone
can fulfill these requirements. The outfit for electrothermic hysterec-
tomy consists of 3 angiotribes, all alike except in the size of the blades,
which vary in width only (Figs. 96 and 97). The heating apparatus is

Fig. 96. — Downes's angiotribe with narrow blades, useful in lieiuostasis. It can be applied deep in
the pelvis and as a hemorrhoidal forceps. The blades are released by pressure on the handles (Am. Gy n.
Dee., 1902),

Fig. 97. — Downes's electrothermic anglotribe with blades % or >^ inch wide. Has a lever at end of
handles to maintain maximum pressure. Blades released on removal of lever (Am. Gyn., Dec, 1902).

such that the acting blade can be brought to the proper temperature in
from 10 to 20 seconds according to the size of the blades. The cable is
made in two parts: one, which does not require sterilization and brings
the current from the transformer to the operating-table; the other,
flexible and covered with lava strips, can be sterilized and be placed
with the instruments. They are connected at the edge of the operating-
table. The author's knife is required. When there is no street current,
a storage battery of 75 ampere hours' capacity when fully charged will
give sufficient current for the 3 major operations. By this method the
author has performed 5 hysterectomies for cancer. The forceps are
applied as in the application of the angiotribe, and then the uterus is cut
away by means of the electrocautery knife. The operations were less
bloody than by the ligature method. As a t3'pe of operation that can
be done by this method, it can be said that any hysterectomy that can
be performed by ligature can more readily be done by electrothermic
hemostasis. The writer thinks that any operation so practicable as

^ Am. Gyn., Dec, 1902.

488 GYNECOLOGY.

this method is worthy of serious consideration and should be given a
fair and honest trial.

X-rays in Cancer of the Cervix. — At the ninety-seventh annual
meeting of the Medical Society of the State of New York/ S. Scully
(Rome, New York) said that the present treatment of cancer of the
cervix uteri was rather discouraging. If found at an early stage, and
complete hysterectomy were done, there was some hope of saving the
patient's life. Nothing short of hysterectomy, however, gave the patient
any hope. In later stages it was recognized that the cases were prac-
tically hopeless. Even under the most favorable circumstances, however,
complete hysterectomy was followed by an alarming number of recur-
rences with fatal results. The first case that came under his attention
after he had resolved to employ the a;-rays was a so-called cauliflower
growth of the cervix. A metal shield was used at first, but this pro-
duced electric induction difficulties, and was liable to cause local
irritation. After the first employment of the x-rays the patient began
to improve, and the growth gradually sloughed away. The tendency to
hemorrhage ceased after a few applications, and other parts of the growth
began to shrivel up. After a number of applications the woman felt
so well that, as she was summoned to a distance by her daughter's con-
finement and serious illness, she gave up treatment, and had written that
she considered herself cured. In the second case in which Scully em-
ployed them the x-rays at once gave relief from pain in urination, and
relieved the discomfort which had existed for a long time. There had
been a very offensive discharge, which began to diminish at once, and
ceased entirely in a few weeks. At the date of the reports, as the result
of some 15 applications of the re- rays, the cervix was practically ob-
literated, the patient had gained in weight, the ulcerating parts were
healed over except at one portion of the posterior vaginal vault, and the
outlook was most promising. The patient herself was very well satisfied
with the results obtained, and there seemed to be every reason to think
that the local condition at least had been obliterated. All cases treated
had been benefited. Scully considered that while the present knowledge
of the x-rays did not justify the putting off of operation in cases in which
the disease had not advanced very far, the x-rays should be employed in
most cases of cervical cancer. In advanced cases, where palliative opera-
tions were employed, this method should always be considered, even
after hysterectomy. Treatment by the x-rays might prevent the devel-
opment of recurrences.

AFFECTIONS OF THE PELVIC ORGANS.

Primary Carcinoma of the Fallopian Tube. — According to Graefe,^
Orthmann reported the first sure case of primary tubal carcinoma in
1888. Subsequentl}^ Zangemeister published a table of 52 cases, but
in 14 years few more have been added to this list. In comparison with
ovarian and uterine cancer the tubal form is exceedingly rare. Graefe

> Med. News, Feb. 7, 1903. ^ Zent. f. Gynak., Dec. 20, 1902.

AFFECTIONS OF THE PELVIC ORGANS. ^ 489

adds another to the list. When he first saw the patient he found an
enlarged retroflexed uterus, a sausage-like tubal tumor the size of an
orange, and a small mucous polyp hanging from the external os. The
diagnosis was hydrosalpinx and pyosalpinx, and because of the blood-
colored watery discharge the possibiHty of a tubal cancer was recognized.
L'or this reason celiotomy was advised, but refused. Hydrastis was em-
ployed and a large Meyer's ring introduced, under which treatment the
discharge ceased and the patient's general condition was much improved.
When Graefe saw her 2 years later, for 3 months she had been suffeHng
from a yellowish discharge and severe abdominal pains. The tubal
tumor seemed unchanged, the uterus was smaller, and just below it
was a movable tumor the size of a child's head. She now consented to
an operation, and a right-sided intraligamentous ovarian cyst was re-
moved, also the left-sided tubal sac. Her convalescence was undisturbed,
and 8 months after operation she was in good condition. The tubal sac
was opened and emptied of a pure serous fluid, and situated on its thin
walls a tumor the size of a chestnut was found, which the microscope
showed to be a papillary carcinoma. This case is an evidence of the
long time that a carcinoma may remain in a tube in a benign form. The
writer suggests two causes for its slow growth — the pressure of the
Meyer's ring upon the tubal sac, and the complete closure of the uterine
ostium of the tube with the cessation of the usual discharge. At the
time of the operation there were nowhere any signs of metastasis.

The Nature of Hydrosalpinx. — In a review of the clinical aspects
of 20 cases of this variety of tubal disease the following ideas are ad-
vanced by Clement White ^: In 9 instances the old view that hydro-
salpinx is a stage of salpingitis cannot be disproved, for the condition
followed extrauterine pregnancy or gonorrhea. In 8 of these the balance
of evidence was in favor of the closure of the ostium of a healthy tube by
the peritoneum in the way suggested by Cullingsworth. Of the cases, 10
were, in his opinion, a retention-cyst, a tumor sui generis, independent
of neighboring organs and due to faulty development. In one case the
condition seemed to be due to peritonitic closure following an extra-
uterine gestation. Uncomplicated cases of hydrosalpinx are rare.
Some definitely are symptomless until some accident interv^enes, such as
sudden enlargement of the tumors, or pelvic peritonitis, or growth of
another tumor. Pain in the hypogastrium and vagina are by far the
most prominent symptoms. There is some pain at the end of menstrua-
tion. Dyspareunia and dyschezia are fairly common, as is congestive
dysmenorrhea. Menorrhagia and irregularity of menstruation are ex-
ceptional. Menstruation is scanty in cases of hydrosalpinx; in fact, in
one case, in which there were frequent attacks of pelvic inflammation, is
almost the only marked exception to this rule. This single point would
make one chary of accepting the view that hydrosalpinx is merely a
stage of salpingitis. Irregular and excessive menstruation is one of the
most common and constant symptoms of salpingitis. The hydrosalpinx
is a retention-cyst, most authors agree. That some cases are little more

' Brit. Jour. Obstet., March, 1903.
.32 S

490 GYNECOLOGY.

than a catarrhal salpingitis with an excessive amount of fluid retained,
the author is disposed to admit. That some are due to an edematous
condition in the final stages of kidney-disease is also probable. That some
are due to peritonitic closure of a healthy tube seems also to be true.
But many of the cases in which the ostium is such as is commonly de-
scribed as due to salpingitic closure of the tube are cases of impervious
ostia due to faulty development. It is in this class of cases that Bland-
Sutton has pointed out that a small pedunculated cyst is often present,
whether due to a hydatid of Morgagni or Kobelt's tube he does not know.
At least the author would insist that the clinical history in too large a
proportion of his cases to be negligible is not the history of a salpingitis,
but is often marked by an absence of diagnostic symptoms, and the
symptoms which are present are such as are found in cases of maldevel-
opment, namely, sterility, pain, scanty menses, dysmenorrhea, and
dyspareunia.

Leukocytosis in Pelvic Suppuration. — Diitzmann^ reports 165
cases in which he was enabled to establish the presence of pus in the pelvis
before operation. Pus was never found when the blood-count was nor-
mal. The writer was even able to infer the cause of the suppuration
from the number of leukocytes, a count of 20,000 to 30,000 pointing to
streptococcus-infection, while one of from 11,000 to 13,000 was commonly
associated with the presence of gonococci or colon bacilli. In peri-
tonitis and septic infection an increase in the leukocytes is a favorable
sign, even in the presence of persistent elevation of temperature. If,
on the contrary, there is no increase while the temperature is high, a
fatal termination may be expected; this is probably due to deficient
phagocytosis. Lavbenburg^ repeats the observations of Diitzmann,
with whose conclusions he agrees, adding some interesting deductions of
his own. He finds that in cases of suppuration there is a diminution of
the red corpuscles, with a rapid increase in the white. The latter gradu-
ally diminish in number after the acute stage, to increase with each
exacerbation. The leukocytosis varies directly according to the intensity
and extent of the suppurative process. If it is limited, the number of
white corpuscles soon sinks to normal; in protracted febrile cases the
leukocytosis varies with the different phases of the disease, the red cor-
puscles behaving in the opposite way. The influence of the patient's
constitution upon the leukocytosis is quite striking. In a subject who
is exhausted by a long illness or by loss of blood, an" increased leukocy-
tosis may persist even after the pus-focus has disappeared. The pos-
sibility of mistaking true leukemia for a temporary increase in the white
corpuscles must be borne in mind. The increase in eosinophil cells and
the presence of large mononuclear cells with neutrophil granules, not seen
in normal blood, would settle the diagnosis. Moreover, it must not be
forgotten that increased leukocytosis may be present in connection with
wasting diseases, fevers, and cancer, and that there are daily variations,
especially during digestion.

Pus in the Female Pelvis. — [The occurrence of a purulent collec-
1 Zent. f. Gynak., 1903, No. 47. ^ Zent. f. Gynak., 1902, No. 22.

AFFECTIONS OF THE PELVIC ORGANS. 491

tion in the female pelvis is due in most cases to inflammatory disease of
the ovary or tube, and under the caption of pyosalpinx or tuboovarian
abscess this has been extensively discussed by gynecologists. Pelvic
cellulitis is now recognized as a rare condition, and while the cellular
tissue at the base of the broad ligament or anterior to the uterus may
become infected and form an abscess, yet the condition pure and simple
is seldom observed. Tubal and ovarian abscess, suppurating fibroid and
abscess of the uterine wall, hematocele (such as ruptured extrauterine
pregnancy which has become infected), suppurating dermoid and ovarian
cysts, and, lastly, appendiceal disease, may be causes inducing an ab-
scess in the pelvis.] A. J. Puls^ remarks that the traumatic influence
on diseased tissue is clearly shown in the case of catarrhal appendicitis
reported by Rose. A laborer with this condition received a bruise over the
abdomen, developed peritonitis, and died, although there was no evidence
of perforation. Similarly, exposure to cold, or a local injury, can inflame
healthy tissues. Both the vermiform appendix and the sigmoid flexure of
the colon, as well as other parts of the intestinal tract, when once glued to
the uterine appendages by peritoneal adhesions, may by their contiguity,
under the influence of traumatism, give rise to intrapelvic suppurative
inflammation. Inflammatory processes in either the appendix or right
uterine appendage may affect both, and ascend or descend along the
connecting ligament either intraperitoneally or extraperitoneally. The
puerperium offers the most favorable conditions for infections. Lacera-
tions of the cervix or perineum, erosions and ulceration of the portio
vaginalis, are open doorways for virulent genns. Purulent salpingitis
is, as a rule, the sequel of an ascending endometritis. Abscesses of the
uterus are formed in the wall of the organ. The pus escapes through
the vagina or breaks into the parametrium, or finds an outlet by way of
the bladder or rectum. Exudations near the uterus take place in the
intercellular tissue within the uterine ligaments. According to its loca-
tion, we designate an anterior exudate precervical when within the vesico-
uterine folds. It is called paravesical when in the space of Retzius.
The lateral parametrial exudates are defined according to their position
at the base of the broad ligament or higher up between the lamella
toward the pelvic brim. Posteriorly the exudate fills the culdesac of
Douglas between the sacrouterine ligaments and descends into the recto-
vaginal septum. Intercellular accumulations of pus seek first an outlet
into an adjacent viscus; next they follow along the sheaths of the nerves
and bloodvessels which leave the pelvis. Parametrial abscesses rarely
rupture into the free peritoneal cavity. A precervical abscess burrows
into the bladder. Paravesical abscesses point in the inguinal regions.
Lateral abscesses situated in the broad ligament fill the iliac fossa and
then point at the anterior abdominal wall, near Poupart's ligament. In
chronic posterior parametritis the ligaments are shortened and con-
tracted, causing acute ante version of the uterus and frequently devia-
tions of the cervix uteri. Pelvic hematocele, as the result of rupture
of a tubal pregnancy, sooner or later becomes infected and undergoes

• Am. Gyn., Sept., 1902.

492 GYNECOLOGY.

pus-formation unless absorption of the blood occurs. The treatment of
pelvic suppuration consists, without exception, in securing effectual
drainage. Paravesical abscesses and those in the broad ligament should
be incised above Poupart's ligament, analogously to the incision for liga-
tion of the iliac artery (external branch). Tubal and ovarian abscesses
should be drained through the vagina. Hysterectomy is justifiable when
there must be complete loss of functional activity for the adnexa. Our
one aim should be to avoid abdominal drainage and to substitute vaginal
drainage.

Inflammation of the Uterine Appendages. — Barbour^ says that in-
flammation of the uterine appendages has received attention only during
the last 20 years, and was not recognized until the days of abdominal
section. Although the part played by germs is well established in the
gonorrheal, tuberculous, and acute septic forms of inflammation, their
presence has not been proved in all cases. The normal vaginal secretion
has been shown to have a distinctly germicidal action. Menge and
Kronig maintain that the distinction between physiologic and pathologic
vaginal secretions does not hold that all are equally germicidal, but that
different germs vary greatly in vitality. Menge tested the efficiency and
rapidity of the germicidal action by introducing pyogenic organisms into
the vagina in 80 cases, and found that the vagina cleansed itself from
these in periods varying from 2^ hours to 3 days. Barbour gives as
the 4 symptoms of inflammation of the appendages: Dysmenorrhea,
monorrhagia, pelvic pain more or less continuous, and sterility. Steril-
ity and dysmenorrhea with scanty menstruation indicate inflammation
of the uterosacral ligament ; but profuse bleeding means that most prob-
abl)^ the appendages are involved. He distinguishes between dysmen-
orrhea which is periodic and the continuous pelvic pain due to act ive
congestion of diseased structures. Sterility naturally results from adhe-
sions of the ovary and the fimbria, and from destruction of the ciliated
epithelium of the tube. The normal tube cannot be felt in ordinary
bimanual examination, and if the ovary and tube are distinctly palpable
it means they are enlarged by chronic inflammation. Nonoperative
treatment consists of antiseptic douches, tonic aperients, and other
internal remedies. Rest is of first importance. Tampons favor rest by
supporting the ovaries; glycerin-tampons induce removal of serum from
the inflamed tissues and ichthyol causes absorption. The minor opera-
tion of cureting is of value in those cases in which the inflammation of
the appendages is secondary to that of the endometrium and is relieved
when the diseased endometrium is removed by the curet. Dilated tubes
which may rupture call for immediate operation and removal. A second
indication for removal is profuse menstruation which is pulling down
the patient's strength and will not yield to ergot or to cureting.

Operative Treatment of Chronic Parametritis. — Von Ott^ finds
that pelvic massage is beneficial only in certain cases of chronic para-
metritis. When there is abundance of cicatricial tissue, such treatment is
useless even when continued for months and years. But the patient

' Scottish M. and S. Jour., Sept., 1902. ^ 2ent. f. Gynak., No. 32, 1902.

ABDOMINAL SECTION. 493

needs active treatment, as subacute attacks come on frequently in tJiese
cases and greatly impair the patient's health. The scar-tissue compresses
the bloodvessels and lymphatic vessels and nerves and drags on the pelvic
and abdominal viscera. Sterility is, of course, very frequent. To leave
a case of this kind to chance is wrong, and Von Ott finds that there are
means of relief. His practice is to divide the cicatricial bands freely;
then each raw surface is closed by suture as in pylorostomy so that its
short axis is made long. There is no rule for operating; much depends
on the position of the scar-tissue, but the principle remains the same,
namely, division of the band and the insertion of sutures placed so as to
counteract the contraction of adjacent parts. The division of scar-tissue
in the broad ligament is specially difficult and dangerous, as not only
bloodvessels but also the ureter may be wounded. Hence a catheter
should be passed into the ureter. Von Ott finds that, as a rule, the
wounds made by dividing the scar-tissue heal by first intention. He has
operated on numerous cases for over 3 years with good results.

Conservative Surgery on the Adnexa. — Reahzing the many dis-
advantages that most women labor under after having undergone the
recognized mutilating operations upon the genital organs, J. Kiriac^
proposes a conservative operation that is believed to be entirely original.
The operation not only frees the diseased organs from the unhealthy
parts, but preserves either the ovary or tube in its totality. The ovary
is freed from its adhesions and brought out of the wound. It is then
divided from end to end, as in treating a kidney. The two cut surfaces
are then carefully examined. All cysts and diseased portions are re-
moved. This operation is called by the author "scapsy," from the
Greek "scapto," to sculpture or to hollow out. If the ovar}^ alone is
operated upon, it is " ooforoscapsy" ; if the tube is in question, it is called
"salpingoooforoscapsy," or, more briefly, "parartimatoscapsy." After
having removed the diseased parts with a curved bistoury' or a pair of
scissors, the two fragments are brought together, that is to say, the organ
is reconstructed. If there has been much tissue removed, two sets of
sutures are necessary to hold the parts together: a deep, retention-layer,
and a superficial layer. In the case of an enormous destniction of
either organ by abscess or cystic formation, the best procedure is to
remove the whole organ, as there is nothing remaining to be preserved.
This method of operating has given excellent success in 6 cases.

ABDOMINAL SECTION.

The Suprasymphyseal Incision of Pfannenstiel. — [Various methods
of opening the abdominal cavity have been exploited within the past few
years, having the common object of avoiding in part or wholly the dan-
ger of hernia through the abdominal wall, which follows any operation in
this field frequently enough.] O. Beuttner^ offers the following notes on
his experience with Pfannenstiel's suprasymphyseal incision through
the fascia. Disinfection of the skin in which the hair about the genital

' Gaz. de Gyn., Jan. 15, 1903. * Z'blatt. f. Gynak., 1902, No. 30.

494 GYNECOLOGY.

organs grows must, of course, be very painstaking. He has found an
admirable addition to the usual method of cleansing the skin to consist
in several liberal applications of tincture of iodin. The fact that the in-
cision passes through the skin in this very region is one of the difficulties of
this operation, but may be surmounted. The skin-incision itself he
has planned, like Pfannenstiel, through the transverse furrow, which is
usually present in this situation, especially in women, just above the
mons veneris. He then differs from Pfannenstiel in that, instead of
loosening the skin and subcutaneous tissue from the fascia itself, he carries
his incision directly through all tissues until he reaches the fascia. The
object of this slight though important modification is to avoid so far as
possible the creation of a "dead space" by an undue loosening of the
superficial from the deep structures. The other steps are the same as
those of the author of the original operation. He shuts the peritoneal
cavity in such a manner that a continuous silk suture of the peritoneum
begins at the upper end and ends near the symphysis. He also uses silk
in replacing the recti muscles and in suturing the fascia, and again for
the skin. He aims to secure as much pressure as possible by the bandage
over the region of the wound, so that no leakage from bloodvessels shall
occur. Heil^ warmly recommends Kiistner's suprasymphyseal crucial
incision (transverse skin incision, vertical muscle, and peritoneal in-
cision) in cases of ventrofixation. He says it offers the best cosmetic
effect; it makes the wearing of an abdominal bandage unnecessary; it
diminishes the danger of hernia. It can also be used with good results in
cases of removal of tubes and ovaries. He avoids the formation of post-
operative hematomas by the use of sandbags for from 24 to 36 hours
after the operation. He reports his results in 12 cases of ventrofixation,
which were perfectly satisfactory. In none of them had he to contend
with the complication of hematoma formation.

Mortality in Pelvic Operations. — A series of 100 consecutive ab-
dominal operations for pus in the pelvis with 2 deaths is discussed by
Hunter Robb.^ From a consideration of the bacteriologic and operative
questions he believes that the mortality following operations for disease
of tubes or ovaries can be kept under 5 %. The virulence of the specific
organisms present, the individual resistance of the patient, the time and
manner of carrying out the operative technic, largely influence the death-
rate. Streptococcus pyogenes is usually the most virulent germ. As the
organisms are generally dead, abdominal drainage is seldom called for,
and is necessary only when it is impossible to remove the suppurative ^
structures or when bowel-perforation is feared from the separation of
adhesions. The pus and its products may be satisfactorily removed
by irrigating the pelvic cavity with salt solution. Leaving from 300 to
500 cc. in the abdominal cavity dilutes and promotes the rapid absorp-
tion of inflammatory products. This and elevating the foot of the bed
for 24 hours tends to prevent the intestines and omentum from coming
in contact with the immediate field of operation and diminishes the
liability to adhesions. Should symptoms of infection follow the operation,

* Miinch. med. Woch., Nov. 11, 1902. ' Jour. Am. Med.'Assoc, Jan. 17, 1903.

ABDOMINAL SECTION. 495

there is usually sufficient time to open the abdomen and wash out
all infectious material. The author thinks that operations for pus in the
tubes and ovaries from the standpoint of the pus per se are not sur-
rounded by any more danger, as a rule, than those in which a purulent
focus is not present.

The Trendelenburg Position. — M. Jayle^ has shown that if there
is anything new under the sun that novelty is not the Trendelenburg
position. Elevation of the pelvis was practised by ancient surgeons
in operations for hernia. Roger, of Parma, and Salerno, who seems to
have lived about the beginning of the thirteenth century, in directing
how to prepare a man for herniotomy, wrote: "First, let the patient
be placed on a bench with the head and shoulders downward, so that all
the intestines may sink away toward the thorax. The hips and legs must
be kept elevated." Roger clearly understood the mechanical advantages
of this position. It is the falling away of the viscera from the pelvis
that makes the elevation of the hips so convenient an aid in pelvic sur-
gery. Roland, of Parma, and Brunns in the fourteenth century both
give the directions detailed by Roger. But in 1749 an anonymous
French author showed that Roger, Roland, and Brunns had copied
Albucasis very freely without acknowledgment, and we now know that
the Spanish-Moorish writers on medicine largely borrowed from classic
authors whose works are lost. Hence, elevation of the pelvis probably
originated in the practice of Greek and Roman surgeons. Guy de
Chauliac, in the fourteenth century, admitted that elevation of the pelvis
was practised in Moorish Spain. Roland furnished his readers with an
instructive drawing of a herniotomy, reproduced by Jayle; the patient's
head is very low indeed, but Jayle also adds to his instructive article a
woodcut of radical cure of hernia from the work of Scultetus. In this
instance the patient's head and shoulders are depressed about as much
and no more than when modern operators open the abdomen to remove a
pelvic tumor. Ambroise Pare, in his directions for taxis in a case of
scrotal hernia, directs that the patient be placed on a bed or table with
his head down and his nates elevated. The history of the reintroduction
of this practice of raising the pelvis is probably well known to our readers.
Freund in 1880 advocated the raising of the legs of a female patient by
two assistants as an aid to exploration of the pelvis for diagnostic pur-
poses. It was in 1885 that Willy Meyer wrote his work on the practice
of Trendelenburg, who was accustomed to elevate the pelvis when placing
the patient in the lithotomy position. The falling away of the viscera and
the effects of the position on the circulation were strongly urged as highly
advantageous to the operator. In 1888 Mendes de Leon strongly recom-
mended the Trendelenburg position both for operations on the pelvic
organ and for gynecologic exploration. He simplified the preliminary
arrangements by fixing a chair in such a manner that the patient could
be kept with the pelvis elevated during the operation without the aid of
an expensive table specially constructed for the purpose. , At the present
day the position is widely adopted. It is rightly associated with the
» La Presse M^d., June 25, 1902, No. 51, p. 603.

496 GYNECOLOGY.

name of a distinguished contemporary German surgeon, but perhaps, in
accordance with general surgical nomenclature, it might more simply
be termed "elevation of the pelvis"; indeed, Trendelenburg himself
emplo^^ed the name Beckenhochlagerung .

Drainage after Laparotomy. — Olshausen^ divides operative cases
into 4 classes : (1) Cases in which during operation pus or fetid material
has proceeded from the operative field. (2) Cases in which partly extir-
pated tumors with raw surfaces remain behind. (3) Cases with per-
forated injuries of intestines or bladder. (4) Cases unclean through
much soiling of the abdominal cavity with cyst-contents, old blood, etc.
Because of the large proportion of cures in these 4 classes, recovering
without drainage, he concludes that drainage is superfluous and repre-
hensible. Sippel, however, does not accept this conclusion. While he
would not drain in the last two classes, in the second he might drain with
tampons according to Mikulicz, and in the first he advocates ordinary
drainage as the more certain method. One cannot say with certainty
in any case that the patient will die without drainage or will live if drain-
age is employed. Much depends upon the sterility or virulence of the
pus, also upon the resisting-power of the abdominal surfaces and their
power of absorption. But Sippel thinks no convinced advocate of drain-
age would abandon the feeling of certainty which it gives for the risks of
the opposite method in critical cases. Sippel also advocates abdominal
irrigation for cleansing purposes, and in his experience has never seen it
cause shock or check the heart-action, though he has often seen it have
a distinctly favorable influence upon the pulse. M. Hofmeier^ disagrees
with Olshausen in his condemnation of drainage in any form as super-
fluous and often positively harmful. He considers drainage in many cases
a proper precautionary measure, whose importance it may be difficult to
prove positively, but from which, when properly performed, he has never
seen any injury. He discusses methods of drainage, apparently in most
cases preferring an open tube to a gauze drain, yet adapting methods to
the peculiarities and necessities of each case.

The Control of Hemorrhage in the Removal of Pelvic Tumors. —
Herman Pearse^ believes that the best way to control hemorrhage in the
removal of pelvic tumors in the female is to search out and control the
vessels that are the source of the hemorrhage as early as may be in the
operation. When the tumor is parovarian and its growth takes it be-
tween the layers of the broad ligaments, in all broad-ligament cysts, in
intraligamentous fibroids of large blood-supply and intimate connection
with the surrounding tissues, and in extrauterine pregnancy with intra-
ligamentous rupture, it is better to tie off the superficial blood-supply
at all points along the pelvic side, and then, instead of tying again on the
uterine side, go to the healthy side, including the uterus and healthy
adnexa in the occlusion, and do a panhysterectomy from the opposite
(healthy) side, coming upon the deep blood-supply of the growth from
below and behind. The electrothermic clamp is a valuable instrument.

•Zent. f. Cyniik., Feb. 7, 1903. ^ Zent. f. Gyniik., Feb. 21, 1903.

' Ann. of Gyn. and Fed., Jan., 1903.

ABDOMINAL SECTION.

497

Ligation is the best method for controlling bleeding vessels. Suitably
prepared chromicized catgut is preferred to silk or any of the other liga-
ture materials.

A. J. Downes^ states that his experience with his method of electro-
thermic hemostasis warrants the conclusion that there is less pain after
abdominal operation with electrothermic hemostasis than with the use
of ligatures. The operations are quite bloodless. In addition to the
hemostasis, there is a sealing of the lymphatics. This is a valuable aid
in preventing the recurrence of cancer. Transplantation through the
desiccated surfaces is impossible. In appendicectomy this method is
superior to the other methods in vogue. The accompanying illustration
(Fig. 98) shows the instrument applied in the operation of hysterectomy.

Fig. 98. — Downes's method of electrothermic hemostasis. Uterus with blades of angiotribe in place on
broad ligament (Jour. Am. Med. Assoc., July 12, 1902).

The Scope of the Vaginal Incision. — The greatest stimulus to the
treatment of pelvic and abdominal diseases by the vaginal route was
inspired by the work of Pean and his followers. This line of work was
quickly adopted by the Germans, and in due course of time, says A. F.
Currier,^ it was employed by operators all the world over. By vaginal
incision is meant any vaginal cut, whether it be anterior to the vaginal
portion of the cervix, circular, or posterior to it. The circular incision
has its sphere of usefulness almost exclusively in those cases in which
the uterus is to be removed, with or without the appendages, whether for
cancer, fibroid tumor, prolapsus, or any other condition. The range of
usefulness of the anterior incision, with its modifications, is somewhat
more extensive. Currier thinks that it is less useful than the posterior
incision because of the space limitation by the pelvic bones, the proximity
of the bladder, and the relative narrowness of the vagina compared with
the posterior vaginal fornix. The posterior incision with its modifica-

' Jour. Am. Med. Assoc, July 12, 1902. ' Ann. of Gyn. and Ped., May, 1903.

498 GYNECOLOGY.

tions affords the greatest possible working space, and it is this variety
which gives the vaginal route of surgical treatment its greatest sphere
of usefulness. Hemorrhage after vaginal section can be most easily
checked by pressure, provided there be no large vessels involved, and
there is a less severe tax to our mental equilibrium than in the more
formidable operation of opening the abdomen. Hernia is less liable to
occur, and when it does, it can be cured by a few well-placed stitches.
The most frequent indication for the anterior incision in operations upon
the uterus is in retroflexion. It may occasionally prove valuable in
making a diagnosis of diseased condition of the anterior portion of the
pelvis. The following are the indications for the employment of the
posterior incision: (1) For diagnosis; (2) in pelvic exudates, whether
adhesive bands, plastic deposits, or collections of pus; (3) tumors of the
appendages ; (4) pedunculated uterine myomas ; (5) intraligamentous cysts ;
(6) displacements of the uterus and appendages ; (7) accumulations of fluid
in the pelvic or abdominal cavity, not encapsulated or isolated; (8)
some exigencies of parturition and of the puerperal state. There are
doubtless other indications for the vaginal route. The most of those to
which attention has been called have been suggested by his personal
experience or observation. This method of operation is of especial
advantage in operating upon the uterine appendages, according to J. M.
Branham,^ The author has successfully employed it in (1) pelvic in-
flammation, (2) neoplasms, (3) myomas, (4) extrauterine pregnancy.
Here it is of especial advantage. If the case is of several days' standing
and an elevated temperature would indicate that there existed an infec-
tion, vaginal drainage is the natural method ; it is by far the more effective
and the safer. Extensive inflammation associated with pus-formation
rapidly walls off the general peritoneum ; this wall should not be broken
through and cannot be interfered with without danger of general peri-
tonitis. Opening through the vagina is associated with a minimum
amount of shock and hemorrhage, and is thus indicated in grave cases
associated with severe toxic symptoms. While freer dissection in the
lateral plane (pelvic) for infiltration complicating uterine cancer can be
made through the abdominal route, yet the less thorough dissection of
the surrounding vaginal wall and the greater danger of transplan-
tation (operative), with increased mortality due to shock and infection
by it, render vaginal hysterectomy the safer operation and the one to
be advised in most cases.

COMPLICATIONS DURING AND AFTER ABDOMINAL OR
VAGINAL SECTION.

Peritoneal Adhesions. — B. Jessett^ thinks it is probable that in a
large majority of cases of celiotomy subsequent adhesions are formed and
pain is sure to follow; the surgeon should bear this in mind and pay
especial attention to the toilet of the peritoneum. He should see that
no blood-clot is left in the Douglas sac, or between the intestines; and,

^ Am. Jour. Obstet., Nov., 1902. ^ Brit. Med. Jour.. Nov., 1902.

COMPLICATIONS IN ABDOMINAL OR VAGINAL SECTION. 499

above all, he should be careful to draw down the great omentu-m over
the intestines, as less trouble will arise from adhesions to this than ta
the intestines. In case of ordinary ovariotomy the stump left should
be carefully stitched over and buried so as to be completely covered with
peritoneum; and for this work ordinary sterilized catgut should be used,
not silk. These adhesions may not only cause pain, but may become a
serious peril to the patient, as in the various forms of intestinal obstruc-
tion resulting from adhesions. Another danger is the kinking or adhe-
sions of the ureters and their possible inclusion in hgatures. This can
be prevented by not hgating the uterine arteries until the anterior and
posterior flaps of peritoneum have been reflected from the uterus, when
the vessels are readily felt running up the side of the cervix and can be
ligated without including other tissues. The appendix sometimes be-
comes involved in these adhesions following removal of the appendages.
Another cause of pain after hysterectomy may be that a remaining ovary
has become adherent. To prevent these troublesome adhesions, Jessett
now uses a specially prepared catgut for all suturing of peritoneum and
ligating of vessels; he carefully buries all stumps of tumors and sutures
any torn or cut portions of the peritoneum.

Suppurating Abdominal Incision. — DamalP dwells on the prin-
cipal causes of suppuration of the wound made in abdominal section.
Among the most frequent are bruising of the fat by the hands or retrac-
tors, small collections of blood, due to carelessness in securing bleeding
points, which form foci for infection; deep sutures conveying infection
through the skin, and buried sutures of nonabsorbable material. Catgut
may be septic, and chromicized catgut often contains free chromic acid
which irritates the tissues. Abscess develops and bursts; if discovered
early, the removal of one or two sutures and the evacuation of the pus
may restrict the destructive process. But the suppuration often travels
the whole length of the incision, which must be reopened, converting the
abscess into a widely open area. To destroy the pus and keep the field
clean hydrogen peroxid may be used once or twice daily, followed by a
weak perchlorid of mercury solution, or solutions of protargol, argyrol,
or formalin. When the surface has become healthy, it is not safe ta
apply sutures, and healing by granulation is tedious, and causes a large
irregular scar. Darnall, therefore, applies the curet to the incision,^
under an anesthetic, to freshen up the granulations. He next places a
narrow strip of iodoform gauze or a few strands of silkworm-gut for
drainage. A strip of adhesive zinc-oxid plaster, about 2\ inches in
width, is now laid on each side of the incision, f inch from its margin, and
interrupted sutures are passed between the inner edges of the plaster
across the incision without penetrating the skin. An assistant brings
the edges of the incision together over the drain by using pressure on
each side of the wound. The sutures are next tied firmly across the
incision. The two sides of the incision being closely approximated by
this means, union takes place promptly, and when the drain is removed
only a straight linear cicatrix remains.

» Am. Gyn., March, 1903.

500 GYNECOLOGY.

Parotiditis following Abdominal Section. — Morley^ has prepared
an instructive table of classes of this formidable complication, including
one in his own experience. Seven cases were in males and 44 in females ;
26 were ovariotomies, and the remaining 25 were operations on the pelvic
viscera (oophorectomy 2, hysterectomy 3, "uterine tumor removed"
3, operation for suppurative peritonitis 1, herniotomy 1, operation for
intestinal obstruction 1, gastrectomy 2, operation for gastric ulcer 1,
removal of vermiform appendix 2, operation for penetrating wound of
abdomen 1, operation for bullet wound of stomach 1, "abdominal sec-
tion" 5 — 2 of these were most probably ovariotomies. Some of the cases
entered as "ovariotomies" were probably removal of the ovaries with
diseased tubes ; thus, the author's new case, in which a pair of pus-tubes
were removed with the ovaries and vermiform appendix, is placed under
this head. There is no fixed period of incubation; 9 occurred on the
third day, 5 on the fourth, 5 on the fifth, 8 on the sixth, and 5 on the
seventh; thus the complication appeared between the third and seventh
days in 32 out of the 51 cases. The remaining 19 cases ranged from the
eighth to the twelfth days, except 3, in which the parotid began to swell
on the second day. In 16 cases both glands were attacked; in 15 the
right and in 13 the left parotid glands were specified as the seat of in-
flammation; in 7 the side was not specified. Pus was present in 20 and
absent in 31 cases. The bacteriology of parotiditis following abdominal
section is, strange to say, very defective, as in a large number of the
reports the complication is merely mentioned as an incident in convales-
cence. Staphylococcus pyogenes aureus was isolated in Bumm's and
also in the author's cases; 38 cases recovered and 13 died; pus was
detected in 9 out of the 13 fatal cases. Morley maintains that these
results justify Stephen Paget's opinion that the deaths were not due to
the suppuration of the gland, but the gland suppurated because the
patients were going to die.

DISEASES OF THE OVARIES.

Adnexopexy. — H. D. Be3^ea^ states that by adnexopexy is under-
stood a surgical elevation of the prolapsed ovary and tube. It is used in
simple prolapse of the ovary and tube into the rectouterine or Douglas's
pouches. It is also applicable to those chronic inflammatory conditions
of the tube and ovary in which there is some degree of prolapse, and in
which the pathologic changes have not become so extensive as to require
ablation of the structures. That a prolapsed ovary may be symptom-
less, or, on the other hand, may cause grave nervous disturbances, is
generally admitted. If permanently replaced in its normal position, the
local congestion and inflammation which seem to be the cause of these
nervous troubles are relieved and there is a return to normal size and
function. The method of operation is as follows: The abdomen is
incised and any adhesions of the prolapsed ovary and tube are carefully

1 Am. Gyn., Dec, 1902.

2 Amer. Med., vol. iii, No. 26, p. 1087, June 28, 1902.

DISEASES OF THE OVARIES. ^ 501

separated. The fimbriated extremity of the tube is caught and" drawn
forward, exposing the suspensory hgament. A fine silk suture is placed
through a small portion of the double end of the suspensory ligament, and
then through the ligament near its pelvic attachment. Two or three
sutures, or a sufficient number to close the fold made in the ligament, are
placed below this one. The sutures are then tied. Care is taken not to
include the ovarian artery or constrict it in the suturing. The position
of the first suture determines the degree of elevation of the adnexa.
It may be necessary to include in the suture the tubo-ovarian ligament.
Successful Transplantation of Ovaries. — Walther Schultz^ gives
his results and a full resume of previous work. So far this has not
touched the wdder anatomic, physiologic, and psychologic questions
(whether castrated males with implanted ovaries develop the female
form of pelvis, show preference for males, etc«), but has related only to
the possibility of success in transplanting, and the changes occurring
in the transplanted tissues. The possibility of transplantation is now-
demonstrated beyond question. Both in young and in almost grown
animals the ovaries become attached in their new position, whether this
be the peritoneal cavity of the same female, of another female, or of a
male, or of the same bred or of a female of a different breed. Schultz's
main conclusions are : On other females of the same breed transplanted
ovaries of mammals can give off eggs and form corpora lutea ; on males of
the same breed such ovaries can develop ripe eggs up to 42 days, and show
such after 117 days; on females of other breeds such ovaries exhibit, in
the first 8 days, no difference from ovaries transplanted on females of
the same breed; the mode of healing and development corresponds in
the animals investigated to the phenomena described by Ribbert; and,
in ovaries transplanted on to males, eggs can be demonstrated in the
root, and tube-formed processes crowding from the germinal epithelium
downward into the tunica albuginea. At the same time, according to
Ribbert and Schultz, changes takes place which at least stimulate the
embryonic condition — mitosis appears in the cells of the germinal epi-
thelium, and from it root-like or tube-like processes grow downward into
the tunica albuginea. In these processes Schultz was able to demonstrate
eggs. The transplanted ovarian tissue appears not to be injuriously
influenced either by the blood of the male or by anything (secretion or
other influence) from the testicles; at least no such influence was noted
in the somewhat short time covered by the experiments. Transplanta-
tion does not operate to produce any unusually rapid growth in ovarian
tissue, as might possibly be expected, considering that it is tissue freed
from its normal connections. The author suggests that it is imperative
that this subject be followed up by such experiments as implantation of
ovaries in a female of another breed whose ovaries have been previously
removed, and that breeding experiments be then carried out with the
male of that breed. And we might mention many other experiments
which crowd on us, but they are too obvious.

Tarry Hematoma of the Ovary. — Borland^ calls attention to a
' Monats. f. Geb. u. Gyn., Dec, 1902. ^ Am. Jour. Surg, and Gynec, Aug., 1903.

502 GYNECOLOGY.

condition not generally mentioned in the text-books, and which he
designates by the title given above. By this term he means the develop-
ment in the ovarian tissue of a large cystic formation which may reach
the size of a fetal head and contain half a pint or more of a dark grumous
or tarry blood precisely similar in nature to the retained menstrual blood
of hematokolpos and hematometra. The pathology of tarry hematoma
is as follows : The ovarian stroma is largely if not altogether destroyed,
and only the capsule, thinned out and distended, remains. Dense
adhesions are formed to the broad ligament and surrounding viscera.
The cyst-wall is dark-blue or almost black in color, of an appearance quite
distinct from the angry reddish-blue color of a cyst that has been sub-
jected to torsion of the pedicle. It is probable that the condition
develops in an ovary the capsule of which has been the seat of a slow,
inflammatory change which has so thickened it that rupture of the mature
graafian follicles is prevented. The retained blood from these follicles
has not been absorbed before other follicles contribute their contents,
and the hyperemia and venous stasis of the organ act as still further con-
tributing causes. Gradually the septa between the unruptured follicles
become absorbed and the ovary becomes the seat of a slowly but pro-
gressively increasing hematoma. The bloody contents undergo a slow
process of inspissation until the tarry fluid results. Borland reports an
interesting case of this condition.

Pedicle-torsion in Ovary Neoplasms. — An editorial in "American
Medicine"^ remarks that two strong arguments in favor of early opera-
tion in newgrowth of the ovary are: First, the impossibility of any
relief being afforded by medicinal treatment and the certainty of pro-
gressive increase in size and symptoms ; second, the danger of the pedicle
becoming twisted and producing symptoms which demand immediate
operation. Recently the writer has seen 2 cases in which this acci-
dent had occurred, producing marked symptoms and requiring immediate
surgical intervention. In one of these an ovarian fibroid was present and
evidences of inflammation and ascites were found. In the other case
a glandular cyst about the size of a cocoanut showed necrotic areas, due
to the axial rotation of the pedicle. Rokitansky found torsion of the
pedicle in 12 % of all cases of ovarian tumors, and in 6 % of the cases it
was the cause of death. Various causes have been suggested for this
axial rotation. It has been attributed to alternative distention and
evacuation of the bladder. Kiistner ascribed it to peristalsis and the
changes from the distention of the rectum; Carlo, to sudden belly-pres-
sure; and Mickinwitz, to contraction of the trans versalis muscle. Any
sudden jar or motion of the body, such as jumping, dancing, or falling,
may be a factor. Torsion is more apt to occur in cysts of small and
medium size than in large tumors. The direction of rotation is usually
toward the median line, although it may take place in the reverse direc-
tion. A spheric, nonadherent cyst with a long pedicle is peculiarly
liable to this axial rotation, which, checking the venous outflow from the
tumor, causes hemorrhage into the interior, sometimes severe enough to

1 July 19, 1902.

DISEASES OF THE OVARIES. 503

result in the death of the patient. If the patient survives this acddent,
the cyst assumes more the nature of a foreign body, exciting a violent
inflammation in all the contiguous parts of the peritoneum and becoming
attached to it by vascular adhesions, which more or less replace the nor-
mal blood-supply. A moderate twisting of the pedicle of 90° produces
no symptoms. It is only when the torsion is sufficient to influence cir-
culation, or above 180°, that symptoms are produced. This accident is
especially liable to occur when an ovarian cyst complicates pregnancy
or the puerperium. According to Kelly, a cause of rotation of cysts is
that large multilocular cysts exhibit a notable tendency to the formation
of one large cyst-cavity, with a number of subsidiary ones, and the tumor
will invariably turn until the convex surface of the large cyst comes to
lie in relation to the concavity of the distended anterior abdominal wall,
and that the alternate relaxation and contraction of the anterior ab-
dominal walls act most decidedly upon that part of the tumor which is
nearest the median line. The result of this change of position depends
upon the extent of the torsion and the rapidity with which it has oc-
curred. The effect is first felt by the veins, which are more compressible
than the arteries, and the venous blood-current becomes obstructed
while the arteries remain open. The tumor may increase rapidly in
size, and in acute cases the patient complains of severe pain in the
abdomen associated with meteorism, marked tenderness on pressure,
acceleration of the pulse, and sometimes singultus, vomiting, and fever.
According to Montgomery, in the more chronic condition, when the blood-
supply is not completely obstructed, the pain and unfavorable symptoms
are more gradual, though many patients are bedridden and show a dis-
tinct loss of strength produced by the absorption of the altered con-
stituents of the tumor, causing a condition resembling cachexia. The
treatment for ovarian tumors in general is ovariotomy, a simple opera-
tion in uncomplicated cases. As it is impossible to decide with certainty
whether the given neoplasm is not malignant, or to insure against the
occurrence of such accidents as pedicle-torsion, cyst-rupture, or infection,
extirpation is positively indicated.

Myoma of the Ovary. — [True myoma of the ovary is perhaps the
most rare of ovarian diseases, and but few cases have been reported.]
J. M. Baldy^ finds that the literature contains but 8 such cases, the case
of the author making the ninth. Mrs. D. T., colored, aged 36 years,
married 15 years, had had one pregnancy which terminated in a mis-
carriage. Menstruation for the past dozen years had lasted 5 to 7 days,
and had been quite free. Three years ago her doctor had told her that
she had a tumor, but it had given her no trouble except for an occasional
hemorrhage, which would last perhaps as long as 10 days. These had
yielded to very simple treatment. Examination disclosed a multi-
locular cyst of the uterus, hard and with the ordinary characteristics of a
fibroid. The history was that of an ordinary fibroid and operation was
performed for that condition. The specimen after removal consisted
of a uterus enlarged by a multiple fibromyoma to the size of a small

1 Am. Gyn., Nov., 1902.

504 GYNECOLOGY.

cocoanut. The right ovary was nowhere to be found. The left ovary
was cystic. Where the fimbriated end of the fallopian tube disappeared
in the capsule at the top of the tumor, beneath the capsule, an exceedingly
small piece of tissue was found which on section proved to be ovarian.
The tumors in the uterus were ordinary fibromas. What is the signifi-
cance of these facts? The first and all-important question to decide
is, Is or is not this a subperitoneal nodule of a fibroid uterus? There are
but two lines on which such a nodule could develop at this point: First,
subperitoneal, in which case it w^ould be subperitoneal at all points of
the tumor; second, a pedunculated nodule, in which case it would come
off the uterus and hang free in the pelvis, but would in no way attain the
relations to the broad ligament which are held by the ovary or by this
tumor on its upper surface. In either case ho^y could we account for
the disappearance of the ovarian ligament and the ovary? A broad-
ligament tumor would have relations essentially different from those
which pertain to this tumor. On the other hand, assuming that this
tumor began to develop in the ovarian ligament or in the capsule of the
ovary, every possible difficulty disappears and all its relations without
exception are accounted for.

- ORTHOPEDIC SURGERY.

By VIKGIL p. GIBNEY, M.D., and J. HILTON WATERMAN, M.D.,

OF NEW YORK.

THE ARM.

Treatment of Fractures and Injuries to the Elbow-joint. — A. J.

Gillette and J. B. BrimhalP read a paper on this subject before the
Minnesota State Medical Society, in which only fractures and dislocations
of the joint are discussed, but other injuries which give no exact lesion
are admitted. Thirty cases which had been under personal observation
were reported, A number of x-ray photographs were shown, one showing
the condition of an arm dressed at right angles for a fracture of the lower
end of the humerus; also photographs showing the arm flexed to the
limit and extended to the limit. The authors conclude that the dressing
which is advised is easy of application and in most instances comfortable
for the patient. Also, that a fracture of the external or internal condyle
is the most frequent fracture, and that the muscles arising from these
condyles have a tendency to draw the fractured portion toward the
median line and in front of the elbow-joint, thus blocking flexion, and
with a straight splint they are easily held in position. Again, if there
is a great deal of callus there is no danger of the olecranon fossa becoming
filled with it and thus blocking extension, and the olecranon process
furnishes an admirable splint to keep in place fragments when the con-
dyles are fractured. An anesthetic should always be used in reducing
these fractures, as they result from such slight causes in children that
they might easily be overlooked; besides, under an anesthetic it is much
easier to reduce the deformity. Finally, the position which these authors
advise gives the very best results, but the fracture must be perfectly
reduced, and two imperfect results reported in this series are due to
imperfect reduction.

Suture of the Brachial Plexus for Birth Injury. — Kennedy^ has
operated upon 3 cases. He describes the operation in detail. He advo-
cates extending the course of the brachial plexus, tearing them in the
region where the injury is probable, and breaking up old adhesions.

Fracture in or Near the Joints. — A. J. Gillette,^ before the Minnesota
Valley Medical Association, read a paper on this subject. He emphasizes
the importance of proper reduction of fractures at or near the joint.
If a fracture of the long bones should not be properly set, we may get a

» St. Paul Med. Jour., 1902. » Am. Jour. Orthopedic Surg., Aug., 1903.

3 St. Paul Med. Jour., March, 1903.
33 S 505

506

ORTHOPEDIC SURGERY,

poor anatomic result and a good functional result, but the functional
result of a fracture at or near the joint depends almost entirely upon
the anatomic results. Regarding massage, there is no doubt that in
cases where it is employed the patient can use the liml) sooner than if

Fig. 99.— A plaster cast properly applied with foot at a right angle and slightly adducted, for all fractures
at or near the ankle-joint (Gillette, in St. Paul Med. Jour., March, 1903).

Fig. 100. — A frequent and bad position of the foot in a fracture at or near the ankle-joint, with a badly
applied plaster cast (Gillette, in St. Paul JNIed. Jour., March, 190,3).

it remains immobilized for the usual 6 weeks. To obtain union this is
not necessary, and there is great danger in removing the dressings to
perform massage. The term massage in this connection does not mean
passive motion. Passive motion before union has taken place is very

THE SPIXE. 507

dangerous, not only because of the danger of displacement, but because
of the irritation and the consequent inflammation, causing exuberant
callus. Where simple, comminutive, or compound, the plaster-of-paris
cast, well padded with cotton and roller-bandaged, is the most serviceable
and easily applied, and, further, in a joint fracture a cast with window-
holes makes the cleanest dressing. A union of an intracapsular fracture
of the hip is not due to the structure of the bone in the neck of the femur
or the peculiar physiologic changes in the agent. This is proved by the
many cases of union where proper mechanical and surgical means have
been applied to hold the fragments in apposition. The nonunion of
these intracapsular fragments is due nearly always to lack of reduction,
thorough immobilization of leg and continued apposition of the fractured
ends. For ununited fracture of the neck of the femur, the operation
first performed by E. Boeckmann is advised. The operation consists,
first, in making a horseshoe incision, beginning it an inch below and an
inch posterior to the anterior superior spine of the ilium, carrying it

Fig. 101. — A properly applied plaster cast for a fracture at or near the wrist-joint, allowing the thumb
and nngurs free luoveineut (Gillette, in St. Paul Med Jour., March, 1903).

down 2 inches below the trochanter major, and bringing it up to the
buttock, to the center of the gluteus maximus muscle; the skin, super-
ficial and deeper fascia are dissected en masse. Two illustrations are
shown, one in plaster cast properly applied, with the foot at right angles
and slightly adducted for all fractures at or near the ankle-joint (Fig.
99); the other showing a frequent and bad position of the foot in a
fracture at or near the ankle-joint, with badly appHed plaster cast (Fig.
100). In fracture of the wrist the author advises a plaster-of-paris cast
extending from the elbow to the base of the fingers, leaving the fingers
and thumb exposed (Fig. 101). In this way the fingers can be kept from
becoming stiffened by the adhesions of the tendons passing in the
locality of the fracture.

THE SPINE.

Case of Double Pott's Disease. — R. T. Taylor^ describes a case of
a boy aged 7 years. He had a very unusual case of double Pott's disease,
1 Amer. Med., Sept. 13, 1902.

508 ORTHOPEDIC SURGERY.

with distinct isolated foci of tuberculous disease involving the fifth, sixth,
and seventh dorsal vertebras above, and the first, second, and tliird
lumbar vertebras below. The a:-ray picture of this case is especially
interesting as showing clearly intense shadows and two foci of disease.
At the dorsal focus the lessened space between the ribs and focus of
tuberculous disease appearing through the heart shadow is noted.

Round Shoulders and Faulty Attitude ; a Method of Observation
and Record with Conclusions as to Treatment. — R. W. Lovett^ read
a paper on this subject before the American Orthopedic Association.
From his study of the subject he states that our knowledge of faulty
attitude has been incomplete because the spine alone has been considered,
rather than the relation of the legs and pelvis to the spine, and the rela-
tion of the whole body to the perpendicular, and the uniform method
of measurement and record is desirable. The method described gives us
a side elevation of the whole attitude, and the relation of legs, thighs,
pelvis, spine, and head to each other and to the perpendicular, but the
seat of faulty attitude is not as yet formulated.

Genesis and Treatment of Spondylitic Paralysis. — Tillmans^
describes two methods : (1) An opening into the vertebral paths from the
side, and of permanent drainage. The best method of performing this
is caustro-transversectomy of Menard. (2) Laminectomy, especially in
cases of caries of the vertebral arch and as a leg operation in the older,
nearly cured cases in which granulations, callus, sequels, and bone edges
have been causative agents. [Our own results in operative procedures
on the vertebras for compression paralysis fail to convince us that such
procedures relieve the cord itself, irrespective of the causes found for
compression. Cases operated on early are inconclusive because of the
well-known tolerance of the spinal cord.]

Round-shoulder Deformity in Childhood, with Especial Refer-
ence to the Proper Adjustment of Clothing in Preventing and Treat-
ing Such Conditions. — J. E. Goldthwaite,' as the result of the examina-
tion of a large number of children, both in the hospital clinics and in
private practice, is of the opinion that the chief factor in the etiology
of this condition is the improper adjustment of the clothing, especially
as the condition develops as the simple clothing of infancy is discarded
and the heavier and somewhat complicated costume of the child is
assumed. This opinion is strengthened by the fact that the difficulty so
often corrects itself at the time of puberty, when the arrangement of
the costume again changes, the shoulders at this time being depended
upon less for support. As regards underwaists, practically all are so
made that the weight is applied at the outer or movable portion of
the shoulder, the position which is least capable of bearing weight.
The waist which has been the most satisfactory is made of firm cotton
material and is cut high in the neck, with a rather narrow back and
with a loose, easy front. Two straps made of double thicknesses of the

* Trans. Am. Orthopedic Assoc, 1902.

^'Arch. f. Orthop., Bd. i, Heft 2; Am. Jour. Orthopedic Surg., Aug., 1903.

' Am. Jour. Orthopedic Surg., Aug., 1903.

THE HIP. 509

same cloth are sewed to the waist, and upon these the chief drag comes.
The straps start well at the side, in front, cross the shoulder near the
base of the neck, and cross back to the opposite hip. In this way the
chest is left free, and whatever drag there may be tends to draw the
shoulder backward rather than forward.

Spondylitis with Unusual Lateral Deviation. — A. H. Freiberg ^
reports a case showing this condition. In conclusion he describes a
modification of old methods in the application of plaster-jackets in Pott's
disease, and especially in cases presenting much lateral deviation. It is
in effect a combination of three well-known existing methods; extension
from the head, the prone position in the hammock, and the oblique posi-
tion of Kebel. It would be found advantageous in cases with consider-
able deviation to allow the patient to remain in the frame for some
minutes before beginning the application of the plaster. By this means
considerable relaxation may be secured, so that unless very unusual,
lateral deviation may be overcome in great measure in one sitting. [We
can bear testimony to the lateral and oblique positions in securing
marked improvement in the curve. Much manual force may be em-
ployed at the same time with slight pain or discomfort.]

Noisy Shoulder. — R. H. Sayre,^ before the American Medical Asso-
ciation, presented a patient seen 2 months before, giving a history of
slight curvature of the spine, accompanied by grating of the muscles
over the scapula on moving the shoulder up and down. There was also
pain over the deltoid on the same side. The impression was given that
the scapula was sliding over some substance. The case was presented
for diagnosis and suggestions for treatment. V. P. Gibney stated that
he had had a similar case under observation in a young woman, aged
20. R. Whitman had seen several such cases, and he thought it was
caused by a snapping tendon between or possibly by a bursa beneath
the scapula. Homer Gibney stated that in giving exercises to patients
he had noticed these crackling sounds in many cases, and especially in
one exercise for lateral curvature.

THE HIP.

Progress of the Treatment of Congenital Hip-dislocation. — H. L.

Taylor^ concludes from his observation of the results of treatment both
in this country and abroad that the femoral head and neck and the
acetabulum are usually more or less malformed or imperfect, rendering
anatomic replacement difficult or impossible in the majority of cases. The
main features of the Lorenz method are thorough tearing of the adductors,
preliminary to reduction, stretching of the hamstrings and contracted
tissues in front of the hips after reduction; fixation in hyperabduction
and flexion, and retention for from 9 to 12 months in plaster-of-paris fol-
lowed by rather careful after-treatment of some months. A point to be
borne in mind is that the use of very great or prolonged force is liable

* Trans. Amer. Ortho. Assoc, 1902. » N. Y. Med. Jour., Jan. 3, 1903.

* Post-Graduate, Oct., 1903.

510 i ORTHOPEDIC SURGERY.

to be followed by serious consequences, and is not good practice. The
various open operations also have their place in difficult operations and
are still being perfected to meet the indications.

Congenital Dislocation of the Hip. — Kirmisson/ in his service at
the Trousseau Hospital since 1898, in 27 unilateral cases reports that
10 were either impossible or for some other reason other treatment was
tried, so that 17 cases were operated by the bloodless method. Five had
no shortening and 2 had 1 cm. shortening, and the others from 2 to 4
cm. shortening. Functional results were good in the majority of cases.

Congenital Dislocation of the Hip-joint and Club-foot. — A,
Lorenz,^ in one of his clinics given in this country in which he demon-
strated the operation of congenital dislocation of the hip, referred to
this method as the functional weight-bearing one and described in detail
the principles of the operation. The first step of the operation is to
place the head of the femur in the acetabulum. The possibility of this
abduction is limited by the age of the patient. In very young children
there will, of course, never be any difficulty in pulling down the head
of the bone to its proper position. In older children and in adults it
is no longer possible to do this. The age limit for this procedure in cases
of bilateral dislocation is said to be the seventh or eighth year. After
this age limit it is necessary, before attempting the reduction, to institute
a rather lengthy preparatory treatment, consisting in extension and
tenotomy. The age limit in cases of unilateral dislocation is about the
tenth year. The oldest case in which reduction was performed was in
a patient aged 23. The real reduction is done by traction and by
bringing pressure to bear down on the trochanter. I orenz prefers
reduction by way of forced abduction, which can be kept up with
a wooden pillow beneath the trochanter to act as a fulcrum until the
head can be felt to slip over the posterior portion of the acetabulum.
Unfortunately, in all these cases the acetabulum is so shallow that the
head would immediately slip out if the leg were brought into even an
approximately normal position. In order to retain the head in its place,
it is necessary to put the leg in a right-angled abduction. In order to
still further insure the fixation of the head in the acetabulum it may
be expedient to stretch the anterior part of the capsule an inch by free
rotary movement of the thigh. After a new position of the leg has been
attained, the flexors of the knee-joint become too short, and we conse-
quently find the knee rigidly placed. This shortness of the muscles is
also overcome by careful but forced stretching of the leg, bending the
knee and extending it until it is possible to have complete extension.
In cases of unilateral dislocation appliances which will permit the
patient to walk as soon as the pain and uncomfortable feeling of the
extreme position have disappeared are advised. In cases of bilateral
dislocation voluntary motion is practically impossible. A stockinet ban-
dage is first put on; under this is run a strip of gauze about 5 or 6 inches
in width, which is allowed to protrude above and below. By pulhng on
the ends of this strip and passing it to and fro under the bandage, the

1 Rev. du Orthop., May, 1903. ^ Canad. Pract. and Rev., March, 1903.

thf: hip, 511

skin under the cast can be kept clean. The strip is replaced after each
cleansing by a fresh strip. Over the stockinet bandage a ver}^ abundant
supply of cotton is applied, and over this the plaster-of-paris bandage.
The operation was demonstrated on a number of cases. In one the leg
was about 1^ inches shorter than in the other, and attempts at abduction
were unsuccessful. The head of the femur was felt very distinctly just
behind the acetabulum. The next case operated upon was that of a
child having a double dislocation. Another case was that of a child
operated on 3 years ago for the same purpose, without any result. The
operator attributed the failure to the abductor muscles, which were
allowed to remain intact. Another case shown at the clinic was that of
a bilateral dislocation in a child of 7, in which it was deemed impossible
to effect a reduction. The final case operated on was that of a child
11 years old, which is about the age limit in this work. Attention was
called in this operation to the danger of tearing the femoral artery, which
might mean an exarticulation of the hip-joint. The bloodless modeling
method of treating club-foot was next demonstrated. This operation so
thoroughly corrects the deformity in the newborn that it is no longer
necessary to resort to cutting operations later on. Lorenz stated that
in his modeling redressment of the club-foot is equally applicable in older
children. The patient on whom this operation was demonstrated was
16 years of age. Not only is it important to overcome resistance of the
soft parts, but such resistance must be completely annihilated. The
principle is to keep on with the active correction until the elasticity of
the soft parts is completely destroyed, so that the foot will no longer
rebound to its original position. Great care must be taken in applying
the cast after this method, as it is kept on for several months, and it
must be renewed after its removal, until the foot is in a perfect valgus
position, when it is no longer restrained by a dressing.

Subtrochanteric Osteotomy in Adults, in Adolescence, and in
Young Children. — E. H. Bradford,' in a paper read at the annual
meeting of the American Orthopedic Association, concludes that the
operation of subtrochanteric osteotomy for the correction of a deformity
following hip disease is one which can be done in adults without fear
of nonunion, or even in middle life, and that the danger of relapse is
greater when the operation, is done in childhood or in rapidly growing
years. The danger of nonunion is apparently not an imminent one when
the operation is undertaken in middle life. For this reason it would
seem to be better surgery, when possible, to defer the operation in young
childhood until the period of rapid growth is passed.

Correction of Deformity at the Hip, the Result of Disease ; a Study
of the Best Methods and Best Positions. — V. P. Gibney,^ at the annual
meeting of the American Orthopedic Association, discusses this subject
from a clinical standpoint. One case reported is at least suggestive of
damage done to tissues undergoing repair and the opening up of an old
inflammatory process. There are cases innumerable where the same

' Am. Jour. Orthopedic Surg., Aug., 1903.
^ Am. Jour. Orthopedic Surg., Aug., 1903.

512 ORTHOPEDIC SURGERY.

amount of force has been employed and the same correction secured
without any untoward symptoms. The most satisfactory results, so far
as improving the length of the limb is concerned, have been accomplished
by subtrochanteric osteotomy. It is the experience of many who have
collected statistics at the Hospital for Ruptured and Crippled to find a
certain number of relapses after subtrochanteric osteotomy. It is also
the experience of these gentlemen that relapses occur about as frequently
after forcible correction through the joint. The cases where relapses
have occurred after osteotomies below the trochanter are reported.
It has been suggested that if disease does occur after forcible correction,
the symptoms are of slight import, and that fixation and a well-fitting
plaster-of-paris bandage are sufficient to guard against any serious re-
lapses. A case reported in this paper fails to substantiate this argument.
The writer favors subcutaneous osteotomy in preference to the open
method.

Treatment of Fracture of the Neck of the Femur. — C. E. Thomp-
son,^ at the Surgical Section of the American Medical Association, read
a paper on this subject. The author quotes from the days of Sir Astley
Cooper down to the latest literature obtainable. In conclusion he states
that in all cases of fractured femoral neck firm bony union and use of
the limb may be obtained; age is not a counterindication to treatment
nor to obtaining bony union. Immobilization should be continued for a
long time and 3 months should elapse before allowing weight on the limb.
The Buck extension with weight and pulley is not sufficient immobiliza-
tion to obtain bony union, but operative treatment in all the neglected
cases has succeeded well, in fact, beyond all expectations, and deserves
a place in surgery among the radical cures for troublesome conditions.

The Orthopedic Hospital Pelvic Rest. — R. A. Hibbs^ presented a
pelvic rest used in the application of plaster dressings after reduction of
congenital dislocation of the hip. This rest, with its attachments for
head and shoulders, holds the patient's body securely on a horizontal
plane, thus making the application of the dressings less difficult than
does the simple rest ordinarily used, which elevates only the pelvis and is
also insecure.

A Review of Lorenz's Visit to the United States. — N. M. Schaffer'
tells of what may be called the aftermath of Lorenz's work in this country.
With whatever reservations the medical profession may accept the
methods of Lorenz, the social significance of his work to America remains.
The author speaks of what measure of recognition has come in the way
of provision for treatment and care of these cases. The operation for
the reduction of the dislocation of the hip, as many know, is not new,
but the one performed by Lorenz is practically the same operation that
is described by many of the old classic writers for acute or recent dis-
location. But the persistence and in many ways the originality of Lorenz
in adapting it to a chronic (congenital) condition which only a few years
ago was regarded by the medical profession as incurable is something

^ Jour. Am. Med. Assoc, Jan. 3, 1903. '^ N. Y. Med. Jour., Jan. 17, 1903.

^ Charities, Oct. 31, 1903.

THE KNEE. , 513

for which he deserves great credit, and his successful effort marks an
era in orthopedic surgery. The writer regards him as a master, and he
feels that he is to-day without an equal in this particular field of manipula-
tive work. The results obtained, so far as they can be definitely made
out at this writing, show that of the patients operated on by Lorenz
the usual percentage of success followed. In short, it may be said that
nothing has occurred to reflect in any way seriously on the method which
Lorenz taught and demonstrated. The cause of humanity has been
advanced by his visit to the United States — a poor child suffering from
disease and deformity has been lastingly benefited.

THE KNEE.

The Surgery of Rickets. — H, L. Taylor,^ at the annual meeting
of the American Medical Association, presented a very extensive paper
on this subject. He concludes that subcutaneous osteotomy of the
shaft is a safe and certain operation for the correction of knock-knees and
bow-legs. Second, it is nearly always to be preferred to cuneifonn
osteotomy into the joint or operation by the open method. Third, the
risk of nonunion of bone or other accidents, with asepsis and an experi-
enced operator, is slight, and not increased in rickety subjects. Fourth,
the commonest errors are imperfect correction, especially failures to
overcome extension of the feet and relapses from improper dressings or
from operating before the subsidence of the rickety process. Out of
42,124 new cases applying for treatment in 10 years at the orthopedic
clinic of the Hospital for the Relief of Ruptured and Crippled, 6583,
or over 15 %, suffered from rickets or the deformities most frequently
caused by rickets, such as bow-legs and knock-knees or pigeon-breast.
The classes in New York among which rickets are most common are
the Italians, the negroes, and the Russian and Polish Jews, and it is
these people who most notoriously sin against sanitary laws. It must
be remembered that the malnutrition of rickets profoundly affects
all the tissues, including the muscles, nerves, and glands, not merely the
bones; the sweating, the weakness, the bronchial and intestinal catarrh,
are evidences of the widespread nutritional vices which must be corrected
if surgery is to succeed.

The Mechanical against the Operative Treatment of Rachitic
Deformities of the Lower Extremities : A New Osteoclast. — R. T.
Taylor^ presents the following views on this subject: (1) In our dis-
pensaries any immediate correction of the deformity which will obviate
the expense of braces is desirable. (2) The dangey of these operations
need not deter us in the slightest degree with modern asepsis, from re-
sorting to the operative method. (3) A comparison of the length of
time the child has to submit to discomfort from the plaster-of-paris
bandages, versus the braces, is wholly in favor of the operative method.
The writer presented a new osteoclast, devised on the lever principle

* Jour. Am. Med. Assoc, Oct. 11, 1903.
' Am. Jour. Orthopedic Surg., Aug., 1903.

514 ORTHOPEDIC SURGERY.

instead of the screw, as seen in Rizzoli's, Grattan's, Colins's, and Lorenz's
osteoclasts. It consists of a T-shaped base, the arms of the T being
some 12 inches wide and the stem some 36 inches long. Arising from
the intersection of the arms on the stem is an arc some 12 inches high
at its summit and 12 inches wide at its base. Some 3 inches above, and
parallel with the stem of the base, is a movable half-inch square rod,
which may slide backward and forward through slots in the arc. From
the stem of the arc depends the sharp arm of the lever, some 9 inches
down to its attachment to the movable rod. The advantages claimed
for this device are the rapidity of the fracture and release, which cannot
be obtained with the other osteoclasts. It can be taken apart readily
and carried.

The Surgical Pathology of Genu Varum and Genu Valgum. —
W. Blanchard,^ at the annual meeting of the American Orthopedic
Association, presented an interesting paper on this subject. The writer
states that advanced genu vanmi generally shows 3 contributing curves,
the primary deviation being usually an exaggeration of the normal out-
bend of the lower third of the femur. This is the typical first stage.
Skiagraphs are shown of a t3'pical case of genu varum and genu valgum,
with the central deformity in the upper third of the tibia (Plates 8 and 9).
In conclusion, skiagraphy seems to prove that the deformity of knock-
knee and bow-leg is seldom, if ever, central in either the condyles or
joint. It is stated that epiphysiolysis is hardly worthy of serious con-
sideration when attempted with either osteotomy or osteoclasis; that
osteotomy has some slight dangers from which osteoclasis is free, and
the comparatively prolonged time taken for bony union and recovery
should condemn it when osteoclasis is available.

Luxation of a Semilunar Cartilage at the Knee-joint. — F. Schultz-
Dinsburg^ reports the results in 33 cases confirmed by operation. He
advises operation where the displaced cartilage can be demonstrated.
The operation may be removal or stitching the cartilage in place. [The
experience of American surgeons is decidedly against stitching a loosened
cartilage. Complete removal has been the better procedure.]

Method of Correcting Flexion-deformity at the Knee-joint. —
R. Whitman^ describes a method which consists of manual undulation
in preference to the use of mechanical appliances. The patient is placed
prone upon a flat table. The operator then holds with one hand the
head of the tibia firmly against the table and with the upper quarter of
the other begins forcible massage.

Lesions of the Tibial Tubercles Occurring during Adolescence. —
R. B. Osgood* has J^Titten an article describing in detail the develop-
ment of the tubercle, its anatomy during adolescence, diagnosis and treat-
ment of conditions affecting it. He concludes that an adolescent tibial
tubercle is susceptible to injuries, especially in athletic subjects. These
lesions are usually caused by violent traction of the quadriceps extensor.
Fracture and complete separation of the tubercle are rare, cause loss of

* Am. Jour. Orthopedic Surg., Aug., 1903. ^ ^rch. du Orth., 1903.

' Am. Jour. Med. Sci., May, 1903. " Boston M. and S. Jour., Jan. 29, 1903.

Plate 8.

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THE [vXEE. , 515

function, and are easily diagnosed, usually clinically and by means of. the
x-ray. [We have found these lesions peculiarly rebellious to treatment.
Fixation before and after incision for a thickened periosteum must ex-
tend over weeks before relief is afforded.]

Lipoma Arborescens. — E. F. Painter and W. J. Erving^ reported
in detail 7 cases selected from a series of 16 cases of hypertrophied syno-
vial villi recently removed at operations because they seemed to represent
distinct tumor-formations and not simply the arborescent overgrowths
of the synovial membrane which are so commonly seen. It becomes
evident that the villi are not so limited as was at first supposed. The
knee-joint is the one most commonly affected, though others are not
exempt. In the series of cases presented all are operative and have
come under observation during the past year. In general, the clinical
symptoms presented by these cases are that of a more or less swollen
joint, without any signs of an acute inflammation, and most commonly
without any excess of fluid. The patient complains of imperfect func-
tion, sometimes with and sometimes without pain — more often the latter.
German authors have described the condition more often than others,
and have regarded the presence of these joint lipomas as representative
of one or two conditions, as a rule: namely, synovial tuberculosis or
arthritis deformans. Zeigler regards them as the result of a fatty meta-
morphosis of the normal synovial villi. Konig, writing in 1885 and
again in 1895, considered the condition as a manifestation of tuber-
culosis, but finding later a similar condition in cases of arthritis defor-
mans, he first tried to distinguish between them, and finally admitted tlie
great difficulty in so doing. Haumann, in 1887, reported a case in which
the condition was associated with a chronic rheumatoid affection. He,
too, thought the structure favored the presence of tuberculosis. Israel
reported a case following trauma in which no focus of tuberculosis was
found. Sokoloff reported one case in the knee in which no tuberculous
focus was found, one in which a focus was found, and one in a case of
syringomyelic arthropathy of the shoulder, with the large joint cavity,
atrophied humeral head, and luxated bone. From this last case he
advanced the theory that a condition of negative pressure in a joint
was also an etiologic factor in the growth of lipoma arborescens as
favoring the hypertrophy of fatty tissue. Stieda, in his conclusions,
states that it is not a lipoma in the sense of being a new growth, but it is
merely a hypertrophy of normal preexisting tissue. Pathologically, it
is a hj^erplasia and fatty degeneration of preexisting synovial tabs,
to an extreme degree. For the treatment he advised arthrectomy,
or, when tuberculosis is present, resection of the joint. The authors
recommend exploration of the joint when any doubt exists as to the
nature of the pathologic process. They give tuberculosis relatively a
less important place in the etiology.

1 Boston M. and S. .Jour., March 19, 1903.

516 ORTHOPEDIC SURGERY.

THE FOOT.

The Occurrence of Painful Affections of the Foot among Trained
Nurses. — R. W. Lovett/ after 500 observations upon normal and dis-
abled feet, concludes: (1) That he has not been able to tell with any cer-
tainty by examination whether or not the feet of an individual are likely
to give trouble. The only reliable information obtained in these cases
was given by the impression seen through glass, A foot with a well-
distributed pressure area seemed rather less likely to give trouble than
one resting on two islands. The degree of pronation, the condition of the
circulation, and the relative weight of the nurse and the dorsal flexibility
of the foot have all proved of little or no value as elements in prognosis.
A flat foot may be perfectly serviceable, as may also a severely pronated
one, while an apparently well balanced foot may become painful. (2)
The factors in causing the trouble among the nurses were to be studied
rather in the general conditions than in any special formation of the
foot. (3) The trouble was caused by rolling in of the foot and the
shifting inward of its weight-bearing areas, and not in any of the cases
observed by the breaking down or even lowering of the arch. (4) Al-
though proof by figures is lacking, it is probable that the amount of
trouble has been decidedly less than it would have been without the use
of a proper boot. (See Plate 10.)

The Importance of Supplementing Tendon-transplantation in
the Treatment of Paralytic Talipes by Other Procedures Designed to
Insure Stability. — R. Whitman^ states that in order to estimate cor-
rectly the permanent improvement derived from the operation of tendon-
transplantation for a paralytic talipes, one should consider it apart from
the procedures with which it is usually combined. The point to which
particular attention is called is the importance of reinforcing the com-
paratively ineffective operation of tendon-transplantation by procedures
designed to prevent deformity and to lessen the strain upon the weak
muscles. The center of lateral motion of the foot, and consequently
of lateral deformity, is the mediotarsal joint, and whenever the principle
of abduction or adduction of the dorsal flexor is lost, the remaining
muscles, although possessing power enough to raise the foot, at the same
time draw it to one side or to the other. The most common and most
important form of acquiring disability is that caused by paralysis of the
tibialis anticus muscle, which last is always accompanied by valgus.
The operation recommended in a typical case of this character is that
described. When the calf muscle is paralyzed, and especially if the
resulting deformity is of the calcaneovalgus or varus type, astragalec-
tomy has been found to be the most effective operation. The forward
displacement of the leg, removal of the cartilaginous surfaces of the
opposing bones, transplantation of the peronei tendons of the os calcis,
shortening the elongated tendon of Achilles, being minor parts of the
operation. The object of operative treatment of paralytic patella is

* Amer. Med., July 4, 1903. = Am. Jour. Orthopedic Surg., Aug., 1903.

PLATE 10.

a
S'

O 00

^°

o S"

P- d

rt- ^

S^ (^
^ S.

^«

o
S3 a"
a p
'-^ 2".

3§
«2.

2 S'
5- 5

P3
o o

5 C3

Ji^

«i

??*

CD 13-

THE FOOT. 517

not perfect functional cure, but a restoration of ability to a degree that
may enable the patient in favorable cases J&nally to discard apparatus.
In this result, stability is the first essential.

The Abuse of Flat-foot Supports. — W. R. Townsend,^ at the annual
meeting of the American Orthopedic Association, contended that the
treatment of flat-foot by means of some form of support under the foot
is largely due to the excellent work of many members of this association,
and it seems proper, therefore, that the attention of the profession should
be called to the abuse of such supports. The fact that such a question is
difficult of solution and that the methods promoting publicity are often
purposely misunderstood is no reason why we should hesitate to give the
proper advice, and urge upon medical men the necessity of properly
examining and treating deformities or disabilities of the foot. The form
of support will vary, individual preferences will prevail, but the treat-
ment of flat-foot should be carried on by medical men. Supports, if
used, should be correct in principle and properly made, and the routine
practice of patients treating themselves or being treated by ready-made
supports, sold by those with no knowledge of the anatomic or pathologic
conditions actually present, should be discouraged. A discussion on
this subject followed.

Further Experiences with a Modification in the Operative Method
for Inveterate Relapses and All Chronic Forms of Pes Equino Varus.
— A. M. Jonas ^ says that first the triangular flap is indicated in cases of
pronounced talipes equino varus where the open operation is necessary
to overcome a deformity which involves the medial dorsal. Second, the
astragaloscaphoid ligaments and the joint and capsule must not be
incised or torn. Third, when the division of the soft structures is not
sufficient to overcome the varus deformity, an incision over the head and
neck of the astragalus must be made and the bursa extirpated. Fourth, the
head of the astragalus must be divided transversely with an osteotome.
If this is not sufficient, remove a wedge from the neck ; and if that fails,
remove the head. Fifth, if the astragalus is rotated so that its superior
articular surface is inclined outward, and replacement is impossible,
the internal lateral ligament must be divided, which can be done through
an opening made by the triangular flap. The best possible guarantee
against relapses is to divide the soft parts and bones so that the foot
falls into its natural position with little or no pressure. [We incline to
question final results after such an extensive operation unless the good
position secured at the operation is maintained many months in a non-
removable dressing. The author should lay more stress on this point.]

Tendo Achillis Shortened for the Restoration of the Function of
the Calf, Lost as a Previous Result of Tenotomy. — R. A. Hibbs^
has made a study of 18 cases in which the tendo Achillis has been divided
for the relief of equinus following paralysis. The distinct object in view
was in determining the question of whether or not the division of this
tendon affected the function of the calf muscles. In this report it was

^ Am. Jour. Orthopedic Surg;.., Aug., 1903.

* Jour. Am. Med. Assoc, Sept. 13, 1903. ^ N. Y. Med. Jour., May 2, 1903.

518 ORTHOPEDIC SURGERY,

shown that in 11 cases the function of the calf was lost so far as being of
value was concerned. It appears that by lengthening the tendo Achillis
it must be expected that there will be still further shortening of the calf
and modification of its function, which fact accounts to some extent for
the results usually seen. It does not fully account for them, however,
because in the 11 cases in which the function of the foot was practically
lost, there was no such impairment of its function or lengthening of the
tendon immediately after the operation as now exists, but Hibbs was con-
vinced that after the patient began to walk the tendon gradually elon-
gated, allowing still further shortening of the muscle and modification of
its function. The writer believes that the preservation of the shaft and
the preservation of the continuity of the tendon are absolutely essential,
and that these cannot be secured except through an open operation.
[We fail to be convinced by this report, as the observations he makes run
counter to those made by orthopedic surgeons in many analyses com-
prising a much larger number of cases. While the paper may be sug-
gestive, it is far from conclusive.]

Advances in the Treatment of Paralytic Difficulties. — A. H.
Tubby^ states that in spastic paralysis the success of tenotomy consists
in preventing elongation of the bond of union and carefully guarding it
vmtil equilibrium of the opposing group of muscles has been established.
He calls attention particularly to the necessity of reshaping the joint
surfaces in old cases and putting the foot or the limb in fully corrected
position and leaving no tension on the reinforced muscle.

MISCELLANEOUS.

The Family Physician, the Specialist, and the Patient. — Louis
A. Weigel,^ at the seventeenth annual meeting of the American Ortho-
pedic Association, read a paper with this title. The writer spoke with
reference to the education of a specialist. Although there is a tendency
in modern times to send full-fledged speciahsts into the world, directly
from college and university, and a few of the influential medical journals
advocate such a course, he still believes that the specialist, to be success-
ful, requires something more than the knowledge which he gains at school.
The specialist is the person who is supposed to have an unusual amount
of knowledge on a limited theme. If he is called in simply to give treat-
ment or to aid diagnosis on that little point, perhaps that will do, but he
may do harm if he sees that one point and overlooks the rest. In closing,
he states that it is incumbent upon this Association to promote the devel-
opment and improvement of orthopedics by insisting upon the proper
qualification of men who are to take up this specialty. Perhaps the
specialist of to-day may be defined as one who has given special attention
and study to one branch of medicine in addition to a general knowledge
of all other branches, such knowledge to be based on practical expe-
rience at bedside, in the home, for a sufficient length of time to broaden
the mind and train his powers of observation and self-reliance.

' Lancet, March 28, 1903. ^ Am. Jour. Orthopedic Surg., Aug., 1903.

MISCELLANEOUS, 519

Osteogenesis Imperfectiva. — Harbitz^ describes the principal char-
acteristics of this condition as being shortness of the extremities, with
well-developed head and trunk. There is incomplete development of
the bone centers of the head and face and imperfect ossification, es-
pecially marked in the long bones. Chondrodystrophy and osteogenesis
imperfectiva are entirely distinct, and to* a degree opposite, conditions.

Treatment of Tuberculosis of Bones and Joints of Children after
the Lannelongue Method. — M. Marta^ has described the technic. The
injections should not be made directly into the affected part, but only
into the immediate surrounding tissues. Differing from Lannelongue,
he at once appUes a compression dressing and prefers to repeat the in-
jection, which for the first time is not very strong. Out of 24 joints
affected, he cured 14 with almost perfect mobiUty, 3 with 90°, 3 with
40° to 45°, and 4 with ankylosis.

The Malignancy of Joint Tuberculosis, Illustrated by a Series
of 47 Cases. — C. F. Painter,^ before the American Orthopedic Associa-
tion, read a paper on this subject. Its principal facts are epitomized as
follows: (1) Tuberculous disease of the joints tends to recur after ap-
parent cure in a considerable proportion of cases. (2) Recurrence is
most commonly local. (3) Trauma, direct or indirect, is most frequently
associated with recurrence. Indirect trauma is probably an exciting
cause of recurrence, especially where partial ankylosis exists. (4) Pa-
tients who have suffered from bone and joint tuberculosis should be
cautioned that they are not well when symptoms have ceased, and that
reasonable care must be exercised to avoid recurrence. [Our own ex-
perience does not corroborate the first conclusion. We believe that a
late recurrence is not the rule.]

Infantile Paralysis — an Epidemic of 38 Cases. — C. F. Painter*
has described in detail cases occurring in Gloucester, Massachusetts,
during the summer of 1900. Reference is made in the article to numer-
ous other epidemics which have occurred. The writer describes in detail
the 38 cases seen in this epidemic. There was only one death, which was
regarded by all those who saw the case as undoubtedly one of infantile
paralysis. There were 23 males and 9 females. The youngest was 13
months and the oldest 10 years of age; 21 were 3 years or younger; 8
were 2 years or younger; 7 were 4 years or more. No patient observed
got entirely well.

Habitual Luxation. — W. Wendel^ has considered the etiology of
this condition as given by Joessel, Roser, Franke, and others. He
describes Huesner's operation of deepening the sigmoid fascia; also the
operation of Loch for habitual luxation of the elbow, and describes 3
cases operated in the Marburg clinic. A^oluntary luxation is a curiosity,
while habitual luxation is a disease.

Recent Advances in Orthopedic Surgery. — H. L. Taylor® read be-
fore the American Therapeutical Society^ a] paperj in which he stated

* Zeit. f. orthop. Chir., xi, 3. '^ ^ Am. Jour. Orthopedic Surg., Aug., 1903.

' Trans. Am. Orthopedic Assoc, 1902. * Trans. Am. Orthopedic Assoc, 1902.
^ Am. Jour. Orthopedic Surg., Aug., 1903. " Med. News, Oct. 10, 1903.

520 ORTHOPEDIC SURGERY.

that orthopedic surgery justified itself not by definitions or by particular
modes of treatment, but by results, due to wise selection and careful
application of means rendered possible by special study and experience.
The Lorenz operation illustrates the present tendency in orthopedics
toward radical interference by simple methods. Cuneiform osteotomies
have been justly replaced by linear, which are usually safer and just as
effective. Early incision for joint diseases in children has been virtually
abandoned as both unnecessary and unsatisfactory, and has been replaced
by erasion or mechanical treatment. Excision of the knee in childhood
is absolutely rejected, except to save life, on account of its enormous
interference with the growth of the limb and the liability to secondary
deformity. In adults joint incision may, for many reasons, be more
freely employed. Another marked tendency in orthopedic work is the
increase of interest manifested in pathology and the exact means of
diagnosis. In some hospitals a culture is being made from all abscesses
opened, and the x-rays are used, and used repeatedly, on practically
every chronic joint. There has been a distinct increase of interest in
and knowledge of nontuberculous lesions and processes in or near the
joint. This tendency is well illustrated by the work of Goldthwaite,
Painter, Foster. Finding, as they do, that many of the obscure knee
affections of adult life are due to hypertrophied synovial fringes or race-
mose fatty tumors, hanging into the joint, brilliant advances have been
made in the study of the chronic rheumatoid affections of the joints.
The routine employment of the a:-ray is laid to the discovery that chronic
osteomyelitic foci are not uncommon, and that these may often be ex-
tirpated with the relief of long-standing and sometimes obscure symp-
toms. In addition to the transactions of the American Orthopedic
Association, there are 3 German, 2 French, and 1 Italian journal devoted
to this subject. About one-half the medical colleges in the Association
of American Medical Colleges afford instruction in this branch. Na-
tional Orthopedic Associations exist in England, Germany, and the
United States, and the former is the oldest.

Report of Final Results in 2 Cases of Polyarthritis in Children,
of the Type First Described by Still, together with Remarks on
Rheumatoid Arthritis. — R. Whitman/ before the Orthopedic Section
of the New York Academy of Medicine, read an exhaustive paper on
this subject. The joints most often involved are the knees, wrist, and
spine. There was usually flexion deformity of the wrist, and in some
instances lateral deviation of the wrist toward the outer side. The
smaller joints of the hand were not affected. Still defines the disease as
a chronic progressive enlargement of the joints, associated with general
enlargement of the glands and of the spleen. He had personally ob-
served 19 cases and had notes of 3 others, yet he confined his statistics
to 12 cases. In 10 of these the disease began at or before the sixth year,
and in 8 during the first three years of life. This type of disease must be
uncommon in this country, and 2 were reported in detail because they
present certain variations from those reported by Still. It can hardly
1 N. Y. Med. Rec, Aug. 18, 1903.

MISCELLANEOUS.

521

be claimed that the cases reported as final results throw any light on the
etiology of this form of disease. To one seeing only the autopsy the
hypertrophied enlargement of the glands, the extreme emaciation and
the abnormal color of the deviated bones would certainly have suggested
some general disease to which the joint lesion was simply incidental
but the history shows that the disease of the joint was, for a time at
least, the most important indication for treatment. The recoven^ of
the second patient makes an interesting addition to the history of Still's
disease. It is to be considered as a distinct affection

General Treatment of Tuberculous Bone and Joint Diseases —
J. E. Goldthwait^ states that until the last few years the treatment has
been considered to be largely local in nature, but that every effort should
be made to better the patient's general condition. Out-of-door life
tZ^A r? !".^^^*^^/P°^ ^j"^^'^ ^ "luch as in pulmonary tuberculosis.
Forced diet is needed and the best possible hygiene, both at home and
when at work should be arranged, and these features are not for a few
months only, but should be observed by the patient the remainder of

' Boston M. and S. Jour., Jan. 8, 1903.

34 S

OPHTHALIWOLOGY.

Bt WALTER L. PYLB, M.D., and SAMUEL HORTON BROWN, M.D.,

OF PHILADELPHIA.

The progress of ophthalmology may be conveniently considered
under two principal headings, laboratory and clinical. Foremost m the
laboratory group is the admirable work of R. L. Randolph on the role
of toxins in the causation of ocular affections. C. Nicolai's series of
experiments on frogs show the presence of muscular tissue m the optic
nerves and suggest the possibility of the same condition m man The
origin of the vitreous has been made the subject of special study by
Hamburger, who brings forth new facts in regard to this structure. Bern-
heimer demonstrates by his experiments the presence of uncrossed optic
nerve-fibers in man. H. J. Parsons has performed a series of experiments
of unusual interest in monkeys with a view to tracing the path of degen-
eration in the optic nerve and tract in the presence of bram-mjury.
Lucien Howe brings forward new methods for studying the orbital con-
nective tissue. Great credit is due George M. Gould for his painstaking
and elaborate biographic studies proving that the inexplicable chronic
suffering of many prominent literary men was due to uncorrected or im-
properly corrected ametropia. His essays on eyestram and civilization
and eyestrain and the literary life will do much to popularize the impor-
tance of eyestrain in the production of many intractable symptoms,
particularly those referred to the head. The many reasons why glasses
have not relieved such symptoms, even when prescribed by physicians,
is also a subject of an interesting and instructive paper. , ^ ^. ..

The new clinical facts are derived largely from a study of statistics.
The work of Barnes. Murray, Bickerton, G. D. Murray, and Pourquie
in coUecting statistics on the subject of color-blindness in the employees
of transportation companies is noteworthy for its exceUence. The exam-
inations of the eyes of school-children have been carefully studied, sta-
tistically, by J. Kerr, and his suggestions will no doubt meet with general
approval In the domain of preventive ophthalmology the collection ot
statistics on the subject of contagious eye-diseases has been a prominent
feature The figures presented by Derby, Roosa, Standish, Davis, Bailey,
Bev Lakah, and Straub show that even trachoma has been greatly
lessened in severity and in the number of cases by isolation and the more
modern methods of treatment. In other subdivisions of ophthalmology
statistical studies are likewise given prominence. Collins and Bronner
show the practicability of lens-extraction in myopia by 47 cases. Casey

522

AMETROPIA. 523

Wood and Brown Pusey review 78 cases of primary sarcoma of the iris
and C. S. Bull gives an account of 5 cases of iridochoroiditis directly
traceable to gonorrheal infection. Friedenwald describes 2 cases of
tuberculosis of the iris and Jessop reports the same disease in the choroid
in 2 instances. Barrett and Orr relate 8 cases of double optic neuritis
in which the terminations differed from those usually described. C. S.
Bull's observations after 94 iridectomies for glaucoma serve to corroborate
the usual teaching.

Great advance has been made in radiotherapy. The beneficial result
of the aj-ray in the treatment of morbid growths is well attested by Sweet,
Mayou, Stephenson, Walsh, and others. Sweet has used it in epithe-
lioma, while Mayou, Stephenson, and Walsh have applied it with success
in trachoma and tuberculous conjunctivitis. Radium has been accredited
with most remarkable properties, most of which are doubtful, but the
report of Javal and Curie as to its possibilities is entitled to consideration.
The relation of the infectious fevers to ocular affections has been brought
to the fore by the numerous reports of isolated cases. For instance,
mumps was shown to be a cause of cycloplegia in 2 instances ; ptosis fol-
lowed influenza in 1 case; orbital cellulitis was a sequel to scarlatina in
2 cases ; corneal ulcer was observed in 36 instances in variola ; diphtheria
induced optic neuritis in 1 case; and herpes zoster ophthalmicus was
shown to be a cause of oculomotor palsy in at least 3 cases and optic
neuritis in one case. Among the instruments, the siderophone is perhaps
the most ingenious. The success of Dimmer in obtaining satisfactory
photographs of the fundus oculi deserves more than passing mention. .

AMETROPIA.

Eyestrain and Chronic 111 Health. — Considerable interest has been
aroused by the publication of a series of "Biographic Clinics" by George
M. Gould, which contain convincing proof that much of the chronic ill
health of De Quincey, Carlyle, Darwin, Huxley, and Browning was due
in great part to eyestrain. Gould believes that the early application of
the proper correcting lenses would have given pronounced relief in each
case. Since then he has made equally convincing studies of the lives of
Herbert Spencer,^ Richard Wagner,^ Francis Parkman,' Nietzsche,*
Whittier,* Mrs. Carlyle,® and Margaret Fuller Ossoli,'' all of whom suf-
fered from pronounced asthenopic symptoms. An admirable summary
of these biographic studies is included in a recent article on " The Role of
Eyestrain in Civilization."* Doubtless the author could find many other
examples of eyestrain in prominent literary workers, but the 12 cases
already studied are sufficient to impress the great truth of the importance
of uncorrected or improperly corrected ocular defects in the causation of

» Amer. Med., March 7, 1903.

'Jour. Am. Med. Assoc, and Lancet, Aug. 1, 1903.
' Boston M. and S. Jour., Sept. 17, 24, Oct. 1, 1903.

* Biographic Clinics, vol. ii. * Cleveland Med. Jour., Sept., 1903.

« Amer. Med., Aug. 8, 1903. ' St. Paul Med. Jour., Dec, 1903.

" Brit. Med. Jour., Sept. 19 and 26, 1903.

524 OPHTHALMOLOGY.

many obscure and intractable symptoms. As Gould says in his paper on
"Eyestrain and Civilization"^: "But it is not only and not chiefly its
geniuses that concern medicine and a nation, when we consider the total
effect of this factor. Civilization has tremendously and suddenly in-
creased the eyestrain by a thousand occupations, which demand 'near-
work' with the eyes. Printing, schools, and city life, give the matter an
entirely new aspect. Sewing women, artisans, artists, machinists, musi-
cians, clerks, typewriters, engineers, pupils, all the professional and
business classes — these are the workers, spurred also to a continuousness
of labor, such as has never been demanded, upon whom the obligation
rests. The nation and the national medical profession that forgets or
ignores this, overlooks a highly important element of progress. And it
is one that is all the more effective because it conditions the peculiar
means whereby modern civilization advances." The same author has
also tabulated the causes of failures in many cases of eyestrain in which
medical treatment has included attention to the eyes. The title of the
paper is "Sixty-eight Reasons Why Glasses Did Not Give Relief,"^ and
a reading of it wUl be of interest to all physicians.

Asthenopia. — F. C. Hotz,^ in a paper on the misuse of glasses,
pleads for the recognition and treatment of blepharitis and conjunctivitis
in some cases, as conditions independent of ametropia. He recognizes
the almost universal association of these conditions, but quotes cases in
which glasses were of no benefit even in the presence of ametropia of
low degree, and which were only relieved by local treatment. [This
seems rather an argument for additional local treatment, than for the
abandonment of correcting lenses.]

In considering the true status of eyestrain as a cause of numerous
disorders, it is interesting to take testimony from both sides. A. R.
Baker* states unreservedly that migraine and facial chorea are mani-
festations of eyestrain and are relieved by the wearing of proper cor-
recting lenses. He qualifies his statement by saying that these forms of
chorea are not true chorea, but habit chorea. The entire claim is dis-
puted by C. J, Aldrich,^ who brings forth overwhelming statistics to the
contrary. In 3400 cases, he states, M. A. Starr failed to find true chorea
induced by eyestrain. Krafft-Ebing in an analysis of 200 cases failed to
detect eyestrain as a cause of chorea. Aldrich closes his criticism by a
reference to Osier's and Ranney's opinions on chorea, and states that at
best eyestrain is but an occasional exciting cause of chorea. He claims
that migraine is an incurable neurosis and is influenced by eyestrain.

Eyestrain and Cataract. — ^The necessity of properly correcting ame-
tropia in persons past middle age in an effort to retard the process of the
ripening of cataracts is insisted upon by C. M. Culver.^ He states that
neglected or faulty correction may increase the tendency toward opacifi-
cation of the lens, and that the elimination of ametropia is of prime
importance in the treatment of cataract.

' Amer. Med., Oct. 10, 1893. " Amer. Med., July 4, 1903.

' Med. News, Aug. 16, 1902. "Amer. Med., March 14, 1903.

* Amer. Med., Mav 9, 1903. « Jour. Am. Med. Assoc, Nov. 22, 1902.

AMETROPIA. , 525

The association of asthenopia with malaria has recently been
shown by J. L. Hiers/ Savannah. This observer states that malaria
induces asthenopia of two forms, acute and chronic, and verifies this
statement by the records of 20 cases in his own experience in which the
diagnosis was rendered certain by the microscope and in which prompt
antimalarial treatment afforded relief.

Changes in refraction of the eyes in the absence of well-defined
pathologic changes have been noticed by many observers. S. D. Risley^
has recently emphasized this fact by record of numerous personal ob-
servations. The suspicion of carelessness on the part of colleagues in
the performance of routine refraction work will be greatly lessened by
a fuller discussion of this subject.

Astigmatism. — Milhkin^ reports a case of very high mixed astigma-
tism, in which during 11 years of observation there was an increase in
the right eye from a total of 17 D. to 26.5 D., and in the left eye from
a total of 10 D. to 14.5 D., the vision after each correction being f in
the right and nearly f in the left eye. During this period the axis in
the right eye changed from 90° to 100°. There were no gross pathologic
conditions in either eye-ground, and the patient was able to use his eyes
without discomfort at close work until 5 years ago, in the incessant visual
strain of bookkeeping. He is very careful to keep his lens-frames accu-
rately adjusted, and for his presbyopia he uses convex lenses in eyeglass
frames to v/ear over his distance lenses. G. J. Bull,* Paris, reports a case
of astigmatism ( — C. 1.75 axis 90°) in which a cure was effected by
a complete subconjunctival tenotomy of the external rectus. Three
days later the vision l:)ecame normal and the patient was able to discard
cylindric lenses entirely. Diplopia was present for a few days, but dis-
appeared spontaneously. [While interesting, this report only shows
the influence of the extrinsic ocular muscles in the production of astig-
matism and does not open a new therapeutic field. Such uncertain
surgical methods can never be satisfactory, and in ordinary cases of
astigmatism they would be worse than useless.]

Hermann Knapp,® in a plea for the modification of the customary
notation of the ocular meridians so as to render it symmetric, pro-
poses the following changes: "(1) The construction of a new plate on the
spectacle frame for the left eye, placing zero on the nasal and 180° on
the temporal side. (2) A diagram of the prescription with the same
change for the optician marked symmetric notation, to distinguish it from
the customary notation, which may be called homonymous. (3) Peri-
meter charts marked symmetrically, i. e., zero at the nasal end of both
horizontal meridians. Counting the meridians from the inner canthus
up, along the brow, temple, and cheek to 360° or zero at the inner can-
thus. When these changes are made, there will be no confusion and we
shall be accustomed to the new system in less than a week." [The disad-
vantages of such changes are obvious. The present system is satisfactory

> Med. Rec, Oct. 11, 1902. => Ophthal. Rec, March, 1903.

3 Trans. Am. Ophthal. Soc, ix, 1902, p. 657.

* N. Y. Med. Jour., Feb. 7, 1903. * Jour. Arn. Med. Assoc, Sept. 13, 1903.

526 OPHTHALMOLOGY.

and commonly accepted in all mathematic calculations. The symmetry
of the meridians may be determined easily by adding their axes; if the
sum is 180, the axes are symmetric]

Myopia. — Fromaget^ reports the case of a young man who was re-
jected from military service on account of high myopia. He was wearing
concave lenses of 6 diopters, with which he could not read at a distance
of 25 cm. Without lenses he read with difficulty at 10 cm. For distance
vision he preferred concave lenses of 9 diopters. Visual acuity was
about ^. There were none of the common myopic fundus changes, but
the papilla was greatly congested. Spurious myopia from tonic spasm
of the ciliary muscles was suspected. By skiascopy no more than 2.50
diopters could be made out. Under atropin cycloplegia he was found
to have a small amount of compound hyperopic astigmatism. B. K.
Chance^ records 7 cases of posterior staphylomas in myopic eyes local-
ized to the nasal side of the optic disk. After careful study of his cases
this observer states that he regards the condition as being of congenital
origin and not an expression of the changes incident to progressive myopia.
J. E. Widmark^ states that opacities of the cornea and astigmatism
lead to myopia. When occurring in both eyes, corneal opacities pre-
dispose to myopia; but if only one eye is affected, that eye seems pro-
tected and the myopia develops in the other. In support of this he
adduces a number of his own cases. He believes convergence and accom-
modation to be potent in the production of myopia, but not to the great
extent usually accepted.

* Ablation of the crystalline lens in the treatment of high myopia
is still enjoying a certain vogue in Europe, and the results of the operation
are apparently satisfactory. Sir Wm. J. Collins,* London, reports 7 such
cases, in all of which vision was improved, and in some very great im-
provement was noticed. A. Bronner^ has removed the lens in 40 cases
of high myopia, and states that the distant vision after the operation is
not so good as one would expect; f is rarely obtained and f is not very
common. The results with near vision, however, are better in most cases.
Retinal detachment occurred in 2 of his cases in children under 16 years
of age at periods of 6 and 14 months after the operation. Glaucoma was
a complication in 4 cases, in 3 of which the symptoms were relieved by
an iridectomy, but in one the cupping was permanent, the fields con-
tracted, and the vision was only -^-^. Large vitreous opacities appeared
after the removal of the lens, permanently damaging vision. He does not
consider choroidal changes as a contraindication to the operation, as in
12 of his cases such changes were present and good results were obtained.
His method consists in performing discission and following it in a few
days by extraction. After the age of 38 or 40 years, the ordinary extrac-
tion operation should be performed.

Decentering Lenses. — G. C. Savage^ gives the following rules to
guide one in the decentering of lenses for near work: (1) If there is ortho-

* Jour, de M^d. de Bordeaux, March, 1902.

2 Phila. Med. Jour., Dec. 20, 1902. ^ Brit. Med. Jour., Nov., 1902.

* Lancet, Dec. 13, 1902. ^ gj-it. Med. Jour., Nov., 1902, 1441.

' Jour, Am. Med. Assoc, Nov. 22, 1902.

AMETROPIA.

527

BLUE.

phoria, presbyopic lenses should be so placed that each visual axis will
cut the optical center of its lens, when a point of fixation is in the extended
median plane of the head. (2) If there is uncomplicated esophoria, both
presbyopic lenses should be decentered directly out, and to an equal
extent so that the two visual axes may cut the lenses to the nasal side
of their optical centers, thus favoring the weak externi. (3) In esophoria
complicated only by hyperphoria of one eye and cataphoria of the other,
the decentering of presbyopic lenses should be confined to the lens for
the hyperphoric eye and should be down and out, so as to develop a
compensating esohypertropia of this eye. (4) In esophoria, complicated
by hyperphoria of one eye and cataphoria of the other, with plus cyclo-
phoria, the decentering of presbyopic lenses should be confined strictly
to the lens for the hyperphoric eye and should be down and out so as to
develop a compensating esohypertropia. (5) In simple exophoria each
presbyopic lens should be decentered directly in and to an equal extent.
(6) In exophoria complicated by hyperphoria of one eye and cataphoria
of the other, the decentering of presbyopic lenses should be confined to
the one for the cataphoric eye and should be in and up. (7) In exophoria
complicated by hyperphoria of one eye and
cataphoria of the other with plus cyclophoria,
the decentering of presbyopic lenses should
be confined strictly to the one for the cata-
phoric eye and should be in and up. (8)
In hyperphoria of one eye and cataphoria of
the other, with or without plus cyclophoria,
the decentering should be confined to the
lens for the hyperphoric eye and should be
directly down, (9) In double hyperphoria,
uncomplicated, both presbyopic lenses
should be decentered directly down and to

an equal extent. (10) In double cataphoria uncomplicated, if any
decentering is necessary it should be directly up. (11) If there is plus
cyclophoria only, in a presbyopic case, both correcting lenses should be
decentered down.

Tests for Vision. — Methods for the measurement of visual acuity
are still being devised, some of which demand consideration. Bouchart^
presents two new styles of tests. The first consists of squares of varying
sizes, made of alternating bars of black and white. The width of the
white and black bars is the same in each square, varying proportionately
to the size of the squares, each of which contains one more of the white
than of the black. The squares with the bars arranged vertically or
horizontally are placed on a roller, similar to a camera film, and this can
be rotated before an opening in the screen. The second design consists
of plates which contain variously sized figures of round, square, lozenge,
and elliptic shape. Some of the squares are placed at angles of 45°,
while the lozenge and elliptic figures are arranged with their axes placed
horizontally and vertically. Starr^ suggests a test-letter made up of

' Recueil d'Ophtal., Sept., 1902. ^ Jour. Am. Med. Assoc, Nov. 8, 1902.

YELLOW.

Fig. 102.— Starr's test letter (Jour.
Amer. Med. Assoc, Nov. 8, 1902).

528 OPHTHALMOLOGY.

two colors in order to produce a more sensitive test-object than the
ordinary soHd letter. By using a background of color the glare of light
and retinal fatigue resulting therefrom is lessened and it is possible to
utilize the phenomena of contrast of colors in such a way that the lessened
illumination is not as advantageous as with the black letters and a white
background. The letters are made up of two colors which are com-
plementary, one-half of the letter being blue, the other half yellow (Fig.
102) . The colors are laid longitudinally on each line of the letter, and the
background is gray. A mixture of complementary colors produces gray,
and a letter which is built up, in this way, of complementary colors will
look gray to an eye which, through lack of proper focusing, receives the
mixed colors on its retina. If, now, the letter is on a gray background
as described, the eye cannot distinguish the outlines of the letter, and
with proper adjustment of colors the letter wdll be quite invisible. A
slight overlapping of the colors, from imperfect focusing, gives the letter
a gray appearance, and a lens which corrects this overlapping and brings
each color sharply into focus produces a much greater contrast than is
the case with a black solid letter on a white ground.

Colored Vision, — C. Pino^ from some individual experiences con-
cludes that erythropsia is a complementary after-image of yellow-green
light, which originates when white light passes the capillary blood in the
inner layers of the retina, and which shows its effect only when the
retinal purple of the rods has disappeared through excessive illumination,
as the function of this purple consists in neutralizing these yellow-green
rays. He also thinks that the blue-violet which he sometimes noticed
in his experiments must be considered as a positive after-image of the
color-proper of light. For white light to reach the macula it must be
of a bluish-white tint on account of the yellow pigmentation of that
locality. With excessive illumination more blue rays will reach the retina
than the yellow pigment can absorb, so that a part penetrates toward
the percipient layer. The blue color is not seen through the intensity of
the light, but manifests itself in the after-image.

A. M. Davis ^ reports the occurrence of chromatopsia following a
normal labor. The visual disturbance was preceded by insomnia and
was manifested by every colored object in the room appearing yellow,
while dark objects appeared absolutely black. The condition was accom-
panied by an inability to concentrate the sight upon objects except for
a very short period after having had the eyes closed for a time [evidently
a paresis of accommodation].

TESTING THE EYESIGHT OF SCHOOL-CHILDREN.

The recent results of this work have been more or less uniform.
James Kerr,* in his report of the ophthalmic examination of the London
school-children, contributes some interesting data upon this subject.
Recent examinations were made by oculists. The examiners distin-

» Weekbl. v. Geneesk May 3, 1902. ^ Amer. Med., March 14, 1903.

^ Brit. Med. Jour., March 14, 1903.

OCULAR MUSCLES. ^ 529

guished the vision in their returns as good (V = -|), fair (V ^ -|or V = -^),
and bad (V = -^-^ or worse). Kerr makes reference for comparison to
the vision testing done by the teachers in 1900. There is an association
between defective visual acuity and retarded position in school. If the
children be divided into two groups — of precocious children (younger than
the average age in their standard), and retarded children (older than the
average age for their standard), then, although when considering the
whole of the children the younger ones have most defective vision, yet
in this grouping the older "retarded" group present more defective vision
than the younger "precocious" group. Probably this means not only
that defective vision retards progress in school, but also that the mentally
backward children do not respond to the visual tests so well. This last
idea is borne out by the fact that the oculists' more experienced testing
found less slight defect (fair vision), by about 25 % at each age of all
examined, than the teachers; and, in testing very young children, the
greater the time and trouble taken, the less the proportion of defects
found. The conclusions as to visual conditions in school may be summed
up as follows : (1) The percentage with normal vision increases with every
year of age and standard of absence during school lifej reaching 80 %
with Standard VII. (2) All through school life 10 % have "bad" vision
— this remains about a constant proportion. (3) The greater part of the
defective vision is due to slight defect, which gives imperfect but fair
vision, due probably both to mental and ocular conditions, and of greatest
importance educationally in the first half of school life. (4) Very bad
visual acuity (-^ or worse), due to accident, disease, and probably also
to spasm and myopia, is met with in a small proportion, increasing
regularly from 1.5% in Standard I to 3.5 % in Standard Ex- VII. Educa-
tionally, the standard of normal vision need not be adhered to; all chil-
dren with vision equal to f or -^^ should, however, be known to the
teacher. The 10 % of children with bad vision (-^^ or worse) require
special arrangements in school, and should be compelled to have attention
paid to this, and, if possible, medical advice with a view to improvement.
Such children are detected by the teacher's testing as readily as by an
oculist's more careful work ; and for practical purposes any future arrange-
ments should be based on each child's distant vision under working con-
ditions, being tested and recorded by the teacher at least once a year.
A list of such children ( V = ^ or worse) in each class should be suspended
in the class-room and kept up to date. The teacher should make frequent
examinations of all the children, and this should be supplemented by
annual examinations of those whose sight is defective.

OCULAR MUSCLES.

C. Nicolai^ observed forward movement of the optic disk in frogs

after punctures of the anterior chamber postmortem, and concludes that

muscular tissue must be situated here which contracts on the sudden

diminution of tension in the vitreous chamber. This muscle he terms

* Verd. d. Koninklyke Akad. v. Wetensch 2 sectie, dl. IX, no : 3.

530 OPHTHALMOLOGY.

"musculus papillce optici/' and claims that it is responsible for the cases
of papillitis in which the nerve is unaffected and which respond to the
salicylates and iron. In further support of his claim he brings forth
microscopic sections of the papilla which show muscle-cells and fibers in
this situation.

Nystagmus, the causes of which are well known, has been recently
shown to be influenced greatly by heredity. T. Fisher^ reports an in-
stance of lateral nystagmus unassociated with disease of the choroid, lens,
or retina, occurring in a child aged 5 months. The condition probably
existed from birth. The father, aged 21, was similarly affected, and had
been so, it was reported, from his birth. Isaiah Frank ^ relates a case in
which nystagmus was present and was transmitted to 1 child and 6
grandchildren. The patient had been married twice ; 1 grandchild of the
first wife and 5 of the second had the affection, showing that the trans-
mission was through the father. Greanelle^ gives an account of a family
in which 2 children, the mother, and the grandfather w^ere affected with
congenital nystagmus. There were no gross lesions to account for the
condition. All the members of the family were brunets. C. 0. Haw-
thorne* and M. M. Sinclair® also record, independently, cases of nystag-
mus in 3 generations. E. Stieren,' Pittsburg, describes a case of a boy
6 years of age in whom there was a congenital absence of both inferior
recti muscles.

A simple method for the determination of the degree of deviation
in squint has been devised by N. M. Black.'' It consists of a wooden
base supporting an upright. At right angles to the center and top of
this upright is attached an arm which can be turned to the right or left
at the center of the upright. A scale of degrees is marked on the back of
this arm. The light is furnished by a long miniature movable electric
lamp that may be lighted or extinguished at will. [This is an ingenious
adaptation of the perimeter test, over which it possesses the advantage
of its convenience.]

A. E. Prince,^ in considering section and resection of recti muscles
for cosmetic purposes, in cases of squint inoperable by tenotomy or
advancement, reaches the following conclusions: (1) In the case of com-
plete paralysis of either internal rectus, the resection of the opposing
muscle will enable the eye to be retained in the straight position without
motion in that meridian. (2) In a case of retraction of either rectus
into the orbit under conditions rendering its advancement impossible, an
equalization of the deviating power is to be obtained through section
of its antagonist, posterior to its capsular attachment, following which,
excursions in that meridian will be restored to an extent varying between
20° and 50°. (3) In case of paralysis or retraction of either rectus, the
operation of section or resection of its antagonist has not been observed
to develop or increase any preexisting exophthalmus to any marked degree.

' Brit. Med. Jour., Sept. 6, 1903. "- Med. Rec, Jan. 31, 1903.

^ Pediatrics, Feb., 1903. * Brit. Med. Jour., Feb. 21, 1903.

* Brit. Med. Jour., May 23, 1903. « Amer. Med., April 11, 1903.

' Ophthal. Rec, Nov., 1902. ^ Am. Jour. Ophthal, Sept., 1902.

OCULAR MUSCLES. 531

F. C. Todd^ describes an^ improvement in the instrument originally
devised by him in 1902 for the operation of tendon-tucking in advance-
ment of the muscles. The accompanying illustration (Fig. 103) shows the
new features to advantage.

Paralysis of the Ocular Muscles. — While it is a common practice
to consider the acute infectious fevers as causes of ocular palsies, reports
of such cases are somewhat rare. Diphtheria is perhaps the most fre-
quently encountered cause. Jacqueau^ reports a case of complete ptosis
in a man 53 years of age following influenza. It occurred first in the
left eye, and within 24 ho.urs appeared in the right eye. Bagneris' de-
scribes a case in which paralysis of accommodation followed an attack
of mumps. A similar condition accompanied by palsy of the velum
palati was observed by Mandonnet* in a child of 9 years as a result of
this disease. Herpes zoster ophthalmicus, while not usually classified as
an infectious fever, is occasionally attended by oculomotor palsy, as is
shown by the records of cases reported by W. Zentmayer^ and J. W. Bar-
rett and W, F. Orr. ^ That internal ophthalmoplegia may be caused by
ergot is shown in a case
reported by P. Schneider^
in which both eyes were
affected during the daily
administration of the
drug. Accommodation
and convergence returned ^"^^^ loa.-Todd's instrument for tendon-tucking.

on its withdrawal.

Total unilateral oculomotor palsy has been observed by Lindner,^
in a woman aged 42, attended by violent headache, vomiting, and tin-
nitus aurium. Optic neuritis and retinal hemorrhage were present in
addition. The symptoms subsided gradually and the patient was com-
paratively well with the exception of the oculomotor palsy, which per-
sisted. Three and a half years after the onset of the condition she fell
over unconscious and developed a right-sided hemiplegia, from which
attack she died shortly afterward. Postmortem examination revealed
the presence of a pea-sized aneurysm of the left internal carotid artery
which had pressed on the oculomotor nerve and later ruptured into the
left ventricle.

Myasthenia gravis and its ocular manifestations have been consid-
ered recently at length by W. R. Gowers," C. S. Myers, ^^ and C. D. West-
cott and Brown Pusey." The chief characteristic of this affection is
general feebleness of all the muscles with quick exhaustion after use and
electric stimulation, with equally rapid restoration on rest. There is no
loss of power in the ocular muscles, the condition thereby resembling

» Ophthal. Rec, March, 1903. ^ New Orleans M. and S. Jour., April, 1903.

' New Orleans M. and S. Jour., Feb., 1903.

' Annales d'Oculistique, March, 1903. ' Amer. Med., Oct. 27, 1902.

* Intercol. Med. Jour, of Australasia, July 20, 1902.

' Miinch. med. Woch., No. 39, 1902. ' ** Wien. klin. Woch., Nov. 6, 1902.

» Brit. Med. Jour., May 24 and 31, 1902.

'"Jour. Path, and Bact., Sept., 1902, A-iii. No. 3, p. 306.

" Jour. Am. Med. Assoc, July 11, 1903.

532

OPHTHALMOLOGY.

strongly at first sight ophthalmoplegia from nuclear degeneration. One
of the distinguishing features is the greater escape of the muscles moving
the eyes downward and the implication in varying degree of those moving
the eyelids upward. The lateral muscles are constantly but irregularly
affected. The light-reflex is usually perfect. In Myers's observations the
ciliary muscle was unaffected, but in the cases of Gowers, Westcott, and
Pusey accommodation was markedly interfered with. The refraction
undergoes variations. Ptosis is usually present. Periodic exacerbations
and remissions are characteristic of the affection.

EYELIDS.

Mori and Ptikuji, Yarmamoto/ report a very unusual case of gan-
grene of the eyelid in a poorly nourished infant 1^ months old. The
lesion was triangular in shape at the right outer canthus and measured

A B

Cr'

Fig. 104. — Allport's modification of Panas's o|ieratioii for ptosis: 1, First incision; 2, second inci-
sion; 3, third incision; 4, fourth incision; 5, tifth incision; 6, sixth incision; 7, edge of upper lid;
A, bridge flap; B, tongue flap; C, nasal tia]); 1>, temporal Hap; E, palpebral flap (nasal side); E, pal-
pebral (temporal side) (Jour. Am. ^led. Assoc, April 11, 1903).

1.5 cm. by 1 cm. Bacteriologic examination revealed the presence of
diphtheria bacilli, but the mucous membranes elsewhere remained nor-
mal. The patient eventually died despite the serum-treatment. Spon-
taneous gangrene or noma has been observed by F, W. Marlow^ in an
infant 3 weeks old. The condition began as a pimple and rapidly ulcer-
ated, destroying both lids and ultimately terminating in death from
exhaustion.

Vicarious menstruation from the lids is an interesting affection
occasionally reported. C. J. Herbert^ describes a case of this character
occurring in a young Jewess, who since the establishment of menstruation
at 13 years of age had noticed oozing of blood from the lower lids about
2 or 3 days previous to each period. Treatment did not influence the
condition,

1 Abstr. Annals of Ophthal, Jan., 1903, p. 172.

2 Ophthal. Rec, Dec, 1901. ^ Jour. Am. Med. Assoc, Sept. 13, 1902.

EYELIDS.

533

The treatment of epithelioma of the lids has always been unsatis-
factory, and the remedies advised are legion. W. B. Marple^ relates a
case in which the affection was cured by the local application of adrenaUn
(1 : 1000). W. M. Sweet^ proves conclusively by the reports of his cases
that the method of treatment by the x-ray is no longer experimental in
character.

Lid-operations. — Among the new lid-operations of the past year F.
Allport's^ modification of Panas's operation for ptosis deserves special

Fig. 105. — Allport'g modification of Panas's operation for ptosis : 1, First suture; 2, second suture; 3,
third suture; 4, fourtii suture; 5, fiftii suture (Jour. Am. Med. Assoc, April 11, 1903).

mention. The accompanying diagram (Fig. 104) gives the outlines of the
incisions advised by Allport. The second illustration (Fig. 105) shows
the manner in which the sutures should be introduced. The puckering
of the lateral flaps after the sutures are drawn tight is avoided by cutting
off their corners and suturing them to the adjacent upper and lower flaps.

* Med. Rec, August 23, 1902. ^ Amer. Med., Dec. 13, 1902.

'Jour. Am. Med. Assoc, April 11, 1903.

534

OPHTHALMOLOGY.

On completion the eyelid has the appearance shown in the third illus-
tration (Fig. 106).

In considering the blepharoplastic operations for cicatricial ectro-
pion, F. C. Hotz^ contributes some very interesting points. For ectro-
pion of the upper lid he advises making an incision starting from a point
5 mm. above the inner canthus, extending upward in the shape of a
curve to the limit of the cicatrix, and terminating 5 mm. from the outer

Fig. 106.— Allport's modification of Panas's operation for ptosis : 1, Siitiires 1, 2, 3, 4, 5, after being tied
2 and 3, sutures in flaps C and D after being tied (Jour. Am. Med. Asssoc, April 11, 1903).

canthus. This flap is then carefully dissected up from the underlying
scar-tissue as far as the lid border. The lid is then released by dissection
from all cicatricial connections until it can be easily turned down into
its normal position, and now the edge of the lid-flap is sutured to the
upper border of the tarsus. Two ligatures may be passed through the
lid and fastened to the cheek until union has occurred, especially if it

^ Jour. Am. Med. Assoc, May 2, 1903.

LACRIMAL APPARATUS. 535

is necessary to use a Thiersch graft. A reversal of the incision, flap, and
ligatures is necessary for operation on the lower lid. A. E. Ewing^ de-
scribes a modification of his original entropion operation on the lower
eyelid. A modification of Desmarre's clamp is used to evert the lid,
after which an incision parallel to the free margin of the lid and extending
throughout its entire length is made. The muscle-fiber should be exposed
throughout the entire wound. The partially detached marginal strip is
then turned over by forceps or ligatures in order to widen the incision.
Three sutures are then passed through the conjunctival margin of the
incision through the tarsus, penetrating the bottom of the wound and
emerging on the dermal surface of the lid. The needles are then reentered
on the same horizontal line, but 3 mm. distant from their points of exit,
emerging at the edge of the marginal strip. The ends are then tied
moderately tight and serve to completely evert the marginal strip.

LACRIMAL APPARATUS.

J. W. Wamsley^ has devised a new form of drainage-tube for inser-
tion into the nasal duct in cases of stricture. It consists of a coil of
14 or 18 karat gold wire. No. 30 gage, made in the shape of a short lac-
rimal probe and varying in caUber. For average use he prefers one about
3.5 mm. in diameter. His method of treatment consists in first intro-
ducing a short thick aluminum probe, allowing it to be retained for a
few days until reaction subsides. He then passes an introducer into the
duct and measures its length and withdraws. The gold wire tube is
placed on the introducer to the required length and both are passed into
the duct, after which the introducer is withdrawn, leaving the wire coil
to maintain permanent dilation of the duct. Priout^ records a case of
acute dacryoadenitis produced by the ingestion of 18 grains of potas-
sium iodid for a period of 9 days. [A condition known as angioneurotic
edema is not infrequent in this region in individuals susceptible to the
iodids, and resembles this affection very closely.] Panas* reports a case
of tubercular syphilis in the region of the left lacrimal sac, and
DeLapersonne^ describes a case of primary syphilis of the eyelid and
lacrimal gland. Among the extremely rare lacrimal conditions is actino-
mycosis. Such a case has been observed recently by Guibert® in a
leather-worker, 34 years of age, affecting the inferior canaliculus. Micro-
scopic examination showed typical actinomycotic structures. C. J. Kipp^
observed a case of streptothrix in the lower canaliculus in a man 28
years of age who complained of a swelling in the region of the inferior
canaliculus and lacrimation. A concretion 9 mm. long and 6 mm. in
diameter was removed and examined microscopically. Tumors of the
lacrimal gland are always of infrequent occurrence and may be confused
with pseudotumors of that structure. This fact is readily demonstrated
by Coppez* in his report of 5 such enlargements, 3 of which were

> Am. Jour. Ophthal., Feb., 1903. ^ Phila. Med. Jour., Dec. 20, 1902.

» La Clin. Ophtal, Oct. 10, 1902. * Arch. d'Ophtal., Dec, 1902.

* Arch. d'Ophtal., Dec, 1902. ^La Clin. Ophtal, Nov. 10, 1902.

' Arch, of Ophthal, July, 1902.

* Soci6t6 Beige d'Ophtal, in Ann. d'Oculistique March, 1902.

536 OPHTHALMOLOGY.

sarcomas and 2 were dislocated lacrimal glands. In operations in which
infection is liable to take place through the tear-passage F. BuUer^
advises ligation of the canaliculi by passing a No. 2 iron-dyed silk
ligature around the canal a little to the inner side of the punctum and
tying it as tightly as possible.

Extirpation of the lacrimal sac for the relief of dacryocystitis has
been performed by E. Rollet/ who believes that in the majority of cases
the affection may be entirely cured by the operation. In 27 cases seen
by him only 3 were total failures; abnormal lacrimation was absent in 16,
insignificant in 2, intermittent in 4, and persistent in 3 cases. In the
suppurative cases there was no subsequent ectropion or disfiguring
cicatrix.

CONJUNCTIVA.

Kikutsi' relates a case in which a Chinese doctor made effort to
remove a nevus from the eyelid by vaccination. The procedure was
successful, but was attended by a most intense mucopurulent conjunc-
tivitis and fever. Marczel Falta* calls attention to itching as the most
prominent symptom of vernal catarrh, and. uses this symptom for
differential diagnosis. He states that upon rubbing the lid itching is inten-
sified, while a similar manipulation in trachoma produces no symptoms,
unless possibly pain.

A. V. Lotine^ reports a case of conjunctivitis due to the presence
of the larvas of Wohlfahrt's fly {Wohlfahrtia magnifica schincrii) in
the conjunctiva. The rarity of this condition demands its consideration.
The first case was reported by Wohlfahrt in 1770, and almost 100 years
later Schiner, an Austrian entomologist, described the fly under the name
of Sarcophela magnifica. The larvas are white with transverse minute
black striations. They measure 0.5 cm. in length and 1 mm. in width.
Coppez' gives the history of a case of conjunctivitis in a boy of 8 years
in which thin filaments of mucus containing leukocytes and desquamated
epitheUum were constantly discharged, greatly disturbing vision. Treat-
ment seemed to increase these filaments. C. O. Hawthorne'' describes a
case of arthritis accompanying ophthalmia neonatorum. The joint-
complications were mild in character and the efficiency of the affected
joints was promptly restored by treatment.

H. D. Bruns^ says he is aware of no study of the relative liability
of the white and the negro to attacks of phlyctenular ophthalmia, nor
has any one called attention to the greater severity of the malady and
its curious varieties in the latter race. Of 17,311 eye cases in his clinic,
5052 were cases of conjunctival disease. Of these, 2002 were colored
and 39 % were phlyctenular cases. Of 3050 whites, only 14 % were
phlyctenular cases. The period of life over which liability to attack

1 Trans. Amer. Ophthal. Soc, 1902, p. 633. * Lyon MM., March 22, 1903.

3 Abstr. Ann. of Ophthal., Jan., 1903, p. 172.

* Arch. f. Augenheilk., Aug., 1902. » Roussky Vratch, Feb. 1, 1903.

* Jour. m6d. de Bruxelles, Oct. 23, 1902.

'' Reports of Soc. for Study of Children, vol. ii, London, 1902.

* New Orleans M. and S. Jour., Aug., 1903.

CONJUNCTIVA. 537

extends is longer in the negro than in the white. The disease is much
more severe in the negro, many of the cases being almost hopeless.
Bruns gives tables showing the effect of local treatment with mercurials
alone, mercurials with other agents, and without mercurials. He in-
terprets them as showing that local treatment has but little to do with
the progress Of the case.

Trachoma is compared to adenoids of the nasopharynx by R. Op-
dyke, ^ who believes that a close analogy exists between them. He states
that one out of every two children with trachoma examined by him
in the New York schools had adenoids, and he considers that these vege-
tations are important etiologic factors in granular conjunctivitis. Myles
Standish^ disputes this, and states that follicular conjunctivitis is confused
with trachoma in this respect, and that the analogy does not extend to
the latter condition. Von Arlt^ employs cuprocitrol in the treatment
of trachoma, by means of a glass rod over granulations in the conjunctival
sac, followed by gentle but thorough massage. In advanced cases he
uses a 10 % ointment 3 times a day, decreasing the strength as the case
improves, or if the applications cause pain. In a few cases cuprocitrol
is not tolerated, and in these Von Arlt uses a dusting-powder of itrol.
He speaks favorably of this substance, but warns against its suscepti-
bility to deterioration from exposure to light and to the products of
combustion of illuminating gas. Niemtchenkov, * a Russian military sur-
geon, advises subconjunctival injections of a 5 % aqueous solution of
carbolic acid solution in the treatment of trachoma. Niemtchenkov has
thus treated with great success 43 patients. M. S. Mayou® reports a case
of trachoma cured by the x-ray. He points out that there is less destruc-
tion, less pain, and less cicatrization than in other radical methods of
treatment. Sydney Stephenson and D. Walsh* also record 2 similar
cases. In one case 17 exposures were required and 6 in the other, with
an average exposure of 10 minutes at a distance of about 8 inches from
the tube. The results were the same with closed as with open lid. H. R.
Elliot^ states that peritomy is entitled to greater recognition than it
receives. Trachoma, while severe in parts of Continental Europe, re-
ceives more attention there than it does in India, where Elliot practises,
and consequently neglected cases of pannus are less frequent. In 500
cases Elliot has never seen the operation of peritomy fail to be of benefit.
He advises the excision of a strip of conjunctiva not more than 6 mm.
in width. S. Snell* is likewise an advocate of this operation in vascular
conditions of the cornea, corneal ulcers, and detachment of the corneal
epithelium.

Growths. — Papilloma of the conjunctiva and cornea has been
observed by R. H. Johnston® in 2 cases, in both of which the diagnosis
was confirmed by the results of a microscopic examination. In differ-
entiating this condition from epithelioma Johnston lays great stress on

* Med. Rec, Jan. 3, 1903. ^ Boston M. and S. Jour., cxlvii, No. 14, p. 367.
« Wien. klin. Woch., May, 1902. * La Sem. m6d., May 28, 1902.

* Brit. Med. Jour., March 28, 1903, ' Lancet, Jan. 24, 1903.
' Lancet, June 6, 1903. « Lancet, May 30, 1903.

» Ann. of Ophthal., July, 1903.
35 S

538 OPHTHALMOLOGY.

the following characteristics : epithelium of the skin or mucous membrane
from which the tumor springs, more or less proliferated in a regular and
orderly manner; squamous, polyhedral, and cylindric from without
inward; connective tissue bound together and containing blood-vessels,
the essential characteristic of the connective tissue being papillas corre-
sponding in some or all respects to the papillas of the skin. His report,
in its entirety, may be considered as a plea for early microscopic examina-
tion of all tumors of the conjunctiva with a view to preventing enucleation
as a result of mistaken diagnosis, H. V, Wiirdeman^ reports a case of
papilloma of the myxofibromatous type occurring on the conjunctiva in
a child of 10 years (Fig. 107). Excision was necessary for the removal of
the granulations. L. A. W. Alleman^ presents a case of amyloid degen-
eration of the conjunctiva in an Italian woman, 54 years old. Micro-
scopic examination confirmed the diagnosis. Swelling and induration of
the lids were prominent features and the conjunctiva appeared tightly
stretched over a waxy mass of an indescribable yellowish-red color.

MoUuscum contagiosum of the con-
junctiva has been observed by Th.
Balaban.' The growth attained the
size of a hazel-nut and was situated
on the bulbar conjunctiva, extending
from the outer commissure nearly to
the cornea. It was firmly attached to
the conjunctiva, but was freely mov-
able on the underlying tissue. The
Fig. io7.-Papiiioraatous degeneration growth was removed and subjected
of ophthTvof xt, Kf 1902).' '" ^""- to a microscopic examination the re-
sults of which rendered the diagnosis
positive. Healing was prompt after the operation. J. R. Bordley*
contributes some new statistics on the subject of tuberculosis of the
conjunctiva. His figures cover 84 cases collected since 1870. Most
of the infections occurred in people ranging from 10 to 30 years,
although no age seemed exempt. Of the patients, 62 % were females;
25 of the cases followed as secondary infections; in 10 % of the primary
infections the health was very poor; 15 cases were ascribed to trauma-
tism; 2 cases followed operations for strabismus, and 1 developed as a
tarsal cyst. The right eye was affected in 47 % of the cases, the left
eye in 40 %, and both eyes were involved in 13 %. The lesion originated
in the conjunctiva of the upper lid in 33.5 % of the cases, in that of the
lower lid in 15.5 %, in the bulbar conjunctiva in 12 %, and in the pal-
pebral and bulbar conjunctiva in 6 %. Sydney Stephenson^ reports a
case of tuberculosis of the conjunctiva in which a cure was effected by
x-rays. The affected conjunctiva was treated by exposure to the x-rays
at a distance of 6 to 10 inches from the focus tube for an average period
of 10 minutes at each sitting. This observer also reported^ a previous

» Ann. of Ophthal., vol. xi, No. 4, 1902.

^ Ann. of Ophthal., vol. xi, No. 4, 1902, p. 448.

» Arch. f. Augenheilk., April, 1903. " Ophthal. Rec, July, 1902.

» Brit. Med. Jour., June 6, 1903. « Brit. Med. Jour., May 3, 1902.

PTERYGIUM. ' 539

case similarly cured. The case of F. L. Henderson^ is noteworthy for
recovery without local interference. The diagnosis was made by micro-
scopic examination of a small section excised. E. Jackson^ describes a
case of tuberculosis of the conjunctiva in which the ocular condition was
preceded by swelling of the cheek and enlargement of the lymphatic
glands of the neck and accompanied by vomiting and fever. The lids
were studded with granules resembling somewhat miliary tubercles. Ex-
amination of the discharge revealed the presence of tubercle bacilli on
several occasions. The local treatment was confined to the use of a
lotion of trikresol [1 : 1500] and iodoform ointment (25 %). The general
treatment included rest, abundant food, outdoor living, cod-liver oil,
and tonics. Under treatment the lids became less swollen and the gran-
ules decreased in size.

Carcinoma epibulbare planum, an extremely rare new-growth of
the conjunctiva, is reported by B. Matys,^ Prague, occurring in a man
78 years of age. The duration of the condition was about 16 months
when it came under the writer's observation, and it occupied nearly the
entire lower half of the bulbar conjunctiva. The growth was removed
and examined microscopically. A diagnosis of carcinoma was made.
Recurrence occurred on the sixteenth day after operation.

PTERYGIUM.

Gonin* reports a case in which several relapses of a pterygium resulted
in complete veiling of the cornea. He applied the term "malignant"
to this condition. Chacon^ makes the statement that while pterygium
may result from the action of irritants, it is, in Mexico at least, diagnostic
evidence of alcoholism. J. 0. McReynolds® shows that the cause varies
in different countries, and that in his experience it is due largely to the
irritation of heat, dust, and high winds. He also states that the operation
for the condition must vary according to these several conditions, and
describes a modification of Desmarres's operation devised by himself. The
details of the operation as given by McReynolds are the following: (1)
Grasp completely the neck of the pterygium with strong but narrow
fixation forceps. (2) Pass a Graefe knife through the constriction and as
close to the globe as possible, and then with the cutting-edge turned
toward the cornea shave off every particle of the growth smootlily from
the cornea. (3) With the fixation forceps still hold the pterygium, and
with slender, straight scissors divide the conjunctiva and subconjunctival
tissue along the lower margin of the pterygiuiii, commencing at its neck
and extended toward the canthus, a distance of i to ^ of an inch. (4)
Still hold the pterygium with the forceps, and separate the body of the
growth from the sclera with any small, noncutting instrument. (5) Now
separate well from the sclera the conjunctiva lying below the oblique
incision made with the scissors. (6) Take black silk thread armed at

' Ann. of Ophthal, July, 1903. ^ Ophthal. Rec, Oct., 1903.
^ Jour. Am. Med. Assoc, April 25, 1903.

* Ann. d'Oculistique, Nov., 1902. * Anales de Ophtal., Sept., 1902.

* Jour. Am. Med. Assoc, Aug. 9, 1902.

540 OPHTHALMOLOGY.

each end with small curved needles and carry both of these needles
through the apex of the pterygium from without inward and separate
from each other by a sufficient amount of the growth to secure a firm
hold. (7) Then carry these needles downward beneath the loosened con-
junctiva lying below the oblique incision made by the scissors. The
needles, after passing in parallel directions beneath the loosened lower
segment of the conjunctiva until they reach the region of the lower
fornix, should then emerge from beneath the conjunctiva at a distance
of about ^ to |- of an inch from each other. (8) Now with the forceps
lift up the loosened lower segment of conjunctiva and gently exert traction
upon the free ends of the threads, which have emerged from below, and
the pterygium will glide beneath the. loosened lower segment of the con-
junctiva, and the threads may then be tightened and tied and the surplus
portions of thread cut off, leaving enough to facilitate the removal of
the threads after proper union has occurred. It is very important that
no incision should be made along the upper border of the pterygium,
because it would gape and leave a denuded space when downward traction
is made upon the pterygium.

BACTERIOLOGY.

In a series of experiments performed for the purpose of determining
the role of the toxins of various bacteria in inflammations of the eye,
R. L. Randolph^ has demonstrated the importance of these toxins in
explaining the pathogenic action of bacteria in ocular conditions. In
these investigations the toxins of the gonococcus, the diphtheria bacillus,
the pneumococcus, Staph3-lococcus aureus. Micrococcus epidermidis albus.
Streptococcus pyogenes. Bacillus coli communis, and Bacillus xerosis
were employed. The first 40 experiments consisted in the 'instillation of
the toxins into the conjunctival sac. In 39 of these the results were
uniformly negative. In one case conjunctivitis was produced, but this
was directly traced to a solution in the continuity of the mucous mem-
brane. Then 31 experiments were performed in which the toxins were
injected into the conjunctiva, and conjunctivitis was produced in every
case. Seven experiments were made consisting in the injection of the
toxins into the anterior chamber. Iritis was produced in all of these
cases, but not panophthalmitis, owing, as the observer states, to the
oozing of the toxin through the corneal wound and its dilution by the
regenerated aqueous. In another extensive series of examinations Ran-
dolph has determined the character of the bacteria normally present in
the rabbit's conjunctiva. A knowledge of this is very important, as
practically all the experimental work of the ophthalmologist is performed
on the rabbit's eye. His experiments extended over 47 cases. Staphylo-
coccus albus was found in abundance in 36 cases. In 10 cases an assort-
ment of miscellaneous bacteria was encountered, and in but one instance
was a sterile plate made. Randolph in his excellent work has demon-
strated beyond a doubt that the formula necessary for certain ocular

' Am. Jour. Med. Sci., Nov., 1902.

PROPHYLAXIS OF CONTAGIOUS DISEASES. - 541

inflammatory conditions is toxins plus a lesion of the conjunctiva. He
has also shown that it is the toxins and not the irritation induced by
the presence of the bacteria alone that give rise to the inflammation, and
that toxins are produced in the conjunctival sac by bacteria ordinarily
devoid of such constituents.

PROPHYLAXIS OF CONTAGIOUS DISEASES.

That the results attending prophylaxis in ophthalmology are becom-
ing more manifest each year is readily shown by recent statistics taken
from all parts of the world. Following the passage of a law in 1886 in
New York State requiring isolation of contagious eye-diseases, the per-
centage of such affections has been rapidly decreasing. A brief review
of Derby's statistics^ in this connection will serve to verify this statement.
In 1886 the inmates of 51 institutions, numbering 12,684 in all, were
examined; and of these, 3862 were declared to have contagious ophthal-
mia. In the New York Juvenile Asylum in 1886 the percentage of such
cases was 17.7, but in 1902 was only 2.5. In 1886 the Five Points House
of Industry showed 66.5 % of contagious ophthalmia; in 1902 it showed
only 4.4 %. In the CathoHc Protectoiy in 1886 there was 40 % of the
inmates with contagious eye-diseases, but in 1902 there was but 3.7 %
of such cases. In 1886 the House of Our Lady of the Rosary showed
18.3 % of contagion? ophthalmia; in 1902 only 1.6 %. In the Hou.se of
Refuge in 1886, 16.2 % of the inmates were afflicted with contagious
eye-disease, but in 1902 only 7 % could be demonstrated. In St. Joseph's
Asylum in 1886 Roosa found 58.34 % of trachoma; the examination in
1902 showed only 1.2 % of such cases. Statistics show that about 19 %
of the candidates applying for admission to these institutions have tra-
choma; most of them have attended public schools and further aided in
the dissemination of the disease. Inspection ordered by the Board of
Health in two New York schools showed respectively 19.2 % and 15.5 %
of trachoma cases. Derby recommends the examination of the eyelids
of school-children at regular intervals and the application to day-schools
of the methods efficacious in institutions where children are permanently
lodged. W. E. Lambert^ verifies Derby's statistics in his report of the
New York Public Schools. Thirty-six pubHc schools were inspected,
resulting as follows: Of 57,450 children examined, 6690 were found to
have some form of contagious eye-disease — over 13 %. Of these, 2328
were severe trachoma, 3243 were mild trachoma, and 1099 acute purulent
conjunctivitis. The percentage in the different schools varied from 3.2
to 22.2, the boys showing a larger percentage than the girls: boys, 3.6
to 28 %; girls, 1 to 18 %. Lambert and Derby urge the eversion of the
lids in examining children or others to determine the presence of the
granulations which would otherwise escape notice. The reduction in
trachoma cases in this country is due not only to the exclusion of infected
immigrants, but to prompt recognition and modern treatment. In sup-
port of the latter statement the statistics of Myles Standish' may be

' Med. Rec, July 5, 1902. ^ Med. Rec, Feb. 21, 1903.

'Boston M. and S. Jour., Oct., 1902.

542 OPHTHALMOLOGY.

quoted : The proportion of cases coming to the Out-Patients' Department
of the Massachusetts Eye and Ear Infirmary suffering from trachoma
was as foUows: In 1880, 3.5 %; in 1881, 3.6 %; in 1882, 4.1 %; in 1883,
3.7 %; in 1884, 3 % — an average of 3.5 % for the 5 years. Comparing
this with the last 5 years, we find there were in 1897, 1.3 %; in 1898,
1.4 %; in 1899, 1.2 %; in 1900, 1.1 %; and in 1901, 1 %; being an average
in the 5 years of 1.2 %. Again in the years 1880-1884 the total number
of in-patients in the infirmary was 2611; of these, 329 were tracho-
matous, or 12.6 %, while during the last 5 years the total number of
in-patients was 4905, of whom 148 were trachomatous, which gives us
3 %. A, E. Davis^ contributes some interesting data as to the influence
of the Immigrant Act of 1897. In 1891 this observer collected reports
of over a half million cases of ocular diseases in the large cities, of which
4.25 % were trachoma cases. In 1901, three years after the law of
exclusion of trachoma cases went into effect, out of 90,640 cases of eye-
disease only 2460 cases, or 2.71 %, were trachoma, showing a decrease
of almost one-half. Bailey,^ in an examination into the causes of blind-
ness in Kentucky, states that trachoma was responsible for the loss of
sight in 14.5 % of the inmates of the Kentucky Institution for the Educa-
tion of the Blind.

Turning to the work of foreign observers, it is interesting first to note
the conditions in Egypt. At the first Egyptian Medical Congress at
Cairo, December 19, 20, 1902, Eloui Bey, of Cairo, stated that in the
governmental schools 32 %, in the national schools 65 %, and in the
kouttabs 75 % of the students were affected with trachoma. In 1884 he
showed that 85 % of the students in the government schools had the
disease. Morax and Lakah^ state that the average number of cases of
granular ophthalmia among the children in several native Egyptian
schools which they examined was 93 %. According to these observers,
this state of affairs is largely due to the employment of wet-nurses, 20 %
of whom are afflicted with the disease. Although the conditions in
Egypt are yet deplorable, a gradual improvement has been noted. Vol-
ney, who traveled in Egypt in 1784, said that for every 100 persons he
met on the streets of Cairo 20 were blind, 10 were one-eyed, and 20
others had their eyes red, purulent, or spotted with leukoma. Mac-
Gregor in 1804 speaks of 2000 English soldiers who returned to England
blind from Egyptian ophthalmia. Of the Continental observers, Straub
reports that the percentage of trachoma in the schools of Amsterdam was
reduced from 76 to 14 in 1897.

THE VISION OF TRANSPORTATION EMPLOYEES.

After a somewhat brief intermission, the subject of the relation of
color-blindness to railroad transportation is again brought to the
attention of the medical public with renewed vigor. J. T. Barnes,* in
an endeavor to collect statistics bearing upon this subject, addressed a

^ The Post-Graduate, May, 1902. ^ j^j^ Pract. and News, March, 190a.

« Ann. d'Ocuhstique, Nov., 1901. * N. Y. Med. Jour., March 14, 1903.

THE VISION OF TRANSPORTATION EMPLOYEES. . 543

circular letter to fifty of the leading railroads of the United States, con-
taining questions as regards the character, frequency, records, and results
of examinations of hearing and sight. Of the 50 companies addressed,
only 32 replied in full; of these, 21 stated that they retained a medical
expert (ophthalmologist) for their examinations, while the remaining
third resort to officials of their own lay bodies. It is inferred that cor-
porations not replying do not resort to a medical referee. A curious fact
is that most of the companies that do not retain a consulting medical
expert referee are among the older and eastern companies (with one very
noteworthy exception), while those that do rely upon such referee are
commonly western, newer, and progressive companies. Barnes also
states that in only 3 States of the United States (Ohio, Massachusetts,
and Alabama) is an examination of sight and hearing in transportation
company employees required by law, and suggests that such examina-
tions, by experts, should be required in all of the States. The necessity
of this is more forcibly impressed upon the mind by a glance at the
report of the United States Interstate Commission for the year ended
June 30, 1900. The total number of railroad casualties was 58,185, the
aggregate number of persons kiUed being 7865, and the number of injured
50,320; of railway employees, 2550 were killed and 39,643 were injured.
The figures show that 1 out of every 399 employees was killed, and one
out of every 26 was injured. With reference to men actually engaged
in the running of trains, one was killed out of every 137 employed and
one was injured out of every 11. The summary shows that in the course
of 13 years ended June 30, 1900, in consequence of railway accidents,
86,277 persons were killed and 469,027 injured in the United States.

Hugh L. Murray, ^ after 4^ years' service as examiner of the Victorian
Railway Employees, reports having examined 7500 men. Of these, 4200
were in the service and 3300 were candidates applying for admission.
Of the 4200 men in the service, the results were approximately as follows :
passed, about 85 % ; failed, about 9 % ; referred for treatment to be kept
under observation and reexamined, about 6 %. Of those who failed, the
causes were : defective vision, about 80 % ; defective hearing, about 16 % ;
and defective color-sense, about 4 %. The visual defects were due to:
refractive errors, about 60 % ; cataracts, about 5 % ; squint, about 3 % ;
injury, about 30 %; the other causes, including diseased lids, optic
atrophy, etc., 2 %. The color defects were usually the red-green blind
variety. Complete color-blindness or monocular color-blindness was not
encountered, neither was any color-defect found in any of the females
examined. This observer states that the standard for vision should be
modified according to the character of the work, and suggests the follow-
ing standards in use by him in examinations for railway service : Class
A. — All men who are or may be concerned in the actual running of
trains, viz., cleaners, shunters, porters, traffic lads connected with the
running, junior clerks, and junior operators. Vision must be normal, f.
Refraction must be normal, except that latent hypermetropia up to
0.75 D. will not disquaUfy. In compound hypermetropic astigmatism
^ Intercol. Med. Jour, of Australasia, Oct. 20, 1902.

544 OPHTHALMOLOGY.

the sum of correcting glasses must not exceed 0.75 D., of which 0.50
astigmatism only will be allowed. Class B. — Men concerned with moving
traffic to a less responsible extent, viz., repairers, ordinary laborers (all
branches), telegraph linemen, masons, carpenters, and painters, all
trades, and apprentices. Vision must be normal, f in each eye; f in each
eye will not disqualify, provided it is not accompanied by latent hyper-
metropia or evidence of progressive disease. Refraction nmst be normal
in each eye, but latent hypermetropia up to 1.25 D. will not disqualify.
In compound hypermetropic astigmatism, the sum of the correcting
glasses must not exceed 1.25 D., of which not more than 0.75 astigmatism
will be allowed. Class C. — Engineering students and draftsmen.
Vision must be normal, -|, with or without glasses. Refraction, myopia
beyond 3 D. will disqualify.

T. H. Bickerton,^ of Liverpool, has also considered this subject at
length as regards the mercantile marine, and urges the necessity of ex-
pert examinations on account of the increased rate of speed recently
acquired by vessels. He has compiled tables from his own examinations,
extending over many years, which serve to emphasize this need.

Returning to the work of American ophthalmologists, one of the most
valuable reports is that of G. D. Murray,^ Scranton, Pa., who personally
examined 4608 employees of the D., L. and W. R. R. for acuity of vision,
hearing, and color-perception. For convenience in recording he grouped
the men in 3 grades. The first was made up of two classes. Class A
included men with normal color-perception and hearing and whose vision
was not less than ^f in one eye and ^^ in the other. Class B was made
up of those whose color-perception was normal, but whose hearing and
vision were slightly defective and amenable to treatment. These men
were subjected to reexamination. In the second grade were placed all
men whose chromatic sense was weak, and whose sight was partially
destroyed by traumatism or disease. Those with one eye only and in
whom deafness, perceptible in conversation, was progressing were also
included. The third grade was made up of men completely color-blind
and markedly deaf. The necessity for this grading, Murray points out,
lies in the fact that to remove from such a service all those who were
unable to attain the ordinary standards (such as suggested by F. Allport^)
would severely cripple the road. By this grading it is possible to retain
in unimportant positions those partially defective in the special senses.
This is but fair to old employees who have been in the service a lifetime,
but for new men Allport's standards should be maintained. His exam-
ination sho-?v^ed that 3.01 % were color-blind, 2.58 % had weak chromatic
sense, and 9.44 % were in need of glasses or' other means to improve
their vision for distance. He suggests that the use of tobacco be dis-
couraged; that annual examinations should be made; and that railroad
employees should have the equivalent of 8 hours' sleep daily.

Pourqui^,* of Torreon, Mexico, in a report of the examination of
vision in the employees of the Mexican International Railroad, adds

» Practitioner, Feb., 1903. ^ Ann. of Ophtlial., Jan., 1903.

' Jour. Am. Med. Assoc, Oct. 13, 1900. *Ophthal. Rec, Oct., 1903.

THE VISION OF TRANSPORTATION EMPLOYEES. • 545

some interesting data. The visual acuity, refraction, visual fields, and
the fundus were included in the examination. Stilling's tables and Holm-
gren's wools were used to detect faulty color-perception. The observer
states that peripheral color-sense is most important in railway employees.
As a result of color-blindness, 2.29 % of the individuals examined by
him were rejected. As regards visual errors, those with less than j vision
were not retained in the service and correcting lenses were allowed only
to old employees. Of the 2400 examined, 130 were rejected on account
of visual defects, 31 of whom possessed only one eye.

In nearly all of these examinations, both in this country and abroad,
the Holmgren test or some adaptation of it was used ; the person under
examination being directed to match the colors. This procedure is
diametrically opposed to the method advocated by Edridge-Green, ^ who
states that no test in which the color names are ignored is efficient. In
support of this he shows that the Board of Trade (England) rejected
38 % one year and 42 % another year as color-blind who were found
to be normal sighted.

Kenneth Scott^ has devised a new color-test for the determination
of working ability of railroad and marine employees. The ordinary tests
frequently disqualify good men by reason of their inability to distinguish
tints and shades of the various colors, and Scott's test is intended to
overcome this disadvantage. His apparatus consists of a revolving disk
containing 5 round apertures, each 10 mm. to 15 mm. in diameter. One
of these openings is unoccupied; the remaining contain red, green, violet
(or purple), and plain frosted glass, respectively. The disk is fastened
to the chinmey of an argand gas lamp and the illumination is modified
by an iris diaphragm, A separate piece of frosted glass is mounted on
an arm so that it may be placed in front of the colored glass during the
test and alter its tint. The colors used are those employed by the trans-
portation companies, while the artificial light and the ground glass are
intended to modify these colors as they are modified in actual work.

P. Fridenberg^ describes a new method for the detection of central
color-perception in which the test-objects are about 4 mm. square and
cut out of variously colored paper or cardboard. The patient should
stand opposite the examiner so that his line of vision meets that of the
examiner and the test object is brought to a point at which it is fixed
by both the subject and the examiner. The targets are held in the left
hand, hidden from the patient's view. One of the squares is picked up
by a small forceps held between the thumb and third finger of the right
hand, the index-finger of which is extended over the square so as to
cover it when the hand is held up before the patient. When fixation is
absolute, the index-finger is flexed and the square exposed momentarily.
The same principle is used in an instrument devised by this observer for
the detection of color scotomas. It consists of a color carrier, not unlike
an ophthalmoscope in appearance, the lenses being replaced by the color
squares. The front of the instrument which is presented to the patient

' Brit. Med. Jour., Nov. 22, 1902, p. 1651.

2 Med. Press and Circ, Dec. 17, 1902. ^ Arch. Ophthal., May, 1903.

546 OPHTHALMOLOGY.

has an aperture 8 mm. in diameter which can be reduced by a sHding
quadrant 1, 2, 3, and 4 mm. in diameter. The aperture is covered by
a shutter moving vertically on a spring slide. The fixation point is
marked by a white dot. The color disks are exposed by drawing down
the slide, the release of which causes the aperture to be closed.

CORNEA.

Kopff^ records 2 cases of keratoconus following traumatism, in
one of which the condition was bilateral. He believes that injury should
therefore always be considered as a possible cause for keratoconus.
Meding^ describes a case in which 8 chestnut-bur thorns transfixed the
cornea as the result of a bur falling upon the eye. It was impossible
to remove the thorns and atropin was instilled. Three of the thorns were
removed one month later, two more in another month, and the remainder
disappeared a few weeks afterward by absorption. The lessons drawn
from this interesting case were: (1) The thorns were aseptic; (2) the
curious tolerance of the cornea and absorptive powers of the aqueous,
not generally believed to include vegetable matter; (3) the wisdom of
retaining the thorns as plugs for the wounds they made, thus preventing
infection; (4) the largest and most opaque scar was left at the site of
the preliminary efforts at removal.

F. Buller^ reports a case of acute suppuration of the cornea success-
fully treated after ligation of the canaliculi, showing the influence of the
tear-ducts in such affections. During the treatment for corneal fistula
there is always more or less danger of injury to the lens, and in order
to obviate this, J. M. Ball* recommends introducing a keratome into the
anterior chamber as in iridectomy. The tip of the instrument passes
beyond the fistulous area and is held in situ while a cautery is used to
destroy the walls of the fistula. Atropin is instilled and a compress
bandage is applied. Detachment of corneal epithelium, according to
Menzies,^ may occur with or without vesicle formation. In the majority
of these cases a history of injury is obtainable; the detached epithelium
does not become firmly reattached and is disturbed by movements of
the lids, causing great pain. If the case extends, an ulcer may result.
The diagnosis depends upon the history and careful inspection of the
cornea under proper illumination. In some cases fluorescin may be
useful. The treatment consists in tying up an injured eye until corneal
healing is complete. In mild cases massage with an ointment or oily
substance is generally sufficient. When there is a distinct blister, the
detached epithelium should be removed, the denuded surface scraped, an
ointment applied, and the eye bandaged.

The endothelium of the cornea has been recently shown to contribute
largely to the pathology of the cornea, according to the investigations of
Grafiin.^ As examples of the conditions in which it takes part may be

' Rev. g^n. d'Ophtal., Sept. 30, 1902. Mrch. of Ophthal., Nov., 1902.

3 Montreal Med. Jour., March, 1902. * Med. Rec, May 7, 1903.

*Brit. Med. Jour., Nov. 1, 1902. « Zeit. f. Augenheilk., May, 1903.

CORNEA. , 547

mentioned parenchymatous keratitis, clouding of the cornea after sec-
ondary glaucoma, iritis, and iridocylitis. As diseased conditions of the
corneal endothelium are factors in the production of these affections, it
necessarily follows that any treatment, to be successful, must be directed
toward the regeneration of the endothelium. The specific influence of
Fowler's solution is thus explained.

Corneal ulceration and its treatment are still the subjects of con-
siderable discussion. Roemer^ confirms the observations of Uhthoff and
Axenfeld in regard to the finding of pneumococci in 95 % of cases of
serpent ulcer. In 8 beginning ulcers cure was effected by the pneu-
mococcus serum. Exclusion of the actinic rays of light has also been
shown to have a beneficial influence upon corneal ulcers by M. Lowe,^
in the report of one of his cases. Red tissue paper was used to modify
the light, and soon after the pain, photophobia, injection, lacrimation,
etc., promptly disappeared. On the third day the patient was comfort-
able and was able to sew and read. The local use of iodin in the treat-
ment of corneal ulcers has been greatly exploited by J. L. Hiers. ' Duane*
recommends iodin-vasogen, a solution of iodin in vasogen, and after a
thorough trial reaches the following conclusions: (1) Iodin-vasogen is a
valuable application in infiltrated and spreading ulcers of the cornea,
whether associated with purulent conjunctival secretion or not. It is
particularly indicated in those cases in which the galvanocautery is con-
traindicated by the situation of the infiltrate. (2) It rarely causes pain,
if not appHed to excess, and never causes any unpleasant reaction or
untoward effects. (3) PreUminary anesthetization of the cornea with
cocain is rarely required and in general is better omitted. (4) The appli-
cation is best made every other day until the infiltrate begins to shrink
decidedly, and then should be made every 3 or 4 days until the infiltrate
disappears. Katz* recommends the employment of eserin in cases of
peripheral ulceration of the cornea, scrofulous keratitis, etc. He uses a
pomade composed of eserin sulfate, 0.03; iodin, 0.12; and vaselin, 6.0.
Fedorow* used an ointment of ichthyol, 0.1; cocain hydrochlorate, 0.15;
and vaselin, 5.0, in 28 cases of corneal infiltration, and is of the opinion
that resorption was hastened and reestablishment of corneal transparency
favored by the appHcations. J. F. Klinedinst' employs acetozone in the
strength of 1 grain to 2 fluidounces of water in all infected wounds of
the cornea, and states that it is very efficient in controlling bacterial
ocular infections.

Tumors of the cornea are of extremely rare occurrence. Semple,
Carcassone, and Villard,* in a biographic study of primary sarcoma of
the cornea, include a case observed by them in a man 68 years of age.
The condition was of 15 years' duration and resembled pannus crassus.
Enucleation was performed and diagnosis confirmed by the microscope.

' Zeit. f. Augenheilk., Sept., 1902, p. 365.

' Intercol. Med. Jour, of Australasia, March 20, 1903.

» PhUa. Med. Jour., Nov. 29, 1902. ^ Arch, of Ophthal., Sept., 1902.

» Westnik Ophthalmol., 1902, No. 3. ' Westnik Ophthalmol., 1902, No. 3.

^ Jour, of Eye, Ear, and Throat Dis., vii, No. 6, p. 139, 1902.

* Ann. d'Oculistique, April, 1903.

548

OPHTHALMOLOGY.

IRIS AND CHOROID.

W. C. Posey^ gives the history of 2 cases of congenital defect of the
iris and choroid in which the anomalous condition was transndtted from
mother to daughter, as shown by the accompanying illustrations (Figs.
108 and 109).

Iritis as a complication of mumps has been recorded by A. Collomb^
and Pechin.^ In CoUomb's case the affection was unilateral and disap-

Right eye.

Left eve.

Fig. 108.— Changes in mother's eyes (W. C. Posey, in .\nn. of Ophtlial., Jan., 1903).
Right eye. Left eye.

Fig. 109.— Changes in daugliter's eyes (W. C, Posey, in Ann. of Ophthal., Jan., 1903).

peared rapidly under treatment. In Pechin's patient the iritis was
bilateral and was accompanied by unilateral keratitis. Both cases were
subacute and attended by very little pain. H. Friedenwald'' describes 2
cases of tuberculosis of the iris in which the miliary tubercles were
distinctly grayish and pearl-like in appearance and did not possess the

' Ann. of Ophthal, Jan., 1903.
2 Rec. d'Ophtal., June, 190L

2 Rev. Med. de la Suisse Rom., Jan. 20, 1903.
<Amer. Med., July 5, 1902.

IRIS AND CHOROID. . 549

usual yellow or reddish color. The deposits on the inner surface of the
cornea diff ered • f rom those ordinarily found in plastic or serous iritis.
Besides the fine deposits, there were a few very large, white, sharply
circumscribed deposits in both eyes, between 1 mm. and 1.5 mm. in
diameter. They were not round, but irregular in form, and had the
appearance of the tubercles in the iris.

C. S. Bull^ describes 5 cases of iridochoroiditis directly traceable
to gonorrheal infection. In reviewing these cases he states that in-
flammations of this character never foUow urethritis immediately, but
are invariably preceded by arthritis. The symptoms are more severe
than those of rheumatic character and always suggest an unfavorable
prognosis, but with persistent treatment the inflammation rapidly sub-
sides without leaving any marked impairment of vision.

Casey Wood and Brown Pusey,^ in a detailed review of 87 cases of
primary sarcoma of the iris, bring forward the following prominent
features of these growths : Histologically, these growths consist of small
round and small spindle cells. There were no degenerative changes and
very little inflammatory reaction. Pigment was present. In most cases
the cells originated from mesoblastic tissue; in 11 cases the growth pro-
ceeded from congenital nevi and 3 showed an arrangement of cells around
the bloodvessels resembling periendothelioma. As to age, 27 cases were
observed under and 57 after 30 years of age; 36 were in females and 45
in males. In 33 cases the right eye was involved and in 28 the left eye.
The lower half of the iris was the primary site in 33; the upper half in 13 ;
nasal 5; temporal 2. Enucleation was performed in 57 cases, 41 of which
showed extension of the growth beyond the iris. Iridectomy was per-
formed 27 times: in 3 cases the results were bad; in 5 cases there was
no recurrence in 3 years. In one case there was no return; the eyeball
was enucleated 11 years afterward for another condition. Sixteen years
after the iridectomy the patient died of generalized sarcoma. The most
important conclusion reached by these observers is that when a diagnosis
of sarcoma of the iris is established, the globe containing the growth
should be immediately enucleated because of the impossibility of deter-
mining the limitations of the growth by clinical methods.

W. H. H. Jessop^ records 2 cases of tuberculosis of the choroid of
unusual interest. In the first case, a girl of 9 years, a growth of the
conjunctiva was also present, and there were 2 areas of retinal detachment
corresponding with 2 masses obscuring the disk. Three months later
these masses disappeared, leaving patches resembling albuminuric retin-
itis. Vision was ^. The second patient, a woman 23 years of age, had
similar masses in the choroid which disappeared in 3 or 4 months leaving
behind no traces. The diagnosis in both cases was confirmed by inocula-
tion experiments.

E. L. Oatman^ reports a case and reviews the hterature of metastatic
carcinoma of the choroid. He has collected 30 cases in which 20 of
the primary growths were situated in the breast, 3 in the lungs,, 2 in

' Med. Rec, Dec. 20, 1902. = Arch, of Ophthal., July, 1902.

' Brit. Med. Jour., May 23, 1903. ■• Amer. Jour. Med. Sci., March, 1903.

550 OPHTHALMOLOGY.

the liver, 1 in the stomach and liver, 1 in the thyroid, 1 in a dermoid
cyst of the suprarenal body, and 3 were not located. The average age
was 44.37 years. The females were affected in the proportion of 3 cases
to 1 in the male on account of the preponderance of breast carcinoma
in the female. In 20 cases the right eye was involved and both eyes
were affected in 10 cases. The deposit always occurs posteriorly, near
the point where a short ciHary artery enters the globe, and appears in
the corresponding region of the second eye when the latter is attacked,
indicating that the second eye is not invaded by way of the lymph-
channels of the optic nerve and chiasm. The typical shape is a flat
discoid thickening of the choroid with a central elevation, sloping off to
the periphery. The eye-symptoms rapidly progress until there is destruc-
tion of vision in 2 to 8 weeks, due to the early and extensive retinal
detachment. The tension is increased in about one-third of the cases and
diminished or normal in over two-thirds. The average duration of life
after eye-symptoms appear is 6^ months. Oatman gives in parallel
columns the distinctive points between sarcoma and carcinoma. The
condition is hopeless. He does not advise operative interference, as it
may hasten the death.

Secretion of the Aqueous. — Hainburger^ believes that Leber's views
as to the secretion of the aqueous are erroneous, and that instead it
proceeds from the anterior border of the iris, as demonstrated by experi-
ments with fluorescin.

The origin of the vitreous in vertebrates has been made a subject
of special study by Tornatola,^ Messina, who states: that the normal
vitreous is composed of fibrillas devoid of granulations ; that there are no
pseudocells at the points of intersection of the fibrillas; that the rosary
arrangement of the fibers is not normal, but pathologic ; that there is no
hyaloid membrane; that there is no true internal limiting membrane of
the retina; that the vitreous arises from cells without nuclei which form
the base of the pars ciliaris retinae and from the elements which in the
differentiated retina constitute the neuroglia.

LENS.

L. Verderau^ describes a series of experiments upon rabbits, consisting
in the artificial production of cataract by traumatism; and the subse-
quent treatment by injection of a few drops of a 5 % solution of potas-
sium iodid into the crystalline lens, and also by subconjunctival injections
of the same solution. While the success of this method of treatment lacks
cUnical confirmation, the results obtained in animals were sufficiently
favorable to suggest the possibility of its future therapeutic value in man.
Under the influence of these injections the opacities diminished and in
many instances disappeared entirely. The author draws the following
conclusions from his work: (1) Potassium iodid has a marked effect upon
opacities of the crystalline lens, in that it stays their progress. (2) It

» Zeit. f. Augenheilk., Sept., 1902. ^ Rev. g6n. d'Ophtal, March 31, 1903.

^ Rev. de ciencias med. de Barcelona, Jan., 1903.

LENS. - 551

also promotes retrogression of traumatic lenticular cataract. (3) Its in-
fluence is very slight in traumatic opacities of the capsule.

Medical treatment for the cure of cataract has been the vain hope
of the medical profession for ages, and this is fostered by the frequent
reports of cases of lenticular opacities disappearing spontaneously.
W. L. Pyle^ has collected a number of these cases, and concludes as
follows: (1) There is no question as to the authenticity of many reports
of the spontaneous disappearance of senile cataract, and these cases may
be explained and classified in 5 groups as follows: (a) Cases in which
there was absorption after spontaneous rupture of the anterior or pos-
terior capsule; (b) cases in which there was spontaneous dislocation of
the cataractous lens; (c) cases in which there was intracapsular resorption
of the opaque cortex and sinking of the nucleus below the axis of vision
after degenerative changes in Morgagnian cataract, without rupture of
the capsule or dislocation of the lens; (d) cases in which there was com-
plete spontaneous resorption of both nucleus and cortex without reported
history of ruptured capsule, dislocation or degenerative changes of the
Morgagnian type; (e) cases of spontaneous disappearance of incipient
cataract without degenerative changes or marked difference in the refrac-
tion. (2) It is not uncommon for opacities of the crystalline lens or its
capsule, the result of traumatism, to disappear, even when the capsule
has been penetrated. (3) Too much stress cannot be laid on the value
of personal hygiene, treatment of associate local and general disorders,
careful and repeated refraction, and the proper use of the eyes in arresting
the progress of incipient cataract. (4) In certain complicated cases,
secondary to grave nutritional disturbances, lenticular opacities may
entirely disappear under appropriate treatment. (5) Generally speaking,
the so-called " nonoperative" treatment of cataract as practised by adver-
tising charlatans and irregular physicians is worthless, often distinctly
dangerous, and consists in no beneficent measures not known and appro-
priately used by all reputable oculists.

Unusual Causes of Cataract. — Lecenius^ reports the case of a drug-
gist who noticed rapid failure of vision after the ingestion of naphthalin
and castor oil for the relief of enteritis. There was a diffuse opacity of
the perinuclear region of the crystalline lens with a number of small
white spots. The patient had always possessed good vision, but was now
able only to count fingers at 1.5 meters. Ophthalmoscopic examination
was unsatisfactory. The visual fields were much contracted, although
there was retained normal color-perception at the last observation.
General health was recovered, and the urine contained neither albumin
nor sugar, but the cataract remained. Concussion has also been shown
to be a cause of cataract by J. W. Barrett^ in the report of a case in
which punctate opacities were seen in the lens one month after being
rendered unconscious in an acetylene-gas explosion. Of equal interest
is the great percentage of hard cataract that occurs in bottle-finishers

* Jour. Am. Med. Assoc, Oct. 18, 1902.

' Westnik Ophthal., 1902, No. 2.

' Intercol. Med. Jour, of Australasia, July 20, 1902.

552 OPHTHALMOLOGY.

in England. Wm. Robinson^ states that 18 out of every 75 cases of hard
cataract observed by him were in bottle-finishers, and inasmuch as there
are only 200 or 300 bottle-finishers in a population of nearly 1,250,000
people in his particular county, he logically concludes that this occupation
is an extremely potent etiologic factor in cataract. In a report of 8
cases of cataract occurring in women the subject of goiter, Becker'
asserts that in his opinion cataract in these cases is due to autointoxica-
tion analogous to the condition that induces lenticular changes in affec-
tions of the thyroid gland, Graves's disease, myxedema, etc. T. R.
Pooley' reports 2 cases attended by unusual complications after ex-
traction of a cataractous lens. In one, a diabetic patient, death occurred
at the end of 7 days, and the other was followed by delirium tremens
on the third day after the operation. G. F. Keiper,* in an attempt to
determine the opinion of American ophthalmologists as to the best time
to operate on mature senile cataract when vision is preserved in the
other eye, addressed the following questions to 119 members of the
Ophthalmologic Section of the American Medical Association: (1) As to
the advisability of removing a mature senile cataract if the lens of the
fellow-eye is clear or if opaque with useful vision. (2) Whether any com-
plaint of difference in the refraction of the two eyes was made by the
patient after operation. To the first question, 16 failed to reply. Of the
remaining 103 questioned, 44 were in favor of extraction, 36 were of
the opposite opinion, and 23 were noncommittal, allowing other circum-
stances to influence the treatment. To the second question, 30 made no
reply, 27 replied in the affirmative, 55 in the negative, and 7 made vague
answers. He urged the removal of the ripe senile cataract, irrespective
of the condition of the other eye, claiming the following advantages:
larger visual fields, avoidance of dangers incident to the extraction of a
hypermature cataract, continuous vision, more comfort from binocular
vision, and better cosmetic effect.

F. M. Wilson and H. S. Miles ^ recommend the conjunctival flap in
the extraction operation for cataract because it exerts a very positive
and easily demonstrated influence in preventing reopening of the wound.
The chief disadvantages are the ensuing hemorrhage and the increasing
difficulty in performing iridectomy, and in removing loose masses of cor-
tical matter after extraction of the cataract proper.

H. 0. Reik^ advocates intracapsular irrigation of sterilized saline
solution in cataract operations as practised by McKeown, and claims
it to be the most satisfactory method of removing cortical matter, blood,
and air-bubbles. He states that it is harmless and does not tend to cause
prolapse of the vitreous.

' Brit. Med. Jour., Jan. 24, 1903. ^ Inaug. Diss. Giessen, 1902.

3 Med. Rec, Sept. 13, 1902. " Ann. of Ophthal., 1902, p. 646.

5 Trans. Am. Ophth. Soc, vol. ix, 1902, p. 503.

« Ann. of Ophthal., July, 1903.

RETINA. , 553

RETINA.

Unusual cases of retinitis have been reported during the past year
that require mentioning. Gonin^ describes 15 cases of retinitis pig-
mentosa with annular scotomas and without true concentric contraction
of the visual field. C. Zimmerman^ records a case of albuminuric ret-
initis of syphilitic origin which was cured with almost complete absorp-
tion of hemorrhage and restoration of vision by prompt administration
of mercury and the iodids. The patient died 8 years later of degeneration
of the heart-muscles. Duane^ reports 11 cases of unusual types of ret-
initis and choroiditis. W. G. M. Byers* observed a hole in the macular
region the result of injury to the eye by a pebble.

H. C. Haden,^ in a paper on retinal hemorrhages as an aid to the
early recognition of general arterial degeneration, reaches the
following conclusions: (1) Retinal hemorrhages, associated with high
arterial tension and accompanied by transitory albuminuria, are signifi-
cant of beginning widespread arterial degeneration. (2) That in those
cases of so-called physiologic or transitory albuminuria occurring in
active, healthy young business men or students, in those who are working
under forced pressure, ophthalmoscopic examination should be made for
retinal hemorrhages. (3) When retinal hemorrhages occur without
albuminuria, the patient should be kept imder observation, the urine to
be examined from time to time and the quantity passed noted. Beard,*
in speaking of retinal arteriosclerosis, states that true embolism of the
retinal artery is an exceedingly rare condition, Haab having found
only 12 cases diagnosed among 60,000 patients. Of these 12, only 2 were
found to be undoubted emboli. A case of spastic ischemia of the retina,
occurring in a physician, is mentioned. In connection with thrombosis
of the choroid, attention is called to a condition that Beard believes has
never before been mentioned. This is a peculiar pigmented spot or scar
that always remains at the site of thrombosis. The outline is either
round or quite irregularly oval, and the pigment is arranged in whorls,
through which the white of the sclera shows. The appearance suggests
that of knots in pine boards. Active thrombosis and one or more of these
old scars have been seen together in the same eye.

H. Gradle'' relates a case of neuroretinitis of nephritic origin in which
marked improvement in vision was noted after decapsulation of both
kidneys after the method of Edebohls. [The ultimate result has not
been reported.]

Ocular Signs in Chronic Nephritis. — G. E. de Schweinitz^ sum-
marized these ocular lesions as foUows: (1) Complete blindness without
ophthalmoscopic lesions, or at least without the presence of lesions more
or less suggestive of disease of the kidneys, generally called uremic

* Ann. d'Oculistique, Aug., 1902.

^Arch. Ophthal., Sept., 1902, vol. xxxi, No. 5.

" Med. News, March 21, 1903. * Montreal Med. Jour., July, 1902.

" Phila. Med. Jour., Feb. 21, 1903. » Chicago Med. Rec, Jan., 1903.

^ Chicago Med. Rec, Nov., 1902. » Amer. Med., Dec, 1902.

36 S

554 OPHTHALMOLOGY,

amaurosis, and most often seen in acute nephritis, but also in acute exac-
erbations of chronic renal disease, (2) Various types of retinitis and
neuroretinitis to which the descriptive term "albuminuric" is commonly-
applied, and which are most often seen in association with chronic forms
of kidney disease, (3) Alterations in the caliber and relation to the
retinal vessels owing to sclerotic changes in their walls, with or without
hemorrhages and exudates in the retina, seen in association with those
forms of renal disease in which vascular changes are evident elsewhere in
the body; also isolated hemorrhages and exudates, without marked
vessel-wall changes. (4) Alterations in the uveal tract, particularly
in the choroid and iris, (5) Some varieties of cataract. (6) Paresis and

Fig. 110. — Occlusion of the superior temporal artery of the retina (de Schweinitz, in Pbila. Med. Jour.,

March 14, 1903).

paralysis of the ocular muscles, particularly the superior oblique and the
external rectus, (7) Recurring subconjunctival hemorrhages.

R. A, Fleming^ noticed in 12 cases of fracture of the skull, all of
which were fractures of the base except one, that when the hemorrhage
into the subarachnoid space was acute, retinal hemorrhages were almost
invariably present, and, further, that when there was a unilateral sub-
arachnoid hemorrhage, the retinal hemorrhages were mostly confined
to the affected side. In 3 out of 4 cases of intracerebral hemorrhage from
other causes there had been sudden effusion into the subarachnoid space
and retinal hemorrhages ; in the remaining case the effusion was less acute
and there was no retinal hemorrhage,

G, E. de Schweinitz^ describes a case of occlusion of the superior

1 Brit, Med, Jour,, Feb. 21, 1903, ^ p^iia. Med, Jour,, March 14, 1903,

RETINA.

555

temporal artery of the retina in a young anemic girl of 15 years. The
characteristics of this case are best shown by the accompanying illus-
trations (Figs. 110, 111, and 112).

Galezowski,^ Paris, records a case of subretinal cysticercus in the
region of the macula, the diagnosis of which was made by means of the
ophthalmoscope. Guiot,^ Paris, describes a similar case. [The rarity of
this condition often leads one to doubt the diagnosis in these cases unless
confirmed by pathologic examination. In a case observed in the Wills
Eye Hospital, Philadelphia, the ophthalmoscopic appearances were not
unlike those of glioma, a condition which was suspected by a number of
competent observers. A subsequent microscopic examination served to
correct this error.]

Fig. 111. — Occlusion of the superior temporal artery of the retina. Visual field, obliteration of lower
and inner quadrant (de Scbweiuitz, in Phila. Med. Jour., March 14, 1903).

Retinal detachment has been considered amenable to surgical treat-
ment by L. Mueller,^ Vienna, who proposes resection of the sclera, punc-
ture of the choroid to allow escape of the subretinal fluid, and subsequent
suturing of the scleral edge. The operation is preceded by a modified
Kronlein operation and the globe is exposed in the equatorial region by
temporarily severing the external rectus and inferior oblique muscles.

Glioma during the past year has received considerable attention,
particularly as regards its histology. Brown Pusey,* in a study of the
genesis of glioma retinse in neuroglia, shows by the staining reaction with
Mallory's neuroglia stain that the much discussed " perivascular rosets"
are neurogliar in character. He believes that the wall of the lumen of

' Recueil d'Ophtal., April, 1903.
" Miinch. med. Woch., 1903, 23.

2 La Clin. Ophtal., April 10, 1903.

* Bull. Johns Hopkins Hosp., Oct., 1902.

556

OPHTHALMOLOGY.

the roset corresponds to the internal limiting membrane and not the
external ; that the radiating fibers which are neuroglia fibers to the fibers
of Miiller; and the distant nuclei to the neuroglia nuclei normally found
in the internal granular layer. The projections into the lumen of the
roset are neuroglia fibers which have not found their termination in the
walls, and not rods and cones. He advises against the acceptance of
the term neuroepithelioma retinae. C. R. Holmes/ in his report of 5
cases of glioma, contributes some interesting clinical data. Deductions
from these carefully taken histories give the following facts regarding 6
eyes affected: Case 1. Right. Third stage. Optic nerve affected
beyond point of section. Recurrence and death. Case 2. Right.

Fig. 112. — Occlusion of the superior temporal arterv of the retiua (de Schweinitz, in Phila. Med. Jour.^'

March 14, 1903).

Beginning of second stage. Optic nerve normal beyond point of section.
Three years and two months since operation. Cured. Case 3. Left.
Beginning of third stage. Optic nerve affected beyond point of section.
Recurrence and death. Case 4. Left. End of first stage. Nine years
since operation. Cured. Case 5. Left. End of first stage. Four
years since operation. Cured. Case 6. Right. End of first stage.
Fourteen years since operation. Cured. In 3 cases, or 50 %, operation
was performed during the first stage, and all ended in cure ; one case with
operation in the second stage ended in recovery. Two cases with opera-
tion in the third stage were fatal. While the number of cases is very
small, yet there can be no doubt that operations during the first stage with

^ Jour. Am. Med. Assoc, March 28, 1903.

OPTIC NERVE. . 557

extensive resection of the optic nerve will give us a large percentage of
recoveries for the operated side. We must also remember that in a great
many of these cases the affection will involve the other eye sooner or later;
by early removal of the second eye, however, the patient's life may be
saved.

OPTIC NERVE.

Bernheimer,^ of Innsbruck, has demonstrated, anatomically, by the
microscopic examination of 20 sections through the upper half of the
chiasm of a child with bilateral microphthalmos, the existence of un-
crossed optic nerve-fibers in man. This confutes Kolliker's statement
that the centripetal fibers arising from the retina in man, dog, cat, and
rabbit cross completely. ^

H. J, Parsons,^ in an attempt to trace the degenerations in the
optic nerves and tracts in 6 monkeys, experimentally wounded the
retina by means of a Graefe knife and examined the visual system micro-
scopically 2 to 3 weeks after the injury. Briefly stated, the results were
as follows: (1) Perforating wounds were found to heal through the
agency of the episcleral tissue, the sclerotic having little or nothing to do
Avith the process. (2) The degenerated fibers in the optic nerve retain
in large part the same position along the whole course of the nerve. (3)
There are invariably some degenerated fibers in the optic nerve of the
opposite side. (4) The fibers from the macular region pass from the
temporal sides of the nerve anteriorly toward the center as they pass
back (author's statement). (5) In all cases there was degeneration in
both optic tracts. (6) The fibers spread out as they pass back into the
tracts and are distributed among the fibers of the roots of the third
and fourth nerves.

W. G. Spiller^ reports a case in which there was an entire absence
of the visual system. The patient was a helpless idiot of 22 years,
afflicted with paraplegia. Postmortem examination revealed absence
of the eyeballs, optic foramina, optic nerves, chiasm, optic tracts, and
external geniculate body. The posterior portion of each thalamus was
rounded and larger than would be expected.

Optic Neuritis, — C. Bolton* reports 2 cases following diphtheria
and unaccompanied by any renal condition. Recovery occurred 2 months
later. Fage^ describes a case following rubeola in a child 3 years of age.
The termination was more favorable than in the preceding, as optic
atrophy took place and absolute blindness supervened. Cabannes'
describes the occurrence of unilateral optic neuritis in the course of
herpes zoster ophthalmicus in one of his cases, and in this instance
believed both to be due to the same cause. C. G. Lee^ gives an account
of 4 interesting cases of monocular optic neuritis in which it was im-

* Arch, of Ophthal., Sept., 1902. ^ Brit. Med. Jour., Nov. 1, 1902.
' Brain, 1902, p. 631. * Lancet, Dec. 13, 1902.

* Ann. d'Oculistique, July, 1902.

* Gaz. hebdom. des Sciences m6d. de Bordeaux, April 12, 1903.
^ Brit. Med. Jour., Nov. 1, 1902.

558 OPHTHALMOLOGY.

possible to attribute the affection to the infectious fevers, constitutional
disorders, poisons, or any of the causes usually given. All were preceded
by unilateral neuralgic pain in the face and head, and in one case move-
ments of the eyeballs caused pain. This observer believes that these
cases could be considered as herpes zoster ophthalmicus deprived of the
cutaneous manifestations. J. W. Barrett and W. F. Orr,^ in an effort
to determine whether double optic neuritis may be considered as an en-
tity or as a manifestation of cerebral tumor, followed 8 cases over a
rather extended period and observed that no less than 5 of these recovered
health; in 2 cases the result as to vision was good; in one it was fair and
in 2 it was disastrous. There was a possibility of syphilis in 2 cases.
Edward Jackson^ reviews several cases, head-conditions, in which the
visual fields were peculiarly contracted, and thereby shows that the
upper portion of the cerebral cortex has to do with the lower part of the
visual fields. In one very interesting case there was a positive history
of cortical cerebral injury with trephining, and the fields showed a pecu-
liar sector defect.

C. L. Mix,^ in a detailed paper on hereditary optic atrophy, describes
8 cases of this interesting condition occurring in one family. Four
members, all males, of this family were living at the writing and were
amaurotic. The history of this disease extends through 6 generations,
and in 4 of them cases have appeared. The outset of the affection
occurred within the narrow Umits of 18 and 25 years for 8 individuals or
22 to 25 for 7 of the 8. In one of these cases the patient became blind
at 18 years of age and remained so until 21, at which age his sight re-
turned sufficiently to enable him to read. In another case a condition
resembling ataxic paraplegia was present, but in none were there any
congenital malformations of the visual apparatus. The males were
selected by preference; the females serving only to transmit the disease;
only one being affected in this series of cases. Syphilis, tobacco, alcohol,
sexual excess, etc., are rejected as etiologic factors by Mix, who regards
the conditions as a result of the imperfectly endowed visual apparatus
which easily undergoes involution, just as brain does in dementia prsecox.

Harman* hesitates to accept the current views of the pathology of
optic atrophy in retrobulbar neuritis. He beheves them to be based
upon an inaccurate appreciation of the ascertained facts of the develop-
ment of the nervous connections of the eye, and of the theory of the
neuron. The retina is known to arise as an outgrowth from the brain.
Within this outgrowth nerve-cells give rise to axons which grow centrally
to make cqnnections with parts of the brain different from the site of
origin of the evagination. Thus the trophic centers of the optic nerve-
fibers are the ganglion-cells of the retina from which they are outgrowths.
The case is parallel with the relation of a posterior root-ganglion cell to
its central axon passing into the cord. Thus degeneration of the optic
fibers should be in the vast majority of cases ascending only, and we

' Intercol. Med. Jour, of Australasia, July 20, 1902.

2 Med. News, Feb. 28, 1903. ^ Chicago Med. Recorder, March 15, 1903.

* Brit. Med. Jour., Nov. 1, 1902.

OPTIC NERVE. / 559

should look in cases of optic atrophy first to the retina for evidence of
damage. He believes a rational classification could be arrived at as
follows: (1) Primary damage in disease of the ganglion-cells (a) from
anemia due to spasm of retinal vessels from drugs, as quinin, reflexly
from cold, and to general anemia succeeding severe hemorrhages, febrile
diseases, etc, ; (6) from poisoning of the ganghon-cells by drugs, — tobacco,
lead, — a view directly supported in the antidote of tobacco-blindness,
strychnin, which it is agreed acts directly upon nerve-cells. In all these
cases the changes at the disk are proportionate to the number of cells
damaged; in cases of great loss of ganglion-cells it is probable that the
rapid destruction and swelling of the myelin sheaths of the degenerating
fibers at the lamina cribrosa produce a mechanical choked disk. (2)
Cases of damage to the optic nerve by contiguity of diseased structures
or in general nerve-changes producing islands of fibroid exaggeration,
and followed by obvious atrophy of the disk. Here ascending degenera-
tion should be the earlier result, with a later degeneration of the axon
segment next the trophic ganglion-cell from disuse, a process the more
easy owing to the special myelin sheathing of the optic nerve-fibers. In
reply to the question as to how he could explain by ascending degenera-
tion undoubted optic atrophy following section of the nerve in fracture
at the optic foramen, Harman says that in these cases there is nothing
to show that the damage was limited to the actual point of injury; exu-
dation was jiist as certainly to be found within and around the optic
sheath even to the disk, which would explain the early onset of atrophy
in some cases; further, he allows the possibility of a degeneration of the
segment between injury and trophic cell, both from disuse and by reason
of the arrangement of the myelin sheaths of the optic fibers.

C. J. Kipp^ reports an interesting case of transient unilateral ex-
ternal ophthalmoplegia which was followed by optic atrophy and
subsequent blindness. The patient was a woman of 35 and gave a history
of 2 miscarriages. The paralysis improved under the administration of
potassium iodid.

H. Ashby and S. Stephenson^ describe. 5 cases in which acute amau-
rosis followed infantile convulsions. In their analysis of these cases
they include 2 cases previously reported by Nettleship and 4 by Gay,
making 11 in all. Of these, 2 were observed between the ages of 6 weeks
and 2 months; 2 between 7 months and 8 months; 4 from 13 to 18 months,
and 3 from 2^ to 3 years. In 2 cases the convulsions followed whooping-
cough and one occurred after congestion of the lungs. In 8 cases no
cause could be assigned. In 1 patient, aged 2 months, the convulsion
and stupor lasted for 2 weeks, and some signs of optic atrophy persisted.
In 4 cases there was no accompanying paralysis; the remaining 7 were
attended by varying degrees of paralysis. Sight was recovered in all
but one case. In one case there was temporary aphasia. From these
facts the authors conclude : (1) That there is a form of amaurosis which
occurs in infants or young children which is posteclamptic, due to an-
esthesia of the visual centers. (2) That the convulsions, which may be
» Amer. Med., April 25, 1903. ' Lancet, May 9, 1903.

560 OPHTHALMOLOGY.

due to various causes, are likely to be severe and accompanied by coma.
(3) That the amaurosis may be associated with aphasia and paresis of
hemiplegic distribution; the hemiplegia may be permanent. (4) That
the amaurosis is for the most part transient. It is possible that in some
instances there is hemianopia,

H. Woods ^ reports a case of permanent left hemianopia following
puerperal eclampsia in a woman of 33. He believes that the poisonous
substance in the circulation in eclampsia may produce thrombi of the
smaller vessels, lead to areas of necrosis, and thus bring about permanent
defect. Profound transient blindness is the rule in cases of eclampsia.
In such cases there is no organic change, the effects cease with the elimina-
tion of the poison, but in a few cases thrombosis destroys a limited area,
and if this area happens to be a part of the cerebrum having important
function there is irreparable loss of that function, as in the case reported.

... i
GLAUCOMA.

In a recent paper read before the '^French ^Ophthalmologic Society,
Zimmerman^ advanced the theory that decrease in blood-pressure,
from mental or physical shock, cardiac disease, etc., is a prominent factor
in the etiology of glaucoma, and in his explanation he utilizes both the
theory of defective excretion and that of excessive secretion. When
vascular pressure is lowered, even though intraocular tension is normal,
the blood enters the eye only with difficulty, and pulsation of the intra-
ocular arteries is noticed. Diminished intraocular supply causes de-
nutritional changes and edema, with actual increase of intraocular ten-
sion. The sclera becomes distended, the intraocular veins are com-
pressed, general edema of the inner tunics results, and the gross changes
typical of glaucoma occur. Zimmerman believes that in certain cases
in which intraocular tension does not rise above normal, glaucoma may
develop from a relatively low vascular pressure, the result of profound
and persistent cardiac disturbance. He also says that prodromal glau-
comatous attacks do not necessarily indicate ocular disease. The eye
may at first be healthy, but the blood-pressure be greatly lowered. True
glaucoma does not develop until repeated prodromal phenomena have
produced such anatomic changes as cupping of the disk and closure of the
filtration angle. The practical application of these observations is that
in simple glaucoma the treatment should include, primarily, measures
to increase and maintain the proper blood-pressure. In 40 cases of sub-
acute glaucoma so treated, Zimmerman had need to resort to iridectomy
but once. As to the drugs employed, digitalis was found unsuitable on
account of certain mydriatic effects. Strophanthus acting upon the
heart-muscle rather than upon the bloodvessels was very satisfactory,
administered in doses of 8 minims four times daily. Adonis vernalis was
found equally effective. This treatment, of course, is not indicated in
secondary glaucoma following disease, injury, or operation, as here intra-

^ Trans. Am. Ophth. Soc, vol. ix, 1902, p. 659.
^ Rev. g^n. d'Ophthal., Sept., 1902.

GLAUCOMA. ' 561

ocular pressure is the primal cause, and the arterial pressure may not be
disturbed.

C. S. Bull^ offers the following brief review of his observations after
iridectomy on 94 eyes. In 7 cases under observation for a period rang-
ing from 15 months to 11 years, the fields remained as they were at the
time of the operation. In 6 of these cases the vision grew slowly worse,
and in 1 case the vision was somewhat improved. In 5 cases the vision
remained as it was at the time of the operation, or improved, while the
fields grew narrower. Age, in itself, did not seem to exercise any def-
initely bad effects, for some of the satisfactory results occurred in patients
past 70 years. The best results as to ultimate vision occurred in the
cases in which the central vision was best and the fields were the least
encroached upon at the time of operation; or, in other words, as soon as
the diagnosis was established. BuU also believes that better results are
obtained by simultaneous operation upon both eyes when bilateral affec-
tion is undoubtedly present, and in all cases early operations are the most
effective.

AndogskyandSelensky,^ St. Petersburg, in an endeavor to test the per-
meability of scleral scars after the operation of sclerotomy, injected 5 %
solutions of iron citrate and india-ink emulsions into the anterior chamber
under pressure. The permeability of these scars was demonstrated, and
was also shown to depend greatly upon the age of the scar. When 8 to 14
days old, the passage of pigment was very evident; when 21 to 40 days
old, but little pigment was found in the scar and in the subcutaneous
tissue; and when 40 to 145 days old, no trace of filtration could be dis-
covered. [These experiments serve to corroborate the well-known
clinical fact of the temporary efficiency of sclerotomy.]

Herbert^ recommends the formation of a subconjunctival fistula
in the treatment of chronic glaucoma, and states that it may be performed
by producing a subconjunctival prolapse of the iris or by infolding the
conjunctiva. In most of his cases he also performs a slight iridectomy.
He claims that the visual results following this operation are much better
than those of typical iridectomy. In support of this statement he cites
130 cases.

Abadie* mentions 2 cases of hemorrhagic glaucoma directly trace-
able to the use of large doses of potassium iodid in syphilitic patients.
Withdrawal of the drug was followed by amelioration of the symptoms.

H. B. Chandler^ believes that iridectomy is productive of no benefit
in chronic simple glaucoma, and bases this belief upon 20 years of experi-
ence with this class of cases. In doubtful cases he prefers to divide the
anterior ciliary arteries before they perforate the sclera, as he has
observed satisfactory results in every instance after this operation.

Karl Hoor® states that resection of the cervical sympathetic

nerve for glaucoma is indicated only after iridectomy has been declined,

' Trans. Am. Ophth. Soc, vol. ix, 1902, p. 429. ^ Arch, of Ophthal., Sept., 1902.
^ Ophth. Soc. of the United Kingdom, June 11, 1903.
* La Chn. Ophtal., Nov. 25, 1902.
^ Trans. Am. Ophth. Soc, vol. ix, 1902, p. 4611.
» Arch. f. Augenheilk., Aug., 1902.

562 OPHTHALMOLOGY,

or after iridectomy has failed to relieve the symptoms, or after sclerotomy
has proved of no avail. He believes it should be supplemented by an-
other iridectomy. He also states that the operation may be performed
without a preliminary iridectomy in glaucoma simplex in which there is
much visual disturbance and narrowing of the visual field, and in which
iridectomy and sclerotomy are of no avail.

MacCallan^ reports 5 cases of glaucoma in which the instillation of
adrenalin induced an increase in the intraocular tension. W. L. TyW
gives the history of an interesting case of bilateral acute glaucoma
following the instillation of a weak mydriatic (cocain and hom-
atropin solution, gr. v to 5 j) in the eyes of a woman aged 50 years. A
typical acute glaucomatous attack occurred 39 hours later. The con-
dition progressed despite treatment by eserin, massage, salicylates, and
mercurial inunctions. Posterior sclerotomy was performed in both
eyes. Normal visual acuity was established in 72 hours, and all traces
of the disease disappeared in two weeks. With correcting lenses vision
in each eye then equaled f . Of great interest in this connection is the
report of Myles Standish^ of the 32 cases of glaucoma reported to the
New England Ophthalmological Society since its foundation. Of these,
9 were induced by atropin, 2 by homatropin, 1 by cocain, 1 by atropin
and cocain combined, 1 by scopolamin, and 1 by duboisin.

ORBIT.

Lucien Howe,* Buffalo, in describing the more recent methods for
studying the connective tissue of the orbit, makes mention of the
following points: (1) That after the orbital walls and the orbital contents
have been removed the outer shell of bone should be sawed down as
far as possible, otherwise the specimen will have to remain unusually
long in the decalcifying acid. (2) The specimen should be hardened in
Zenker's fluid for 3 or 4 days, after which the excess of mercury is washed
out by means of Gram's solution of potassium iodid. (3) For the decalci-
fying process, the specimen should be washed thoroughly with water,
then covered by absorbent cotton which is kept moistened with a 20 %
solution of hydrochloric acid. (4) For staining, Unna's orcein stain. Van
Gieson's picrofuchsin stain, Mall's differential method, Ribbert's phos-
phomolybdic-acid hematoxylin, and Mallory's phosphomolybdic-acid
anilin-blue may be used, but Howe prefers the following method: After
hardening, the specimen is placed in water, then in a 1 % potassium
permanganate 1 to 3 minutes, washed in running water, placed in 1.5 %
oxalic acid solution 4 to 6 minutes, washed in water, stained in 0.25 %
to 1 % aqueous solution of acid fuchsin 1 minute, washed in water,
stained in -^ % to 1 % solution of anilin-blue 1 to 3 minutes, washed
in water and placed in alcohol xylol-balsam.

Enophthalmos has been observed to follow injury by Kilburn,^ who

' Lancet, May 16, 1902. ^ Jour. Am. Med. Assoc, June 20, 1903.

2 Ophthal. Rec, May, 1902. Ann. of Ophthal., vol. xi, No. 4, 1902.

* Arch, of Ophthal., July, 1902, vol. 31, No. 4.

INJURIES. - 563

reports the condition in a man 53 years of age and believes it to be due
to rupture of Tenon's capsule or its thickened bands known as the check
ligaments. Exophthalmos, while usually bilateral, may be unilateral.
Rutten^ describes a case of unilateral transient exophthalmos in a boy
of 14, in whom the Graefe and Stelwag symptoms, diminution in vision,
tachycardia, enlargement 6i the preauricular glands, and goiter, were
present. Recovery occurred in 3 weeks under the administration of
mercury and potassium iodid.

C. Veasey^ reports a case of endothelioma of the orbit of 12 years'
duration, situated beneath the outer third of the left orbital ridge, in a
man of 35. The growth was removed without the aid of an anesthetic
and a microscopic examination was made, confirming the diagnosis.
Wakabayashi^ gives an account of the occurrence of a distoma cyst in
the orbit of a girl 3 years old and of the same condition in the left upper
lid in a boy aged 13 years. Both were removed and the parasites were
detected. De Lapersonne,* Paris, reports a case in which sarcomatous
elements were found in an irritable stump one year after excision of
the anterior segment' of a staphylomatous eye in a child 4 years of age.

INJURIES.

E. A. Shumway^ gives an account of a unique case in which a severe
burn of the face and eye with subsequent loss of the eye was produced
by contact with amyl nitrite. The patient was an epileptic, and was
seized with a convulsion while handling a bottle containing the drug,
which was accidentally thrown into the eye. This case is of decided
interest in view of the fact that amyl nitrite is said by several well-known
authorities to be devoid of irritating properties. [It is likely that some
chemical change had taken place in the drug.]

Sympathetic ophthalmia with complete recovery in both eyes is
reported by Vail® as occurring in a boy aged 14 following a penetrating
wound of the left eye with hernia of the iris. He believes that the in-
tensity of this affection is less in youths than in adults, and that the
conservative method of treatment should be given a fair trial in such
cases.

The giant magnet is considered favorably by Leartus Connor^ in a
report of 2 cases in which foreign bodies in the vitreous were removed,
saving the eye and maintaining some vision.

Mules's operation is compared with enucleation by N. J. Hepburn,^
who concludes that enucleation may be performed for cosmetic purposes,
for wounds of the globe of considerable extent, and for intraocular disease
with destruction of vision, and absolute glaucoma. It must be performed
in cases of sympathetic irritation, absolute glaucoma with much thinning
of the ciliary sclerotic, in malignant growths of the eyeball, and destruc-

' La Clin. Ophtal., Aug., 1902. ' Medicine, Nov., 1902.

' Tokio-Iji-Shinsi, n. 1250. ■• Arch. d'Ophtal., April, 1903.

' Phila. Med. Jour., Oct. 11, 1902. « Am. Jour, of Ophthal., June, 1902

'Jour. Am. Med. Assoc, March 21, 1903.

*Jour. Am. Med. Assoc, Aug. 23, 1902.

o64 OPHTHALMOLOGY.

live ophthalmitis. The Mules operation is adapted to cases in which only
a cosmetic result is required, when range of motility is desirable, in blind
eyes without extensive ciliary involvement, and when it is desirable to
prevent shrinkage of the orbital tissues.

Bronner^ recommends a modified glass ball for use in Mules's
operation, with a hole in the middle, which is covered in with glass so
as to keep out air and water. He operates as follows: A catgut suture
is passed through and tied on to each of the tendons of the 4 recti muscles.
The eye is then removed. The glass ball is introduced into Tenon's
capsule, a thick silk suture is passed through the center with a needle
attached to either end. The superior and inferior and also the external
and internal recti muscles are then tied together over the ball. Three or
four catgut sutures are put through the subconjunctival tissue above,
below, and over the ball, and tied together in a vertical line. The needles
attached to the end of the silk suture of the glass ball are passed through
either side of the subconjunctival tissue. Four sutures are then put
through the conjunctiva on either side and over the ball, and united in
a horizontal line. The ends of the suture of the glass ball are not covered
in by the conjunctiva, but are allowed to hang out at the outer and
inner ends of the hne of suture. They are then loosely tied together
over the sutures so as to keep the glass ball in situ. The silk suture is
not removed for 5 or 6 weeks, so as to give the parts time to become
thoroughly organized and hardened.

Suturing of the tendons after enucleation is performed by a new
method by Snell,^ who rejects the " pursestring" suture commonly
employed. Briefly stated each tendon is separated from its sclerotic
attachment and fastened to the conjunctiva, after which the lateral
tendons are united to each other, and the vertical tendons are brought
together.

Paraffin has been used by Suker, Oatman, and others to form an
artificial vitreous after Mules's operation, with varying results, but the
record of cases in which embolism of the pulmonary artery with subse-
quent death and blindness from embolism of the central retinal artery
followed its use has prevented its receiving a fair trial. Ramsay,' in an
effort to prevent such disastrous results, proposes injection of the paraffin
into the capsule of Tenon after enucleation, and in support of this method
produces 22 cases in which the cosmetic value was undoubted.

Penetrating Wounds. — H. Wokenius* introduced iodoform into the
vitreous body of the human eye in 3 cases without any injurious results,
and advises it as a routine procedure in penetrating wounds. He intro-
duces the iodoform through a cannula. The drug requires several weeks
for its absorption, but its disinfecting power seems positive.

Biirstenbinder^ has pubHshed an observation of a penetrating wound
of the eyeball by a grain of lead, which had remained in the anterior
chamber 8 years without causing any inflammation. There was a pro-

' Brit. Med. Jour., Sept. 26, 1903. ^ Brit. Med. Jour., Nov. 1, 1902.

3 Lancet, 1903, i, 299. ^ Zeit. f. Augenheilk., Aug., 1902.

Abstr. Rev. gen. d'Ophtal, Aug. 31, 1902.

OCULAR SYMPTOMS IN GENERAL DISEASES. . 565

lapse of the iris, adherent in the corneal cicatrix, a circumscribed opacity
of the lens, and a rupture of the choroid and retina from contrecoup.
Vision = -j^, with a defect in the superior field. Besides the lead in the
anterior chamber, the skiagram showed several grains in the orbit, which
in passing had wounded the right externus and levator of the eyelid,
explaining the slight ptosis and convergent strabismus.

First aid in injuries to the eyes from lime has been considered by
Hoppe,^ of Cologne, who recommends providing workmen with a broad-
necked gelatin bottle closed up by a gelatin cap containing 10 gm. of
a lanolin salve with 2 % holocain. For use the cap is knocked off and
the salve squeezed beneath the lids.

OCULAR SYMPTOMS IN GENERAL DISEASES.

The influence of the infectious fevers in the production of ocular
affections. — In 2 cases recently reported by B. K. Chance^ scarlatina
produced orbital cellulitis, a rare sequel of this disease. The intensity
of the affection was so great that death eventually ensued in both in-
stances. The exact cause of the fatal termination, however, is much in
doubt. This same author^ has carefully analyzed the ocular complica-
tions of variola. In over 2000 cases at the Municipal Hospital, Phila-
delphia, there were 36 instances of corneal ulcer, of which 17 were fol-
lowed by perforation with destruction of 1 eyeball, and 15 were cured
without perforation. Of these, 15 were in unvaccinated individuals; in
6 others, vaccinated at periods more or less remote, the lesions were less
severe. Chance says that specific lesions of smallpox do not involve
the cornea, and the corneal complications arise as secondary affections
dependent upon the intense conjunctivitis encountered in these cases.
[That the specific lesions of this disease are not responsible for the ocular
complications is by no means proved. That they may be the same lesions
altered by the histologic structure of the region in which they occur is
shown by analogy; the hard papule of syphilis becomes a moist papule
or mucous patch on mucous surfaces; the lesions of scarlatina and measles
are likewise altered when occurring on the pharynx. Why should variola
be an exception?] The conjunctivitis usually appears on the fifth day,
and is in direct proportion to the eruption on the face and eyeUds. Pus-
tules seldom occur on the conjunctiva. In only 3 instances out of 2000
cases were they observed. Iritis occurred in 10 cases. Parenchymatous
keratitis occurred in but 2 cases. Of serous iritis 10 cases were noted.
Cicatrices of the eyelids and eyeball as the result of ulceration were
frequently encountered. Dacryocystitis and inflammation of the nasal
duct were observed as the result of pustulation.

Collomb* reports a case of double iritis following mumps in a young
man of 29. The right eye was attacked simultaneously with the swelling
of the parotid glands and a marked posterior synechia was the result.

' Abstr. Jour. Am. Med. Assoc, Aug. 23, 1902.

» Amer. Med., June 13, 1903. ' Arner. Med., April 18, 1903.

* Rev. g^n. d'Ophtal., vol. xxii, No. 2, p. 75.

566 OPHTHALMOLOGY.

A subacute iritis of the left eye followed a month later, with resultant
synechise, that could not be broken by vigorous atropin instillations.

Gradle/ in a review of the eye-symptoms of nervous diseases, states
that monocular or binocular blindness with normal pupillary reaction is
a manifestation of hysteria. Tubular visual fields in the absence of
fundus changes have been observed in hysteric girls by Greef^ and others,
and they are now considered hysteric manifestations. Ogusti^ observed
this symptom combined with crossed diplopia for near vision in a hysteric
individual.

Neuburger* records 2 cases in which myopia was suddenly produced
in the course of diabetes mellitus. Hirschberg was the first to demon-
strate that myopia may develop in the course of diabetes mellitus in eyes
previously emmetropic or hjTpermetropic without turgidity or opacity
of the lens. The explanation usually given that the myopic change is
due to the altered refractive index of the lens-substance induced by
the glycosuric state is not very convincing, as the myopia may disappear
abrupth'' and the diabetic changes elsewhere increase. Neuburger makes
a plea for a careful examination for glycosuria in all cases of myopia
beginning in middle life.

According to some observers, the diagnostic importance of in-
equality of the pupils is much overrated. L. Naxera,^ in an examina-
tion of 500 cases, found anisocoria in 88 cases, or 17.6 %. In 15 cases
only was there an organic lesion of the nervous system, whereas in 73
cases the condition was physiologic.

Paradoxic reaction of the pupil in accommodation was observed
by W. G. Spiller^ in 3 cases in which tlie pupil became smaller on fixing
on a far object, and larger on fixing a near object; and larger when the
eyeball was directed downward and inward, the other eyeball being cov-
ered. In only one of these cases was organic nervous disease unquestion-
ably present, so that Spiller hesitates to consider this phenomenon as a
positive indication of organic disease of the nervous system.

The exophthalmos of Basedow's disease has usually been considered
necessarily bilateral. Trousseau' and Guilbert* both record well-marked
cases of this affection, attended only by unilateral exophthalmos.

Ergot and its preparations were noted by Traube in 1770 to produce
ocular disturbances, but the experimental study of this poison has only
been recently given careful attention by K. Ch. Orloff.* In order to
determine the effects of ergot and its derivatives on the eye, he inoculated
a series of 21 animals with ergotin, ergot infusion, sclerotinic acid, sphace-
linic acid, and cornuto-sphacelinic infusion. In all the injected animals,
symptoms of poisoning appeared, and in some they were followed by
death. Special attention was paid to the condition of the eyes, and in
4 animals cataracts were found as the result of the injections. There was
also dilation of the pupils and absence of reaction to light, and in some

1 Chicago Med. Recorder, Jan., 1903. ^ Berl. klin. Woch., May 16, 1902.

3 Ann. of Ophthal., Jan., 1903. •• Munch, med. Woch., No. 12, 1903.

^ Wien. med. Woch., May 3, 1902. « Phila. Med. Jour., May 2, 1903.

"> La Clin. Ophtal., April 10, 1902. » Ibid., May 10, 1902.

» Roussky Vratch, Dec. 14, 1902.

THERAPY. . 567

animals a distinct impairment of vision. Microscopically, the changes
noted in the ganglion-cells of the retinas of these animals were: (1) Dis-
integration of Nissl's bodies; (2) destruction of these bodies at the cir-
cumference; (3) complete dissolution of these bodies, so that the cells
stained diffusely with the specific dyes; (4) indistinctly outlined nuclei;
(5) vacuolization of the protoplasm; and (6) complete disintegration of
the ganglion-cells. C. O. Hawthorne^ describes a case of double optic
neuritis and sixth nerve palsy in a chlorotic girl which he attributes to
intracranial thrombosis. Upon treatment by rest and the internal ad-
ministration of iron the condition subsided entirely.

Metastatic Ophthalmia. — C. Zimmerman and Bro\vn Pusey^ have
described in detail a case of purulent metastatic ophthalmia which oc-
curred in the course of meningitis. It gave rise to manifestations of
meningitis and sympathetic disease 13 years later. A subsequent enu-
cleation was followed by recovery.

In a case of congenital heart-disease in a boy aged 9 years, reported

by S. M. Hamill,^ W. C. Posey detected a neuroretinitis of marked degree.

The retinal arteries and veins were swollen and tortuous, resembling large

angle-worms. The disc was obscured by the swollen retina and there

■were a few hemorrhages in the nerve-fiber layer close to the nerve-head.

The association of retinal changes with mental disease is well
shown by the report of Kuhnt and Wokenius.* Of the 511 patients
examined by these observers, 143 possessed fundus changes. Optic
atrophy was observed 4 times; choked disc once; optic neuritis 4 times;
neuroretinitis once; hyperemia of the disc 11 times; pallor of the nerve
12 times; pallor of the temporal half of the disc 17 times; retinal hemor-
rhage 4 times ; retinitis punctata albicans once ; connective-tissue changes
in the retina 3 times; Uhthoff-Klein cloudings in the retina 27 times;
disc-shaped cloudings in the macular region 34 times ; f oveal changes 42
times; central chorioretinitis 3 times; central choroiditis 14 times; central
myopic choroiditis 13 times, and simple glaucoma 3 times. The reddish-
yellow spots which surrounded the fovea were found associated with
paranoia and dementia in 19 instances; with paralytic dementia in 2
instances; with periodic dementia in 2 instances; with senile dementia
once ; with the mental disturbance of epilepsy in 7 instances ; with melan-
cholia twice ; with mania 4 times ; with imbecility twice and with idiocy
once. This interesting study demonstrates the necessity of routine
ophthalmoscopic examinations in all mental disturbances and also points
out the importance of a careful neurologic investigation in cases presenting
unaccountable central retinal changes.

THERAPY.

Perhaps the greatest advance in ocular therapeutics is the adaptation
of the x-ray for curative purposes. As already mentioned, Mayou,^

' Brit. Med. Jour., Feb. 8, 1902. ^ Ann. of Ophthal., July, 1903.

^ Pediatrics, May, 1903. ■* Zeit. f. Augenheilk., Feb., 1903.

5 Lancet, Feb. 28, 1903.

568 OPHTHALMOLOGY.

discusses the use of the x-ray in locating foreign bodies and in the treat-
ment of rodent ulcer and trachoma. He believes the a;-ray is effective
through the leukocytosis its application causes. Sydney Stephenson^
reports 2 cases of tuberculosis of the conjunctiva in which cure was pro-
duced by its use. The newly discovered element radium promises to
produce more startling results. Javal and Curie ^ have made numerous
studies with a very active radium salt, placing it in a covered glass vessel,
and this in a dense pasteboard box through which no ordinary light
could pass. Two men absolutely blind, one as the result of optic-nerve
atrophy, the other through glaucoma, did not perceive the presence of the
light at all. A third individual, afflicted with prolapse of the retina,
retained light^perception in a small portion of his visual field. When
exposed to the radium rays he announced at once the appearance of a
light, and precisely in that part of his visual field which corresponded to
the inviolate portions of his retina. A fourth individual, blinded by
ophthalmia neonatorum, had thick corneal scars, form-perception was
completely lost, color-perception was present to a slight degree. Ex-
posed to the radium rays, he at once noticed a lighting up of his visual
field, even after the eye was covered with both hands. In a fifth case, the
eye had become glaucomatous after an iridectomy, and all form-percep-
tion was lost, light-perception was retained ; later the lens became cata-
ractous, and light-perception also failed. In case of prospective opera-
tion, knowing that a sensitive retina would perceive the approach of the
radium light, one could determine whether or not the removal of the
cataract would be of service.

A. Benedetti^ presents the results of his experiments with silver
fluorid, a salt discovered by Paterno in 1901, and to which the name
tachiolo has been applied He finds it useful as a collyrium, in solutions
varying in strength from 1 : 1000 to 1 : 100. Solutions of greater strength
than the latter produce irritation. Instillations of this salt seem very
useful in cases of catarrhal conjunctivitis, owing to its antiseptic potency
to its superiority over silver nitrate.

Schuftan* reviews the literature of sublamin and concludes that it
is more effective and less irritating than mercuric chlorid.

A. Chtchepinsky^ employs the soluble salts of sozoiodolic acid (bi-
iodoparaphenolsulfonic acid), especially sodium sozoiodolate or zinc
sozoiodolate, in acute or chronic conjunctivitis in a 2 % to 6 % solution.
In mild cases he confines himself to simple lavage, at first with a medi-
cated solution, then with water; in the graver forms he begins by freeing
the lids and conjunctiva from pus and the products of secretion, then he
drops 2 or 3 minims of the sozoiodolate solution into the conjunctival sac.
Usually this is done once a day, but it may be repeated morning and
evening. In the majority of cases it causes a burning sensation which
diminishes in 5 minutes, to disappear completely at the end of about 15

» Brit. Med. Jour., May 3, 1902, and June 6, 1903.
* Bull, de I'Acad. de M6d., 1902, xlvii, 478.

» II Policlinico, June 14, 1902. * Inaug. Dissert. Berl., Aug. 15, 1902.

* Abstr. Amer. Med., Jan. 10. 1903.

THERAPY. , 569

minutes, without causing an increase in the hyperemia or photophobia.
In some cases it is not accompanied by any disagreeable sensations.
Under this treatment the inflammatory phenomena quickly disappear;
the purulent secretions become purely catarrhal. In Chtchepinsky's
experience zinc sozoiodolate is particularly efficacious against acute con-
junctivitis, as well as in subacute outbreaks of chronic conjunctivitis.

Bellencontre^ advocates hyperiodized oil (iodipin and lipiodol)
as a substitute for iodin and potassium iodid. Iodipin contains 25 %
iodin and lipiodol 40 % ; both are colorless and tasteless and do not dis-
turb the stomach or produce iodism. A. Adamkiewicz,^ Vienna, re-
ports the restoration of sight in an eye nearly blind as the result of can-
cer by the repeated injection of cancroin.

Roemer^ advises the use of jequiritol and jequiritol serum as sub-
stitutes for the infusion of jequirity beans in the treatment of trachoma.
This has also been recommended at a more recent period by Carl Hood.
H. Salomonsohn* speaks favorably of yohimbin, a new local ocular
anesthetic discovered by Magnani in Turih, by whom it is employed
in 1 % solution. It produces anesthesia in one minute and its effect lasts
a half hour. R. Mengelburg^ advises caution in the use of atropin and
adrenalin combined, owing to the great tendency of such a mixture to
induce symptoms of atropin-poisoiiing in individuals otherwise insus-
ceptible to the drug. Darier," Paris, describes a new mydriatic, bromid
of methyl atropin, which in 1 % strength induces mydriasis lasting 24
hours, and cycloplegia which extends over two or three hours.

Subconjunctival injections of saline and other solutions have been
studied experimentally by K. Wessely' to determine the manner in which
their effects are produced. He discards the theory of osmosis in this
connection and supports this statement by the results of analyses of these
various solutions which have shown their penetrating effect to be very
small. Neither do they act as lymphagogs nor by any direct action in
setting free leukocytes, according to his studies. They really act by
powerful local stimuli to the conjunctiva, and even when frequently
employed have no injurious effects. The nerves of the conjunctiva thus
energetically stimulated act in a reflex manner, presumably through
the vasomotor nerves in the vessels of the adjoining vascular territory,
leading to dilation of the ciliary area. The hyperemic condition of the
ciliary vessels renders their walls more permeable, and the result is the
secretion of aqueous humor containing much albumin, in the place of
normal aqueous which contains none. Wessely observes a similarity
in action between the injected solution and the edema that accompanies
inflammation, and that both in inducing an increase in the albumin in
adjacent fluids serve as safeguards by the several protective materials
[bacteriolysin, agglutinin, hemolysin, precipitin] contained in the
albumin secreted.

' La Clin. Ophtal., July, 1902. "^ Medicine, Jan., 1903.

'Graefe's Arch. f. Ophthal., lii, Hefte i, 1901.
* Woch. f. Therap. u. Hyg. des Auges, No. 28, 1903.
" Woch. f. Therap. u. Hyg. des Auges, No. 32, 1903.

« La Clin. Ophtal., Nov., 1902. ' Abstr. Lancet, London, April 4, 1903.

37 S

570

OPHTHALMOLOGY.

INSTRUMENTS AND APPLIANCES.

N. Bishop Harman^ has devised a portable refractometer for con-
venience in retinoscopy and rough subjective tests (Fig. 113). To each
outer extremity of the face-piece of the skeleton trial-frame is affixed
a pivot; upon each pivot there rotates a disc. The discs (3 inches in
diameter) are perforated by 7 holes (f inch in diameter) ; 1 is open, and 6
are glazed with lenses from 1 D. to 6 D., the disc of one side^with plus

Fig. 113.— Harman's portable refractometer (Brit. Med. Jour., Feb. 18, 1903).

lenses, the other with minus lenses. By rotating the discs the lenses come
in succession before the eyehole, and, since the instrument is reversible,
either disc may be placed before the eye to be examined. If a higher
sphere than 6 D. is desired, a 7 D. or, if necessary, a 14 D. lens is placed in
the cell hanging in front of the eye-hole, so that by rotating the disc as
before from 1 D, to 20 D. are obtained. For fractions of a diopter an

independent flat rule, carrying 6
lenses + and — 0.25, 0.5, 0.75, with
a space, is provided; this "fraction
rule" is held vertically before the
eye first at the central space, then
raised or lowered as + or — frac-
tions may be desired.

Edward Jackson^ describes a
binocular magnifier with an illu-
minating mirror attached to a hard-
rubber head-band as an aid in the performance of operations upon the
eye (Fig. 114). The great advantage of this apparatus is that it allows
the free use of both hands. .

This same observer^ has devised an instrument for measuring the
forward projection of the eyeball. For this the name protometer
has been suggested. It consists mainly of a rule with one straight and

Fig. 114. — Jackson's magnifier with illuminating
mirror (Jour. Am. Med. Assoc, Nov. 22, 1902).

Brit. Med. Jour., Feb. 18, 1903. ^ Jour. Am. Med. Assoc, Nov. 22, 1902.
3 Am. Jour. Med. Sci., July, 1903.

INSTRUMENTS AND APPLIANCES.

571

one curved edge with parallel lines on the upper surface, along which
the observer sights and is thus enabled to measure the degree of promi-
nence of the eyeball. The instrument measures within 0.5 mm.

N. Bishop Harman^ describes a scotometer (Fig. 115), an instrument
used for the detection of central scotomas. Behind a screen in which is cut
a square aperture there rotates a disk bearing squares of red and green
color — 2 mm., 3 mm., 5 mm., and 7 mm.
in diameter. The rotary disk has an au-
tomatic check action, so that it stops as
each successive test is brought into the
aperture. The observer, using the nose as
a convenient point of fixation, can pass
the scotometer over it and judge the
presence and extent of color disturbance
in the patient by his perception of the
color of a larger or smaller square or by
the movements of a square of given size
from the fixation point. The color squares
are of the greatest range and size con-
formable with the handiness of the instru-
ment, which is of the same size and
thickness as the usual 1^-inch trial lens,
so that it finds a convenient place in the
ophthalmoscope pocket-case or in a slot
of a trial-lens case.

Martin Jansson^ has constructed an instrument to which he applies the
name siderophone, and which is intended to overcome the disadvantages
of Asmus's sideroscope (Fig. 116). The principal part of the instrument
consists of two cylindric-shaped pieces of iron, united by a framework
of ebony, and placed so that the smaller piece (b) is at right angles to
the larger (d). The latter is surrounded by a middle-sized copper wire,

which is connected with a small
Helesen's dry element, fitted with
an interrupter. The smaller piece
of iron is surrounded with very
fine copper wire, which leads to
a common telephone trumpet.
When the electric current from
the dry element is closed and the
interrupter acts, the larger piece of iron becomes magnetic, and again in-
fluences the smaller piece of iron. This induces a current in the copper
wire by which it is surrounded, and this secondary current is led to the
telephone trumpet, where it is heard as a sound by the ear. The smaller
piece of iron is placed so that the axis of the larger piece divides it care-
fully in half. Thus two electric currents of different directions arise which
meet in the telephone ; if these currents are equally strong, they neutralize
each other, and there is no sound to be heard in the trumpet. But if
' Lancet, July 12, 1902. ' Brit. Med. Jour., Nov. 1, 1902.

Fig. 115. — Ilannaii's scotometer (Lancet,
July 12, 1902).

Fig. 116.— Janssou's siderophoiie (Brit. Med. Jour.,
Nov. 1, 1902).

572 OPHTHALMOLOGY.

the end (c)] is approached to the smallest iron splinter, the current is
increased in the corresponding half. A sound is then produced in the
telephone trumpet. The adjustment of the instrument is made by a
screw (a), which contains a small iron splinter. At a certain position of
the screw the two currents are equally strong. If it is unscrewed, the
current at the opposite end is stronger. The instrument is most sensitive
when the above-named side is slightly overbalanced.

W. Martindale^ has overcome the difficulty of keeping eye-drops
sterile by keeping the solutions in small glass tubes sealed at both ends.
An injector accompanies each case of two dozen, and in using them each
end should be broken off, after which the ejector is applied and the
drops instilled. The same principle has long been in use in connection
with the vaccine virus tubes.

Photographing the Ocular Fundus.^ — The difficulties of photo-
graphing the intraocular picture are many, and heretofore efforts in this
direction have met with little success. The retina must be illumined from
without through the small pupillary aperture, and the rays of light must
traverse all the mediums twice. Again, the dark red of the ocular fundus
is a very poor photographic color, and the photograph must be taken
almost instantaneously. However, Dimmer^ has recently exhibited at
Gratz some very satisfactory photographs of both normal and diseased
eye-grounds. One-half of the pupil was utilized for illumination with a
special mirror covering only that half, while through the other half a
photograph of the corresponding side of the retina was made. The
pupil was dilated ad maximum and the patient was instructed to fix
one eye upon a bright point while the camera was directed toward its
fellow.

^ Brit. Med. Jour., Sept. 27, 1903. ^ Amer. Med., April 25, 1903.

^ Berl. klin. Woch., Dec. 8, 1902.

DISEASES OF THE NOSE, THROAT, AND EAR.

By D. BRADEN KYLE, M.D., and GEORGE FETTEROLF, M.D.,

OF PHILADELPHIA.

DISEASES OF THE NOSE.

An Unusual Case of Nasal Syphilis in a Child and a Considera-
tion of Syphilitic Nasal Tmnors (Syphilomas). — C. F. Theisen^ re-
ports an interesting case of a boy, aged 7 years, illustrating the diffi-
culties sometimes met in making a correct diagnosis. The only history
that was at first obtained from the boy's mother was that during the past
8 or 9 months he had been breathing very badly, the difficulty having
increased very much during the past 2 or 3 months. He had lost weight
and slept poorly ; in fact, had to almost sit up in bed during the night. On
examination both nostrils were found completely occluded by tumors
about the size of small cherries springing from the septum. In each
nostril there were two tumors, one of which had a distinct pedicle and
looked somewhat like a papilloma. They were fairly firm to the touch,
of slightly irregular shape, grayish in color, but covered with an intact
mucous membrane, which showed absolutely no evidence of ulceration.
The pharynx and larynx showed normal conditions, with the exception
of slightly enlarged tonsils. The boy's father had died of tuberculosis
and his mother had lost a sister from the same disease, but at this time no
history of syphilis could be obtained. Owing to the mother's objection
to operative procedures the boy was treated locally and given Fowler's
solution for a time, but his condition finally became so pitiable that an
operation was permitted. Under general anesthesia both nostrils were
thoroughly cleaned out; examination with the probe failed to reveal the
presence of caries. He improved very much for a time, but within 2
months both nostrils were again completely obstructed. The mother
then finally admitted that her husband had acquired syphilis, and that
she had been infected before the birth of this child. The boy was given
potassium iodid and began to improve at once. Within 2 months he was
practically well, and at present, 6 months later, both nostrils remain
entirely free. An examination of the removed growths showed that the
tissue was made up of round-cells, with here and there cells sinlilar to
spindle-cells. There was also a connective- tissue formation, and thicken-
ing of the walls of the bloodvessels. Neither tubercle bacilli nor tubercles
were present. This examination, with the result of the treatment, made
the diagnosis of syphiloma positive. Theisen thinks the case of unusual
1 Jour. Am. Med. Assoc, Feb. 28, 1903.

573

574 DISEASES OF THE NOSE, THROAT, AND EAR.

interest, since it presents a case of congenital syphilis — the only indication
of the disease being the presence of the nasal tumors — which had never
before received antisyphilitic treatment, and nevertheless the nasal
growths at the time of examination showed no evidence of breaking
down. This one fact, without the histologic examination, is enough to
prove that they were neither gummas nor tuberculous granulomas.
Another interesting point is the distinct pedicle one of the tumors had
and the presence of the sjrphilomas in both nostrils.

The Presence of Diphtheria Bacilli in Atrophic Rhinitis. — J. 0.
Symes,^ in a report of 23 cases of atrophic rhinitis, the patients varying
from 9 to 57 years of age, and in which the average duration of the disease
was 7 years, found a bacillus in 20 of the cases resembling in morpho-
logic and cultural characteristics the Klebs-Loffler bacillus. In 17 cases
the organism was of the long variety, and in 3 the short. To ascertain
whether these were true diphtheria bacilli, a series of cultures was made
from the noses of healthy children ; in no instance were any long diphtheria-
like bacilli found, but in 58 % a short pseudodiphtheric type of bacillus
was present. A series of cultures was also taken from persons suffering
from ozena secondary to congenital or acquired syphilis and lesions other
than atrophic rhinitis, in none of which were diphtheria-like bacilli found.
By inoculation experiments on animals he then found that the organism
present in the atrophic cases proved to be a virulent diphtheria bacillus.
On these experiments he based the following conclusion: If the fore-
going facts can be substantiated and the identity of this bacillus with the
Klebs-Loffler bacillus can be established, then we may regard atrophic
rhinitis as a chronic form of nasal diphtheria. In addition to the bac-
teriologic evidence, the following points seem to support this theory:

(1) The accessory sinuses of the nose are constantly infected in diphtheria.

(2) Chronic sinus-suppuration is looked on as the direct exciting cause
of atrophic rhinitis. (3) Multiple cases of atrophic rhinitis exist in the
same household from time to time. (4) An attack of diphtheria may
be the starting-point of atrophic rhinitis, (5) Atrophic rhinitis, like
diphtheria, attacks females more than males, and is a disease of early
life. (6) Atrophic rhinitis has been successfully treated by diphtheria
antitoxin. (7) In atrophic rhinitis the type of diphtheria bacillus does
not alter.

Adenocarcinoma of the Nose. — H. Cordes^ makes observations
concerning other recorded cases of this character, with the report of a
case of his own in a man 75 years of age, in the treatment of whom elec-
trolysis was found to be of marked benefit, reducing the growth to such a
degree that its total extirpation was readily accomplished. After 9
months no recurrence was perceptible.

The Use of Cargile Membrane in the Nose to Prevent Adhesions. —
H. P. Mosher^ reports satisfactory results with the use of cargile mem-
brane as a dressing on the septum after the operation for the correction
of deflection ; as a sleeve for a packing which has to be left in the nose for

» Brit. Med. Jour., Feb. 28, 1903. ^ Berl. klin. Woch., Feb. 23, 1903.

2 Boston M. and S. Jour., Feb. 26, 1903.

DISEASES OF THE NOSE. • 575

any length of time ; on the turbinates after cauterizing, in order to keep
the cauterized turbinate from cauterizing the septum opposite; to hold
down flaps of mucous membrane after the submucous dissection of car-
tilaginous spurs ; in fact, after any operation in the nose in which adhesions
are likely to result. Owing to the difficulty of application of a single
layer he secures it in place by folding the membrane into a wedge-shaped
strip several layers thick and then introduces it just as an ordinary
packing would be inserted between the cut ends of the adhesion.

Case of Intractable Nasal Hemorrhage Successfully Treateji by
a New Method. — G. Hunter Mackenzie^ reports a case of persistent
hemorrhage from the anterior third of the septum about 1 cm. above
the nasal floor. Cocain and adrenalin were applied on pledgets of cotton
without effect, after which the electrocautery was used with the same
futile result. After these methods had been used for 2 days, with con-
tinued periodic attacks of bleeding, the entire mucous membrane over
the bleeding surface was curetted away; following this the hemorrhage
soon ceased of its own accord. This case, he states, is the only one in
his experience in which the galvanocautery failed to control the hemor-
rhage, and thinks that the method resorted to is submitted for the first
time.

Treatment of Atrophic Fetid Rhinitis by Interstitial Injections
of Paraffin. — A. BrindeP has made the experirnent of applying the
paraffin-injection idea brought out by Gersuny and Eckstein to the treat-
ment of atrophic rhinitis, by injecting it into the atrophied turbinates,
thus favoring the expulsion of decomposing secretions, and perhaps
modifying the character and quantity of the secretion as well. In 10
cases reported not only was the desired mechanical result effected, but
the morbid secretions underwent a marked and rapid change with the
consequent disappearance of the ozena and crust-formation. The tech-
nic consists in the injection of the paraffin mixture recommended by
Eckstein into the inferior turbinates. With the aid of cocain the opera-
tions were made painless, only 2 cases being followed by any ill results,
these being a phlebitis of the facial vein, which, however, gave no serious
permanent effect.

The Etiology of Nasal Polyps, with Especial Reference to Their
Association with Other Pathologic Conditions. — Francis R. Packard'
points out the confusion in the nomenclature employed in reference to
nasal polyps. The paper is accompanied by original drawings of a num-
ber of sections of polyps, taken from different cases, in not one of which
is there any evidence of the structure of a true m3rxomatous tumor; in all
of them, however, there was mucoid degeneration. In all of the cases the
polyp was associated with the presence of dead bone in the nose. The
sooner the profession realizes that nasal polyps are symptoms of under-
lying conditions, and not merely "tumors," the mere removal of which
will result in a complete cure, the greater will be the benefit to all

» Brit. Med. Jour., Sept. 27, 1902.

' Rev. Hebdom. de Laryng., June 21, 1902.

' Trans. Amer. Laryngol. Assoc, 1903.

576 DISEASES OF THE NOSE, THROAT, AND EAR.

concerned. The frequent recurrence is undoubtedly due to a failure to
remove their underlying cause.

Rubber Splints in the Treatment of Septal Curvature. — J. Price-
Brown^ says that while yomeric ridges and exostoses may extend all the
way back to the posterior nares, ciuvatures are usually confined to the
anterior two-thirds of the septum, and the majority to the triangular
cartilage. ' It is in the treatment of the latter class of cases that rubber
splints are particularly suitable. In speaking of the etiology of these
conditions, he claims that whatever may be the primary cause of the
curvature, the habit of wiping the nose from the convex toward the con-
cave side is habitual in almost all these cases, and has a serious effect in
aggravating the deformity. His experience differs from some clinicians,
also, in the character of curvatures usually found. When the principal
bend is in the triangular cartUage, any extension backward into the
vomeric region, whether as curvature or ridge, has in the majority of
instances been on the same side. Quite frequently one side of the tri-
angular cartilage is deeply concave or book-notched in form ; and it is in
this class of cases that rubber splints are specially useful. They are made
from pure rubber sheeting of varying thickness — J, i, or f inch — and are
cut by the operator by means of scissors and sharp knife to the required
shape and size, and then the edges smoothed by the use of a steel file and
sand-paper. To prepare them for use, they are immersed in an anti-
septic solution and before insertion smeared with vaselin to facilitate
entrance into the nasal cavity. These splints cannot become septic
any more than can the vulcanite, and have the advantage of elastic com-
pressibility which the harder material does not possess. To reduce the
curvature, the nasal passages are first cleansed by the use of antiseptic
sprays, etc. Then a 1 % solution of cocain is thrown into each nasal
cavity, followed by a 5 % to 10 % solution applied on a cotton holder to
both sides of the septal cartilage, followed bj'' a solution of adrenalin. Any
existing spur or ridges are next removed by saw. Either on this occasion
or on a subsequent one, the septum is next cut on its convex side by one,
two, or three linear incisions, from behind forward, the cuts being parallel
to each other. The level of each incision is made to suit the special
condition of each case. The incision may or may not penetrate the
mucous membrane on the opposite side of the septum. This must be
determined by the judgment of the operator. By the finger or strong
spatula, the septum is then pressed into the mesial line, and the splint,
made specially for the case, inserted. It should fit with moderate tight-
ness, and by its elasticity keep the septum in position. The advisability
of moderate tightness on the part of the splint is illustrated in several
ways. Not only does it keep the septum in position, but it promotes
absorption of any roughened edges that may be occasioned by overlap-
ping; while the smooth, flat surface of the splint, presented to the car-
tilage, insures in large measure a smooth septum as a result. After in-
sertion, if the splint fits and retains its position, it should not be removed
at all until healing and solidity have been accomplished, whether this
* Laryngoscope, Aug., 1902.

DISEASES OF THE NOSE. - 577

takes 2 weeks, 4 weeks, or even longer. Still, the patient should for a
time be under the regular supervision of the surgeon, and the passage
cleansed daily of exuded secretions, by means of carefully applied cotton
holders, etc. When the operation with regard to hands and instru-
ments is done antiseptically, and within the nasal passage is placed a
smooth, compressible, aseptic body, which — as stated by Lake — cannot
become septic, and when by proper care the parts above and below the
splint can be regularly cleansed, it is difficult to believe that the con-
tinuous retention of the instrument, during the process of healing, can
be productive of any undesirable results. The paper closes with a record
of 7 cases all treated in this manner, the results in all being satisfactory.
The periods of continuous retention of the splint in these cases varies
from 1 week to 4 months. In the last case, after wearing the splint
for 1 week, with Price-Brown's consent the boy, aged 13 years, was taken
home by his father, with instruction to return to have the splint removed
a month later. The letters received, however, were so satisfactory that
the period was allowed to extend, and it was only upon insistence that
he finally came back to have it removed at the expiration of 16 weeks.
No harm had accrued from the prolonged retention.

The Use of Suprarenal Extract in Hay-fever. — J. Payson Clark,*
from the experience of two summers in the use of suprarenal extract in
hay-fever, draws the following conclusions : Of the 3 forms in which he
used this substance, — i. e., powdered desiccated capsules, solution of
suprarenal extract with chloreton, and solution of adrenalin chlorid
(Takamine), — ^he found the last-mentioned most reliable and satisfactory.
In simple vasomotor rhinitis, with no discoverable local abnormality and
no general dyscrasia, suprarenal extract used locally appears to give
favorable results in a large proportion of cases, either entirely preventing
or much diminishing the severity of the symptoms. In cases of hay-
fever in which there is some local abnormality in the nose, the suprarenal
extract does not act favorably until such abnormal condition is remedied.
In cases in which there is a rheumatic or allied dyscrasia, the suprarenal
extract is apt to cause some reaction at first, and in any event does not
act as favorably as in uncomplicated cases.

Deformity from the Injection of Paraffin. — H. H. Curtis^ reports
the case of a young woman who had received an injection of parafhn for
the removal of a depression at the junction of the lip and nose. The
operation had been done by a physician who claimed to be skilful in this
line of work, but the result was unfortunate, for the paraffin had escaped
and had made two exceedingly unsightly swellings on the sides of the nose
and below the orbits. [This is but one of many deplorable accidents which
have happened as a result of Gersuny's suggestion for the relief of deform-
ity by the hypodermatic injection of paraffin. It cannot be insisted on
too strongly that this procedure should be used with the greatest care,
caution, and skill, and not the least of the precautions to be adopted
is that the immediate area whose contour it is intended to change
' Boston M. and S. Jour., June 19, 1902. ^ Laryngoscope, April, 1903.

578 DISEASES OF THE NOSE, THROAT, ANt) EAR.

should be so firmly isolated that escape of the paraffin into surrounding
.areas is rendered absolutely impossible.]

Experiments on the Nature and Specific Treatment of Hay-
fever. — Sir F. Semon^ states the following as the result of his expe-
rience: (1) There can be no doubt that Dunbar has succeeded in ex-
tracting from the poUen of certain grasses a toxin which, when instilled
into the eyes or nostrils of people predisposed to hay-fever, produces in
these parts the characteristic subjective and objective symptoms of the
disease. (2) The toxin, when injected into the eyes or nostrils of people
not predisposed, produces in the great majority of cases no symptoms
whatever. But it certainly appeared as if there were instances of tran-
sition in which, although the persons experimented upon never suffered
from typical hay-fever, they were 3^et more susceptible to the influence
of the toxin than the ordinary run of people. (3) The effects of the
toxin in people suffering from hay-fever are as variable in intensity as
are the attacks of the affection itself, with regard to both the local and
the constitutional symptoms. (4) Dunbar's antitoxin certainly pro-
duced immediate disappearance of the subjective, and, after a few min-
utes, great amelioration of the objective, symptoms. (5) The mixture
in equal parts of a toxic solution (1 : 500) and the antitoxic serum suffices
to neutralize the specific effects of the toxin. (6) The effects of the anti-
toxin appear in some instances to be sufficient to prevent a reappearance
of the subjective symptoms, while in other instances repeated instilla-
tions of the antitoxin were required to produce ultimately the return to
normal conditions. But all we know at the present is not sufficient to
build therapeutic hopes on, and this for the reason that we are ignorant
of the nature of the special predisposition which exists in hay-fever sub-
jects.

Adenoma of the Nose with Incipient Sarcomatous Metamor-
phosis.— Emil Mayer^ reports a case of this affection occurring in a man
aged 68. The points of interest are: the immense size of the tumor,
weighing 117 grams when removed; the unusual methods required in
operation, consisting of tracheotomy and external operation; and the
absorption of all intranasal bones, the cartilage remaining intact. The
patient made a complete recovery ; there had been no recurrence 4 months
after the operation.

The Asch Operation for Deviations of the Cartilaginous Nasal
Septum, with Conditions Complicating Its Performance. — Emil
Mayer' reports 3 cases of deviations of an unusual nature, the first being
an S-shaped deviation with dislocation of the columnar cartilage; the
second, complete occlusion with many points of adhesion of the septum
and inferior turbinate; the third, with an orbital tumor complicating the
deviation and where the operation was advised as a means of diagnosis.
He further combats some of the statements made by other writers that
the Asch operation is performed without the aid of sight, that it is one
requiring unusual force, that the operation is one of magnitude, and that

» Brit. Med. Jour., March 28, 1903. ^ Amer. Med., Aug. 2, 1902.

" Jour. Am. Med. Assoc, March 7, 1903.

DISEASES OF THE NOSE. . 579

the tubes occasion the formation of granulation-tissue. He conchides as
follows : The last word regarding any operative procedure is never spoken ;
the more popular it becomes, the more frequently it is mentioned and
assailed. By our own mishaps and those of others we learn to avoid
these and perfect our technic. Intelligent and fearless criticism is cor-
dially welcomed, and it becomes incumbent on us to weigh these care-
fully and to answer them as best we may in the same cordial spirit.

A Rapidly Recurring "Bleeding Polyp" of the Septum Nasi Ap-
pearing Twice in a Woman, Each Time at the Seventh Month of
Pregnancy. — Jonathan Wright^ reports the following case, interesting
in the light of the anatomic and clinical interrelation between the erectile
tissue of the sexual organs and that of the nose. The patient was a
woman aged 25, with a history of the septum having been burned several
years previously for obstruction, and from this a perforation had resulted.
Since that time she had been married and was 7 months pregnant.
Springing from the posteroinferior edge of the perforation was a round
vascular growth, which, after removal, showed nothing but very vascular
granulation-tissue. It recurred rapidly and on second removal bits of
underlying cartilage were removed with it. This specimen showed some
disordered cell structure and greater vascularity than the first. About a
year later the woman returned with the history that there had been no
noticeable recurrence until she had again reached the seventh month of
pregnancy. The tumor at this time was attached mainly to the inferior
border of the perforation and was of the same appearance as the previous
ones. It was removed and rapidly recurred, and on further removal
gave the following appearances: There was an outer layer of degenerated
flat epithelium and underlying it a layer of what appeared to be hyaline
degeneration of the connective tissue. The mass of the growth was made
up of loose edematous connective tissue containing a large number of
mononuclear round-cells, which stained very deeply with hematoxylin,
and the whole growth was traversed by numerous capillaries lined with
a single layer of endothelium whose nuclei were much swollen and pro-
jected into the lumen of the bloodvessel. There was every evidence of
considerable inflammatory action, but no proof of malignancy.

Failures in Attempted Correction of Septal Deviation. — Chevalier
Jackson^ enumerates 14 causes of failure in attempted correction of septal
deviation. He concludes that "almost every case of deviation demanding
operation requires resection of the inferior turbinal on the concave side
for two purposes : to secure immediate correction of the septal deviation,
and to secure adequate nasal respiration during sleep. It is an error to
base the estimation of the adequacy of the nasal respiratory channel on
either the patient's statement or the apparent size on inspection of the
channel, whether the parts be cocainized or not. If the imprint of the
inferior turbinal is seen on the septum, it is a certain indication for a
radical resection of the inferior turbinated body (including a fringe of
bone) on the concave side. ' Soft' hypertrophies will expand at night and

* Am. Jour. Med. Sci., June, 1903.

* Trans. Am. Laryn., Rhinol., and Otol. Soc, 1902.

580 DISEASES OF THE NOSE, THROAT, AND EAR.

push upon the septum, yet shrink so small as to leave a large, free, and
open channel during the day. They often do more harm than 'hard'
hj^pertrophies, as they are often even more expansile. If left untouched,
or, what amounts to the same thing, if temporized with by the utterly
useless galvanocautery, the septum may as well be let alone, for the
deflection w^U sooner or later reappear and be worse than ever." When
a tube is needed, he uses Kyle's, though, if the resection of the turbinal
be sufficiently radical, he seldom finds need of a tube, or of packing, to
hold the septum in its new position.

DISEASES OF THE ACCESSORY CAVITIES.

The Prophylaxis of Sinus Diseases. — D. Bryson Delavan^ states
that, since of late years diseases of the sinuses adjacent to the nose have
been so distressingly common, the cure of the disease is without doubt
an unspeakable benefit to mankind; yet its effective prevention is a far
greater one. It is weU, therefore, that we should give it more careful
attention in the hope that through a better understanding of the causes
of sinus disease some suggestions may arise through the aid of which a
certain number of cases may be altogether eliminated, and others, des-
tined by reason of neglect to fall into serious trouble, may be quickly
rescued. The writer believes that a large amount of sinus disease could
be done away with if the knowledge of the general physician were suffi-
cient to recognize its predisposing causes, or, where it has already de-
veloped, to appreciate its early acute symptoms and to apply a few
simple principles of cure. He divides the causes into predisposing and
exciting. Of the former are mentioned anything which seriously hinders
free drainage from the upper half of the nasal cavity ; various abnormali-
ties of the septum, one of the most important of which is fracture with
displacement where the narrowing occurs somewhere in the neighborhood
of the middle turbinate ; catarrhal thickening of the tissues of the upper
and middle parts of the septum; hypertrophy or unusual size of the so-
called tubercle of the septum; congestive and hypertrophic conditions of
the soft parts of the middle turbinates; and anything which promotes
acute or chronic irritation of the nasal cavities. Under exciting causes he
places the acute infectious diseases, particularly influenza. Dental irrita-
tion, injury from fracture of the walls of the sinus, and not infrequently
operations of the nasal cavity, in which the adjacent parts have been
treated with violence or instruments not properly aseptic, have infected
the parts. Probably another prolific cause of irritation is the inhalation
of dust from filthy streets, and that which is necessarily associated with
automobile racing may contribute a large addition to the list of cases.
Among the microorganisms most commonly found are the streptococcus
and staphylococcus, Diplococcus pneumoniae, pneumobacillus of Fried-
lander, and Bacillus coli communis. He touches on some of the more
practical points of active treatment and summarizes the prophylaxis as
follows: (1) By recognizing the conditions under which inflammation of
* Jour. Am. Med. Assoc, Feb. 21, 1903.

DISEASES OF THE ACCESSORY CAVITIES. • 581

the sinuses is likely to occur and, if possible, removing them. (2) When
removal of the predisposing conditions is not practicable, by guarding the
patient against the various exciting causes which may determine an
acute attack. (3) When acute inflammation is already threatened, by
applying immediate treatment for its relief.

Transillumination of the Nasal Accessory Sinuses during Acute
Coryza. — C. M. Cobb^ reports the results of some work done in trans-
illumination of the accessory sinuses during the course of an acute coryza.
He states that the results are, of course, subject to all the sources of
error that may be encountered in transillumination in general, and that
the conclusions to be drawn must be accepted subject to this element of
doubt. He divides a series of 30 cases into 4 groups: (1) those seen
during the first 24 hours of the beginning of the acute coryza; (2) those
seen during the later stages of the attack, or rather the cases in which
the attack persisted longer than the usual cold and gave discomfort
enough so that the patients sought relief through special treatment; (3)
those who had pain either in the face or head; (4) those who had otitis
media as a complication during the course of the acute coryza. He
makes the following summary: (1) That to do satisfactory work it is
necessary to have lamps of much greater candle-power than those usually
sold by instrument dealers. (2) That it is rare to find the accessory
sinuses dark on transillumination during the early stages of acute coryza.
(3) That during the later stages of a prolonged attack it is the usual
result to find one or more of them dark. (4) That hemicrania is often
closely associated with antrum disease. (5) That it is almost the rule
to find one or more of the nasal accessory sinuses involved when the ears
are affected during acute coryza.

Observations on the Diagnosis of Nasal Sinusitis. — Walter J.
Freeman,^ although believing in the value of transillumination as a con-
firmative measure in making a diagnosis of frontal and antral sinusitis,
thinks that generally too much reliance has been placed on it. The
position of pus in the various parts of the nasal fossa and the presence
of edema and congestion around the sinus openings are much more
reliable objective symptoms. Clinically, frontal sinus disease is charac-
terized by a late morning headache, fulness over the eyes on leaning
forward, and exquisite tenderness at the inner angle of the orbital roof,
so that when these symptoms are found in conjunction with pus at the
peak of the vestibule, an almost positive diagnosis can be made. The
sweUing of the turbinals and a capillary attraction produced by the con-
tiguous surfaces of the septum and the agger nasi, cause the pus to flow
anteriorly instead of posteriorly into the hiatus groove. Among some of
the more important signs of antrum inflammation may be mentioned the
following: Pus flowing over the posterior end of the inferior turbinal;
well-defined odors such as those of sulfuretted hydrogen and sour pus,
and intermittent cacosmia. A sixth-year upper molar which has been
capped should be considered most suspicious when a cause of antral
disease is being looked for. Positive evidence of disease of the antrum
' Jour. Am. Med. Assoc, Feb. 28, 1903. ' Araer. Med., July 11, 1903.

582 DISEASES OF THE NOSE, THROAT, AND EAR.

may be obtained by washing out pus from the ca\dty, and this, in the
majority of cases, can be done through the normal opening. The opening
should first be sought by a delicate cotton-wound probe, the point curved
down. The washing cannula, preferably made of hard rubber, must then
be fashioned after that shape which by the probing has been found to
enter most readily the ostium maxillare. While acute ethmoiditis is one
of the most common of conditions observed during the prevalence of
grip epidemics, the author has yet to see an exception to the rule that
complete resolution takes place within a few weeks under appropriate
local and constitutional treatment. Most cases of "chronic ethmoiditis"
which he has seen have been inherited from other operators and have
been cured by treatment of hitherto unsuspected frontal, antral, or
sphenoid suppuration. In all cases except those of marked atrophy it
is impossible to distinguish by the position of the pus between a posterior
ethmoiditis and sphenoid disease. As crusts are found in the vault in
almost any sinus suppuration, they are not of much importance in diag-
nosing disease of the sphenoid sinus. The presence or absence of pain
and its position are not reliable symptoms for diagnostic purposes. The
use of suprarenal extract in the nose is not advisable when an examina-
tion for sinus disease is being made, as the bleaching of the membranes
renders the recognition of small amounts of pus very difficult. Alternate
blowing of the nose and sniffing is a very good method of drawing the
pus from the sinus openings so that it may be detected. The morning
is the most favorable time for detecting pus from the frontal and ethmoid
and the evening from the antrum and sphenoid sinuses.

Diagnosis and Treatment of Antral Empyema. — J. W. Barrett^
calls attention to the remarkable frequency of this disease as compared
with a few years ago, and attributes it to the fact that almost the only
cases diagnosed formerly were the acute cases — cases in which there were
pain and bulging. Such acute cases he thinks, however, exceedingly rare,
while the chronic are very common. He thinks, moreover, that cases
which have long been classed under general debility may be due to the
disturbance caused by the presence of pus in these cavities and the con-
stant swallowing of the fetid discharge. He favors transillumination as
a diagnostic agent, though he does not regard it as infallible. In case of
doubt he advises exploratory puncture, the nose first being sprayed with
a 10 % adrenalin solution and cocain, the trocar being passed under
the fore part of the inferior turbinate and then pushed out through the
inner wall of the antrum, which is very thin in this position. A fairly
large sized trocar with a gimlet point instead of the old-style sharp point
is recommended, since with this the opening can be made gradually and
thus avoid slipping through and puncturing the opposite side of the
cavity. As soon as the trocar has entered the cavity it is withdrawn
and soda bicarbonate solution syringed through the cannula. In the
more obstinate qases he advises the usual opening through the alveolus
or through the canine fossa.

Disease of the Maxillary Antrum. — R. Claoub^ advocates opening
» Intemat. Med. Jour., Oct. 20, 1902. ^ l^ Sem. med., Oct. 15, 1902.

DISEASES OF THE ACCESSORY CAVITIES. . 583

the antrum through the nose instead of through a tooth socket or canine
fossa, in order to prevent the conveyance of pus into the mouth and the
possibiUty of a reinfection of the antrum from the mouth. He recom-
mends the following procedure: By means of a long, straight, thin, but
strong, bladed scissors the anterior half of the inferior turbinal is re-
moved at its attachment. This renders easy access to the ostium maxil-
lare, which is now enlarged to the extent of removing the inner wall of
the antrum down to the floor of the nose, using for this purpose a trephine
or suitably shaped chisel. When this is accomplished, free access to the
antrum is afforded and thorough subsequent treatment can be carried
out. Claoub states that the cures are obtained with greater rapidity than
in the other methods of operating and that the results are much more
permanent.

Empyema of the Sphenoidal Sinus. — F. W. HinkeP reports an ex-
perience of 20 cases, the jiiagnosis in each instance being confirmed by
operation. The pain was uniformly severe, but was not distinctly local-
ized; it is occasionally located in the ears and the temporoparietal region.
In 8 of the cases there had been chronic cough with purulent expectora-
tion, and in 2 there had been considerable pharyngeal catarrh. In 7,
polyp-formation was present. Irrigation through the natural opening
was unsatisfactory because it failed to relieve the symptoms or control
the pus-formation and often gave rise to headache. The best treatment
consists in the removal of the anterior wall with a sharp spoon through
the nose. Following this procedure in one case there had been severe
secondary hemorrhage 10 days after the operation, which was attributed
to wounding of the sphenopalatine artery at the time of the original
operation.

Polyps in the Nasal Accessory Cavities, with Specimens. — A. R.
Solenberger^ accounts for the recurrence of nasal polyps by a study of
the various pathologic conditions of the nasal accessory cavities. He
begins with the general statement that the first degenerative force in
the history of nasal polyps is an irritant; it may be of internal or external
origin. It may be one of the many poisons eliminated by the respiratory
mucosa from the blood, such as uric acid and the various irritants seen
in gingivitis ; or else it may be one of the numerous irritants in the atmos-
phere, material or organic. The process at which the initial point of
attack is on the bone seems, from the pieces of diseased tissues examined
in the various stages of its evolution, to be this: The periosteum is
irritated, then infiltrated and easily separated; large cells appear in the
soft tissues and osteoclasts in the hard tissues ; then, as larger cells appear
in the polyp, larger osteoclasts appear in the bone. These break down,
disintegrate, and abscess and rarefying osteitis occur. The process seems
to be the same in the bones of the nose ; and the reason why polyps pre-
dominate more largely in the latter is due to the vastly greater air area
of exposure to irritants, the presence in the nose of extensive areas of
tissues of lower organization and less resistance in both internal and
external irritants. This pathologic process explains why we see nasal
' Med. Rec, July 19, 1902. ^ Phila. Med. Jour., Dec. 20, 1902.

584

DISEASES OF THE NOSE, THROAT, AND EAR.

polyps without pus, and why we sometimes find them without caries.
When nasal polyps exist without pus, either there has been causal caries
which has healed and left a stranded polj^, or the polyp is due to the
limitation of the initial irritative force to the mucosa, the process having
stopped short of bone erosion. A polyp situated at the orifice of the
accessory cavities, more or less occluding it, may become a mechanical
cause of creating suppuration, caries, and polypoid conditions in the
cavity, and the persistent flow of pus over this orificial polyp may cause
it to inflame and erode the bone beneath. In recurring polyps we fre-
quently find evidence of more or less thorough work having been done;
the anterior end of the middle turbinate and parts of the ethmoid bone
are frequently absent, demonstrating that a rhinologist has been at work.
In this case an %ffort must be made to carry out pathologic research
deeper than our predecessor. What is true of the bony structure of the
nose is likewise true with reference to the temporal bone, particularly
the mastoid process. The most important far-reaching element in the

pathology of polyps is that
in all advanced cases of
tissue degeneration, when
aU surgical measures of
curet and gouge have been
faithfully and scientifically
done, we still have to do
with diseased processes in
the outlying area, and that
these are now not so much
peripheral as they are sys-
temic. The scooped-out
area has become the deep-
ly entrenched dumping-
Fig. iiv. — Showingavenue— ethmoid cells^tlirough which ffrOUnd a SOrt of COnCCU-

sphenoid polyp was removed, and sphenoid cavity contain- ° ,

ing polyp (Solenberger, in Phila. Med. Jour., Dec. 20, 1902). triC termmUS of Scavenger

and offal trains from all
parts of the body. His conclusions are that nasal polyps recur, first,
because the rhinologist does not always trace them to their deeper
pathology; second, he often fails to find the seat of their first origin;
nor does he differentiate the various stages in their evolution, or the
accessory causes of their continuance; third, all the necrotic tissue,
therefore, not being recognized and removed, nature's drainage avenues
are not re-established; fourth, many cases recur after all surgical measures
have been exhausted because too many of the scavenger trains are keeping
up the pernicious habit of carrying the wastes of the body to the old
dumping-ground. Specimens were exhibited all of which seemed to grow
from bones undergoing necrosis ; some of them being removed with their
bony base. Four were found in the maxillary antrums, 4 formed a part
of the middle turbinates, and 3 grew around the antral orifices. The one
particularly described and illustrated was found in the sphenoid cavity
(Fig. 117). The ca^e was that of a woman, aged 45 years, who had suf-

DISEASES OF THE TONSILS. . 585

fered from asthma 6 years and each year bilateral nasal polyps had been
removed without much relief. Severe headaches, especially occipital, were
marked. Upon examination both nostrils were found packed with polyps.
These having been removed and the ethmoidal cells thoroughly curetted,
upon entering the last cell with a stout probe to test the condition of its
posterior wall, the probe suddenly slipped onward, having entered the
sphenoid cavity. The opening was enlarged and a white body which
felt soft to the probe could be seen. With a Hart man ear forceps this
was removed and found to be a polyp nearly 2 inches in length, vermi-
form in outhne and i inch in thickness. The patient was soon relieved
of all the more distressing symptoms of asthma and has had no evidence
of recurrence for 6 months.

DISEASES OF THE TONSILS.

The Faucial Tonsils : The Indications for Their Removal and
the Best Methods by which to Accomplish It. — Francis R. Packard*
discusses the causes which lead to the overdevelopment of the faucial
tonsils. "Several reasons besides hypertrophy may render it necessary
to remove the tonsils: (1) They may constitute a locus minoris resis-
tantise, the openings in the crypts on the surface of the tonsil affording
lodgment to various germs, especially those of diphtheria and scarlet
fever. (2) Cyst-formation is not infrequent. (3) There may be an
accumulation of cheesy material in the ciypts. (4) Tumors, principally
sarcomas, are not uncommon." The article deals only with the removal
of the tonsils because of their hypertrophy. Operative measures are the
only really effective means. "The causes readily divide themselves into
very distinct classes : those in which the patient is young, before the age
of puberty, and those of more mature years. In children the tonsil
tissue is soft and not very vascular, and the removal is not attended
by very much subsequent pain; in adults the tissue is usually the seat
of inflammatory troubles, there is considerable vascularity, and the
tissiies being more dense and harder to cut, the subsequent pain is more
severe." Most operators prefer to use the tonsil guillotine. Where the
patient will cooperate, it is much easier to operate under local anesthesia.
For children and nervous patients a general anesthetic is necessary, as a
rule. Although serious hemorrhage has occurred subsequent to tonsil-
lectomy, there have been few, if any, deaths directly attributable to it,
except in hemophiliac patients.

The Controlling of Hemorrhage after Tonsillectomy. — Hermann^
reports a case of a man of 46 in whom severe hemorrhage followed re-
moval of the tonsil. After all the usual methods of checking the hemor-
rhage had failed, silk ligatures were passed through the anterior and
posterior faucial pillars and tied. The hemorrhage was immediately
checked and there was no subsequent distress. E. Escat^ reports a more
serious case of the same trouble. The hemorrhage was at first slight,

* Intemat. Climes, iii, twelfth series, 1902. ^ Arch. f. Laryng., xii, No. 111.
* Rev. Hebdom. de Laryngol., d'Otol., et de Rhinol., Sept., 1902,
38 S

586 DISEASES OF THE NOSE, THROAT, AND EAK.

was not controlled b}^ gargling with cold water, and continued for about
15 minutes. Inspection revealed a jet of arterial blood at the upper
part of the stump. A tampon of cotton-wool was pressed against the
bleeding point by means of forceps, but was ineffectual. The application
of the galvanocautery only served to increase the hemorrhage. An
attempt then made to seize the artery with hemostatic forceps was in-
effectual. A tampon of cotton-wool held between the middle and index
fingers was then pressed against the bleeding point for 10 minutes; this
held the hemorrhage in check, but it recurred as soon as the tampon was
removed. Various hemostatics, including ice and iron perchlorid, also
proved ineffectual. Ricord's compressor was then applied and arrested
the hemorrhage, but it caused so much pain that it had to be removed
and the bleeding was woise than before. By means of a staphylorrhaphy
needle-holder a large curved need'e carrying a silk thread was carried
through both pillare of the fauces by one movement and the suture tied.
This proving insufficient, a similar suture was passed 2 cm. below *^}ie
first. This closed the cavity, but the hemorrhage still continued. A
clot then formed, and as the hemorrhage seemed to be stopping, gelatin
was injected into the cavity; but this only served to increase the hemor-
rhage. Finally, a cylindric tampon of cotton-wool the size of the little
finger was passed from above the upper suture into the cavity and carried
downward until it appeared below the lower suture. The hemorrhage,
which had lasted for 4 hours, was permanently arrested, and at the end
of 24 hours the sutures and tampon were removed with no recurrence of
the bleeding.

Death from the Bursting of a Tonsillar Abscess. — A. Lyons ^
reports a case of a man of 28, who was admitted to the hospital suffering
with a very large suppurative tonsillitis on the left side. After a warm
bath he was put to bed and given a glass of milk. Half an hour after-
ward a nurse in charge heard him coughing feebly and on investigating
found him cyanosed. Lyons was sent for and arrived in 5 or 6 minutes
only to find the patient dead. Autopsy showed that the abscess had
burst and that a large quantity of pus had gotten into the upper part of
the larynx.

New Instruments for the Removal of the Fauciai Tonsils. —
Charles M. Robertson^ describes a knife and scissors for the purpose of
complete removal of the fauciai tonsils. The knife is a double-edged
bistoury, curved on the flat, with a radius of 1 cm., a cutting edge of 2 cm.,
and with a dull point. The scissors are made in two sizes, for adults and
children, and are made rights and lefts. The advantages claimed for the
scissors are: (1) They allow of the removal of every part of the gland,
or any portion of it, as the operator may choose. (2) They are bent on
the long axis so that when fitted into place the handles are horizontal.
(3) They are made with a double joint so that the cutting edges can be
thrown wide apart, with little movement of the handles, allowing the
operation to be done in cases in which the jaws cannot be widely sepa-
rated. (4) The blades are curved enough to make it unnecessary to turn

* Lancet, Sept. 20, 1902. ^ Jour. Am. Med. Assoc, Nov. 1, 1902.

DISEASES OF THE TONSILS.

587

the scissors on their long axis, in cutting the lower portion of the gland.
(5) They enable the removal of small diseased tonsils which it is im-

Fig. 118. — Robertson's scissors (Jour. Am. Med. Assoc, Nov. 1, 1902).

Fig. 119. — Robertson's knife (Jour. Am. Med. Assoc., Nov. 1, 1902).

possible to remove with the tonsillotome. (6) The operator is enabled

to remove the entire gland with no injury to the pillars. (7) There

is not the soreness following the

operation that is so common in /^^^\

the use of the galvanocautery, hv*" ^^

and ear complications are not so

liable to occur.

A Modification of Farlow's
Tonsil Punch. — Emil Amberg^
describes a modification of Far-

Fig. 120. — Aniberg's modification of Farlow's
tonsil puncli.

Fig. 121. — W. Stuart-Low's anatomic tonsil
lotome.

low's instrument in which the jaws are oval instead of round (Fig. 120).

The advantage claimed for the oval shape is that when the space is

' The Phys. and Surgeon, Aug., 1902.

588

DISEASES OF THE NOSE, THROAT, AND EAR.

limited the blades can be employed to greater advantage than can those
which are round.

The Anatomic Tonsillotome. — W. Stuart-Low^ describes this in-
strument and claims that by its use the hypertrophied tonsil can be much
more completely^ excised and not merely clipped (Fig. 121). Another
advantage is that on account of the shape of the opening the lower part of
the tonsil is removed. The serration of the blade has a marked effect in
lessening hemorrhage, especially in adults, as the tonsil is lacerated rather
than sharply cut. A third feature is that the handle is not only massive
and molded to fit the fingers and the thumb, but is prolonged into a hook
at the end. The advantage of this is that the operator, by using the ulnar
side of the hand, has increased power for outward leverage and can thus
press the blade well over the base of the tonsil before driving it home.

The Tonsilsector. — A. B. Francis^ describes this instrument. The
advantages claimed are that it avoids the risk of wounding large vessels

Fig. 122. — Francis's tonsilsector.

Fig. 123. — Babei's tongue-depressor for exposing the tonsil.

incident to the use of the probe-pointed bistoury, and that it can be used
by one hand, leaving the other free. It consists essentially of a pair of
circular scissor-blades moving inside a circular guarding ring (Fig. 122).
A Tongue-depressor for Exposing the Tonsil. — C. Baber^ describes
a modification of Jaeniekc's instrument (Fig. 123) . It consists of an angu-

' Lancet, July 5, 1902. ^ Lancet, Mav 2, 1903.

3 Brit. Med. Jour., April 25, 1903.

DISEASES OF THE PHARYNX. • 589

lar depressor having on one side a small double blunt hook fixed at right
angles to the blade. It is reversible and by having a hook attached to both
blades can be used for either tonsil. By engaging the hook in the anterior
pillar or in the pUca triangularis and drawing it forward and outward
the surface of the tonsil and the opening of the supratonsillar fossa can
be fully exposed.

DISEASES OF THE PHARYNX.

Lithemic Nasopharyngitis and other Manifestations of Systemic
Disturbances. — J. A. Stucky/ in a paper read before the American
Laryngological, Rhinological, and Otological Society, said that consid-
ering the pharynx more especially a portion of the alimentary tract,
rather than of the respiratory tract, we can readily understand how it
might be influenced by the lithemic diathesis, as this has its origin in
the faulty metabolism occurring in the liver, or perhaps just as often to
autointoxication caused by the absorption of by-products from the intes-
tinal tract. He states that of the recent leading text-books on laryn-
gology and rhinology consulted, the views of Kyle more nearly corroborate
the clinical features in his observ^ations than any other. He further
defines the condition as an acute inflammatory or congestive process
caused by acid urates which have not been eliminated through the proper
channels. The excess being distributed to the structures specially con-
cerned in secretion and elimination, irritation of the superficial structures
follows; marked vascularity of the pharynx renders it particularly
susceptible, the position making it more disagreeable to the patient
because of the use of the muscles in swallowing. The local manifesta-
tions of the diathesis may not be confined to the pharynx alone, but may
also be manifested in affections of the laryngeal, nasal, and gastro-
intestinal tracts, without other constitutional symptoms. There may
be no distinct pathologic alteration, this being a local manifestation of
a systemic condition. The attack may come on gradually with slight
tendency to headaches, pain in muscles, especially the neck, or it may
be ushered in suddenly without apparent cause known to the patient;
when the latter is the case, the first symptom noticed is sensation of
fulness and accumulation in the throat, which is increased by swallowing,
attended with much discomfort, the throat having a rigid, stiff feeling,
hot, dry, and irritated. The systemic disturbances, as indicated by the
temperature, pulse, and inflammatory condition, are not sufficient to
account for the pain and discomfort. The primary cause of lithemic
pharyngitis, as well as many cases of spasmodic rhinitis or vasomotor
coryza, is internal, and the exciting factor in precipitating the acute
attack is not more frequently exposure to cold than to overindulgence
in eating and drinking. This fact is noticeable since, as a rule, the cases
are overfed and underworked and lead a sedentary life. A starving
man neither takes cold nor suffers from lithemic or rheumatic trouble.
Under treatment he directs attention to the systemic condition instead
' Trans. Amer. Larjnigol., Rhinol. and Otol. Soc, 1902.

590 DISEASES OF THE NOSE, THROAT, AND EAR.

of local. The production of increased metabolism by stimulating the
liver and regulating the action of the bowels, also the diet and habits of
the patient, not only will prevent the further formation and retention of
uric acid in excess, but will check the autointoxication from the intes-
tinal canal. The drugs indicated are those that will hjrperalkalinize the
blood and increase its solvency for urates. Subalkalinity of the blood
indicates diminished oxidation and consequently retarded nutrition,
both being favorable to the formation of uric acid in the body, as well as
to the growth of pathologic microorganisms, which favor autointoxica-
tion. Attention to the best hygienic principles, both with reference to
the care of the body and daily surroundings, is emphasized.

Cancer of the Tonsil, Pharynx, and Adjacent Parts. — G. Bend-
andi^ reports 5 cases upon which he had operated. He states that
primary cancer of the tonsils spreading to adjoining parts is rare, while
it is fairly common to see the condition arise in the pharynx and spread
to the tonsil, soft palate, tongue, and esophagus. In the author's cases
the anterior pillars of the fauces were involved, thus giving additional
space. The following method of operating was adopted : The patient's
head was extended as far as possible and Kocher's incision made in the
geniomastoid region. The tongue was then amputated and the incision
prolonged downward along the anterior margin of the sternomastoid
if the condition showed that the glands were infiltrated in that direction
or that the disease involved the laryngopharynx. The skin, super-
jBcial fascia, and platysma were raised, the superficial veins and the facial
artery tied, and the flap thus formed turned up and sutured to the zygoma.
The mandible was then cut at the level of the last false molar, disarticu-
lated without opening into the mouth, and resected. The lymph-glands
and connective tissue in the carotid groove and submaxillary fossa were
then removed. If the base of the tongue was then found to be involved,
the lingual artery was tied, and if it was found to extend to the lower
portion of the pharynx, the superior thyroid artery was tied. The
pharynx having been reached, the cancer was palpated, the mouth
opened, and the tumor removed by means of the Paquelin cautery.
After removal healthy tissues were sutured to the angles of the wound;
there was practically no deformity, and good ability to masticate re-
mained. In those cases in which the condition was so far advanced that
extirpation was impossible and the necessity for relief imperative, trache-
otomy was performed; and in some cases in which the pharynx was
blocked, a very low esophagotomy was resorted to. In the 5 cases re-
ported the growth was totally excised. In one there was favorable prog-
ress for 3 years, but death finally resulted from recurrence ; in the second
the patient died 5 days after operation, from cerebral hemorrhage ; in the
third the result is unknown because the patient did not return after
being discharged apparently cured; in the fourth the result was apparently
favorable, but in 3 years there was recurrence; and in the fifth recovery
was perfect, with no recurrence.

Keratosis of the Pharynx. — C. W. Richardson^ presents an ex-
1 Rif. Med., Feb. 18, 1903. ^ Am. Jour. Med. Sci., Oct., 1902.

DISEASES OF THE PHARYNX, ' 591

haustive paper on this subject. He takes the position, with Seibenmanh,
Brown-Kelly, Friedland, and Kyle, that there is a condition in the
pharynx which is a true keratosis, is entirely independent of the lepto-
thrix, and is often described as a phaiyngomycosis. The disease occurs
in several forms, the variation being due in part to the location of the
deposit and the age of the process. There may be minute pinpoint-
like, intensely white spots on a level with the mucous membrane of
which they seem to form a part; there may be broad, plaque-like, white
masses projecting above the surface of the mucous membrane and seen
most frequently on the pillars and lateral walls of the pharynx; or they
may be found as conical or triangle-like horny projections from the
mucous membrane protruding from 2 mm. to 8 mm. above its surface.
This last form is most frequently found on the faucial and lingual tonsils
and the epiglottis, and is the most frequent and most characteristic
lesion of the disease. The tufts are small, tough to horny in consistence,
and are firmly adherent to the mucosa, from which they can be separated
with difficulty, and when separated do not undergo disintegration ; after
being forcibly removed they are rapidly reproduced, while new tufts are
slow in growth. The firmest, hardest, and most elongated tufts are found
at the base of the tongue and the crypts of the tonsils. Those located
around the isthmus of the fauces are frequently found to be surrounded
with a soft pultaceous substance, which is usually absent from those
found at the base of the tongue and the pharynx. The most frequent
seat of the disease is Waldeyer's ring, and frequently the tonsil will be
found studded with a half dozen or more distinct tufts, while between the
pillars and the tonsil and at the upper fornix will be found a continued
chain, making almost a continuous white line. They are often found at
the base of the tongue and in typical forni, and also on the glossoepi-
glottic folds and in the corresponding fossas. They have also been
observed in the larynx, on the pharyngeal tonsil, in the nasal chamber,
on the conjunctiva at the inner can thus, and in one case pervaded the
whole upper air-tract. While they are stated to vary in color from white
to yellow, in all the cases seen by Richardson the spots had a distinctly
pearly, clear white appearance. The disease usually occurs in those of
early adult life, of robust constitution, and unassociated with any con-
stitutional disorders. It is most frequently found in the female sex, and
heredity, occupation, and general environment seem to have no etiologic
influence. Most of the cases occur in the well-to-do; climatic conditions
and season seem to have no effect. It is possible that local morbid
changes in the tonsil affect the production or the course of the disease.
The symptoms complained of are a sensation of scratching, prick-
ing, or stiffness about the region of the fauces, more or less difficulty
in swallowing, the sensation of the presence of a foreign body, more
or less hawking or cough, and vocal fatigue. The disease sometimes
shows a tendency to spontaneous resolution, which may occur in from
a few months to several years. In studying the pathology of this con-
dition unsuccessful attempts at inoculation have been made. Seiben-
mann's investigations showed the masses to be made up of a central narrow

592 DISEASES OF THE NOSE, THROAT, AND EAR.

lumen containing bacteria, detritus, and mucus surrounded by an epi-
thelial wall composed partly of layers of hardened, unnucleated epithelial
cells and partially of a homogeneous horny substance; on the outer sur-
face of the quills which projected from the crypts were bundles of lepto-
thrix, and in the neighborhood there was absence of every evidence of in-
flammation. His conclusion was that the process is an unusually intense
cornification of the lacunar epithelium which terminates in quill-formation
and that the presence of the leptothrix was incidental only. On account
of the discovery of subepithelial buds and the absolute demonstration of
the epithelial formation of the quill, which show the manifestation of
spores only on the outer surface, Seibenmann considers the question
settled, and considers that the name of the condition should be changed
to "hyperkeratosis lacunaris." Kelly agrees with Seibenmann and
holds that the disease known as mycosis leptothricia is really a keratosis,
that it is more extensive than Seibenmann describes, and suggests the
more adequate term of ''keratosis pharyngea." He describes leptothrix
filaments in the center of the masses removed from the tonsils and tongue
also as present in smaller numbers than those obtained from the pharyn-
geal wall and entirely absent in the excrescences taken from the naso-
pharynx. He also describes the excrescences removed from the naso-
pharynx as being identical in their histologic characters with those re-
moved from the tonsils and pharynx. It is found that the leptothrix
deposit is most pronounced where the greatest abundance of epithelial
cells exists, and this fact, independent of the histologic change, is the
strongest point in favor of the nonleptothricial origin of the disease. An-
other point is the apparent subepithelial origin of the keratoid masses.
Kyle has demonstrated, along this line, the presence of a peculiar fibrous
band which, extending from the subepithelial structures, penetrates and
obliterates the basement membrane, extends out over the epithelial sur-
face, and maintains its connection with the subepithelial structures from
which it obtains its nutritive supply. The conclusion seems justifiable
that there is a keratosis of the faucial and pharyngeal mucous membrane
in the condition commonly called pharyngomycosis, and it is probable
that the changes begin in subepithelial tissue. There seems to be no
doubt that the change is identical whether it appears in the nasopharynx,
oropharynx, or fauces, and that the leptothrix is not a constant factor,
but accidental and bearing no causative relation to the structural changes.
It is probable that there is a condition occurring in the pharynx of the
young and the aged which is attended with the presence of the lepto-
thrix and is a true mycosis.

Acute Gout of the Pharynx. — M. Lermoyez and G. Gassne^ describe
a case in which a sudden, violent sore-throat, lasting several days, with
inflammation simulating peritonsillar abscess, suddenly subsided into a
first attack of typical gout in the great toe of the opposite side. Mani-
festations of true gout can be differentiated from periamygdalitis by their
sudden onset, acute evolution, instantaneous subsidence, violent fever,
intense local pain altogether disproportionate to the apparent lesion, the
' Ann. des Mai. de I'Oreille, du Larynx, etc., May, 1902.

DISEASES OF THE PHARYNX. ' 593

tendency of the inflammation to extend to all portions of the pharynx, the
fluxionary character of the lesions which give the throat a somber red
color, the edematous aspects, the absence of exudation, and the non-
involvement of the submaxillary glands.

Primary Epithelioma of the Uvula and Soft Palate and Treat-
ment with the Rontgen Rays: Report of a Case. — J. F. McCaw^ re-
ports a case of great interest. His patient was a woman of 37, a house-
wife, with a negative family history. There were slight irritation and
soreness of the throat 8 months previous to examination, and soon two
or three small ulcerated surfaces were noticed on the soft palate which
seemed to improve under treatment by the family physician. About 6
weeks before McCaw saw her the soft palate at the site of these ulcera-
tions began to enlarge rapidly; this was soon followed by dysphagia
pain which was worse at night, muffled intonation, and soreness in the
cervical muscles of the left side. Examination revealed a mass involv-
ing the uvula, soft palate, both posterior faucial pillars, the right lateral
wall, and a portion of the posterior wall of the pharynx. It was of
Irregular, nodulated outline, had an ulcerated and necrotic surface, and
was dense and almost cartilaginous in consistency. There were stiffness
and soreness of the neck-muscles, but no glandular involvement. There
had been some loss of flesh, but the patient's general condition was good.
Examination of a small excised portion proved it to be an epithelioma.
Under ether as much as possible of the growth was excised from the soft
palate and posterior pillars with the electrocautery knife and the ulcerated
areas on the pharyngeal wall vigorously curetted and thoroughly cauter-
ized. At the end of 4 or 5 days the eschars began to separate and cica-
trization to appear. After the lapse of 2 weeks, when the reaction follow-
ing the operation subsided, the application of the Rontgen rays was
begun. A double anode, extra large improved German tube of moderate
vacuum was used, excited by a static current from a machine composed
of eight 30-inch revolving plates run as rapidly as safety would permit.
For the purpose of protection the lower part of the face, the inside of the
mouth, and the tongue were covered with a specially devised apparatus
composed of sheets of block tin. The tube was adjusted as close to the
mouth as possible, while the upper part of the face was covered with a
sheet of heavy tin-foil, in spite of which there was some tanning of the
nose and forehead and a slight conjunctivitis. The treatments were
given 3 times a week for 7 weeks and varied in length from 10 to 15 min-
utes. At the end of the first week the soreness was almost entirely gone,
and at the end of the second the healthy part of the fauces began to show
more redness and a network of veins could be seen where the most direct
rays came in contact with the mucous membrane. The diseased areas were
in a condition of healthy cicatrization, and the only unpleasant symptoms
complained of were a peculiar smarting in the throat and the feeling of
dizziness and fulness in the head which followed treatment and kept her
awake most of the night. At the end of 5 weeks a direct inspection
showed that the throat was entirely healed, but examination with the
' N. Y. Med. Jour., Aug. 9, 1902.

594 DISEASES OF THE NOSE, THROAT, AND EAR.

mirror revealed an unhealed area on the upper surface of the soft palate.
The rays were directed against the palate and healing was much slower
than when the diseased parts were in the immediate path of the rays.
At the end of 7 weeks only one small pea-sized area was unhealed. The
patient stopped treatment for 3 w'eeks, at the end of which time there
was marked increase of the ulceration and infiltration of the palate
with extension to the right lateral and posterior pharyngeal wall. Under
chloroform this growth was curetted and cauterized with the electric
cautery, and a portion of the growth on examination confirmed the pre-
\dous diagnosis. In this specimen, unlike the first, there was evidence
of very rapid colloid degeneration of the epithelial cells. Treatment
with the Rontgen rays was continued for 5 weeks, 3 times a week, with
20-minute seances, and following that once a week; The last examina-
tion of the patient showed that the ulcerated surfaces were entirely healed,
the amount of scar-tissue almost unnoticeable, and the slight degree of
contraction of the velum that had been present had disappeared. There
was nowhere to be seen any evidence of further infiltration.

Direct Endoscopy of the Upper Air-passages and Esophagus;
Its Diagnostic and Therapeutic Value in the Search for and Re-
moval of Foreign Bodies. — Gustavo KiUian^ demonstrates the advan-
tages of a wider application of Kirstein's autoscope to the extent of ob-
taining a direct view of the air-passages and esophagus without injuring
them. He claims that neither the olive-shaped bougie nor the skiagraph
is invariably reliable, because in the case of a foreign body in the anterior
wall of the esophagus the former may slip past it along the posterior wall,
while in using the latter the shadow of the foreign body may be obscured
by the shadow of the vertebras or heart, or be absent entirely. In using
direct esophagoscopy cocain-anesthesia is frequently sufficient, while
in children and nervous individuals general anesthesia may be necessary.
The head is thrown backward and the tongue and epiglottis drawn for-
ward by a Kirstein spatula, while the parts are illuminated by the head-
light; when a general anesthetic has been administered in children, the
head should be drawn over the end of the table. In removing foreign
bodies from the trachea Killian uses a straight tube sufficiently wide and
long to pass through the glottis, and by this means is independent of the
pharyngeal and laryngeal reflexes, and foreign bodies are readily dis-
covered and extracted. When tracheotomy has been required and the
foreign body not ejected, a short, straight tube can be inserted through
the wound, the trachea cocainized, and the bronchi inspected. For this
purpose and method of extracting foreign bodies a good view, great care,
and stillness of the patient are necessary; the most valuable instruments
are slender tubular forceps and blunt hooks. Of 15 cases with operation
for the removal of foreign bodies from the bronchi by the aid of bronchos-
copy, 13 were successful and 2 unsuccessful. In only 1 of the 13 was
there a subsequent fatal result, death occurring in this case 9 months
afterward from empyema upon the healthy side.

Acute General Infections Originating in the Lymphoid Tissue
1 Jour. Lar., Rhin., and Otol., Sept., 1902.

DISEASES OF THE PHARYNX. ' 595

of the upper Air-tract. — Discussion at the twenty-fourth Annual Con-
gress of the American Laryngological Association/ J, L. Goodale, in
reviewing the pathology of the tonsil, stated that finely divided sub-
stances in the crypts of the tonsil can enter the tonsils proper through the
interfollicular lymph-spaces. He found a complete absence of bacteria
in the tonsillar tissue proper, although there might be large numbers of
them in the crypts. He disagreed with the common statement that the
leukocytes found in the tonsils are phagocytes, and does not regard the
tonsils as protective organs in the sense of themselves producing phago-
cytic leukocytes, but rather as affording open channels along which poly-
nuclear leukocytes pass from the bloodvessels over the surface of the
mucous membrane. The number of leukocytes in the crypts is found to
depend directly upon the presence of substances with positive chemotaxic
properties. Acute infecting bacteria multiply in the proper tonsillar
tissue only after penetration into the centers of the follicles has been
effected. If the interfollicular abscesses discharge into the veins, the
conditions are favorable to the development of a general septicemic
condition.

H. L. Swain, in discussing the symptoms and treatment of tonsillar
infection, emphasized the fact that this region is an active portion of the
lymphatic system. Lymph-nodes are normally places of detention where
cells are quarantined and the lymph cleansed. The fact that the pro-
found constitutional disturbance is associated with acute inflammation of
this part of the lymphatic system is explained by the more direct con-
nection of the faucial and pharyngeal tonsil with the lymphatic trunks
and by their much greater mass. The tonsils are now conceived to be
the point of entrance of the germs causing acute articular rheumatism,
and in one of his cases acute Hodgkin's disease and lymphadenoma had
originated from the tonsil. In very young chiklren inflammation of the
third tonsil predominated, and in those from 3 to 6 years of age results
of inflammation of the tonsil were likely to be lasting. Frequently such
an attack will begin with fever and with practically no local symptoms
except slight nasal stoj^page. After a few days of fever, headache, and
foul breath the attack often passed off, the examinations of the physician
having revealed nothing. Or, perhaps in a few days the neck would
swell, the child wo\ild become decidedly ill, and the diagnosis of lymph-
adenitis made. The interest in these cases lies in the absence of marked
local manifestations ; but even in young children it is usually possible, by
spraying the nose with weak cocain solution, to inspect and accurately
estimate the condition and size of the pharyngeal tonsils. Friedlander
has reported that in 133 autopsies at the New York Foundling Hospital
tuberculous lymph-nodes were found in the chest in every case irrespec-
tive of the cause of death, and infection was believed to have originated
in the tonsils. The tonsils should be looked upon as being just as normal
as any other lymph-node, but if infected or otherwise abnormal, they
should be removed. In the treatment of inflammations of the pharyngeal
tonsil the instillation of boric acid and suprarenal solution is of value,
' Med. Rec, July 19, 1902.

596 DISEASES OF THE NOSE, THROAT, AND EAR.

as both opening up the passages and cleansing them. A weak solution of
hydrogen dioxid is sometimes beneficial, but prolonged use is likely to be
followed by irritation, and its use should in every instance be followed by
an alkaline spray or wash.

E. L. Shurly stated his belief that the tonsils had an important phy-
siologic function in assisting the fermentation of food lodged there and
in the destruction of saprophytic organisms located there.

As regards the normal size of the tonsil, R. C. Myles stated that it
represented from 30 to 60 cu. mm.

C. C. Rice deprecated the use of such astringent applications to
the inflamed tonsil as silver nitrate because they aided inward progress
of infection, preferring soothing disinfectants and relaxing gargles.

W. E. Casselberry suggested, in treating young children, that the
medicine dropper should be substituted for the spray, as the in-
stantaneous propulsion of a httle fluid with the dropper was quite effective
and could be more readily used. For the purpose of diagnosis he advised
using a solution of cocain as weak as 0.1 %.

Samuel Johnston advised commencing the treatment by a calomel
purge followed by citrate of magnesia. As a gargle he suggested dis-
solving in a tumbler of hot water a saltspoonful of the powder composed
of 2h drams (10.0) each of the biborate, bicarbonate, and salicylate
of soda, 4 grains (0.24) of carbolic acid, and 4 minims (0.24) of oil of
cassia, to be used every half hour or hour. Cases of acute follicular
tonsillitis usually succumb to this disease in 3 days.

W. K. Simpson stated that acute follicular tonsillitis was self-limited
and practically unaffected by treatment.

Emil Mayer deprecated the introduction of the finger into the naso-
pharynx either for curetting or for diagnostic purposes, stating that the
presence of adenoid tissue on the posterior wall of the pharynx was
almost positive evidence of adenoid tissue in the nasopharynx.

E. Fletcher Ingals believed it possible to abort acute follicular
tonsillitis by the application of a solution of equal parts of guaiacol and
oil. The severe burning lasts for about half a minute and is then usually
followed by complete relief from pain, which lasts for many hours. This
method of treatment aborts about three-fourths of the cases, and even
after the disease has existed for 3 or 4 days is worthy of trial.

Tumor of the Pharynx ; an Accessory Thyroid Gland ; Removal
Followed by Myxedema. — E. L. Shurly^ reports a case of a girl of 16,
apparently well nourished and with normal thyroid gland. Attached
at the base of the tongue, near the epiglottis and a little to the right
of the median line, was a tumor about the size of a hen's egg, which was
diagnosed as adenoma. It was removed under chloroform by means
of a snare and the operation was followed by rather persistent hemor-
rhage. Subsequently she returned with well-marked mjrxedema and was
put upon thyroid extract, 5 grains (0.3 gm.) three times daily. Of about
25 cases of accessory thyroid of the tongue or pharynx reported by
American surgeons, in all there has been an absence of serious subse-
1 Med. Rec, July 19, 1902.

DISEASES OF THE LARYNX AND TRACHEA. • 597

quent subjective or objective symptoms and myxedema had been noted
only rarely after removal. ■

An Outbreak of Septic Sore Throat Caused by Milk. — ^W. Gifford
Nash^ reports the occurrence of 42 cases, occurring in 22 families, of
cases of sore throat, cultures from which showed the presence of staphylo-
cocci and Streptococcus brevis. The disease is characterized by a large
amount of swelling of the tonsils, fauces, palate, uvula, and, in many
cases, the pharynx. The affected areas were bright red in color and on
the tonsils there were present numerous patches of exudation. In a
number of the cases there were distinct points of ulceration on the tonsils
and fauces which gave rise to considerable dysphagia. The tongue was
dirty, and in some instances there were associated gastrointestinal dis-
turbances. The general symptoms resembled those of influenza, includ-
ing great weakness, and in many instances the persistence of marked
debility for several weeks after the subsidence of the acute sjonptoms.
In one case there was a peritonsillar phlegmon. It was found that all
the patients affected obtained their milk from the same dairy, and that
those who obtained their milk from other dairies had no such trouble.
Investigation of the hygienic conditions of the bams, cowsheds, milk cans,
etc., showed that apparently the usual precautions as to cleanliness were
observed, although when the farmer was asked what was done with milk
from cows with sore udders the answer given was that it was put through
the separator, which was supposed to filter the milk and remove tubercle
and other disease germs.

DISEASES OF THE LARYNX AND TRACHEA.

Pachydermia and Carcinoma Laryngis. — B. FriinkeP describes
the case of a man who came to him in March, 1897, suffering from what
seemed to be a simple pachydermia of the pharynx. When again seen
in July of the same year, a marked alteration having taken place, a
section was removed for examination, which showed a condition closely
simulating carcinoma. He then decided to operate and the diseased
tissue was removed endolaryngeally. Following this it was found that
other operative procedures were necessary in order to remove all the
diseased tissue, the last being done in March, 1898, when only granulation-
tissue was found. When last seen in 1902, he was found to be perfectly
well. The vocal cord removed was cut in series showing the transition
from pachydermia to true carcinoma, which was illustrated by drawings.
The outline of the basement membrane can be followed through the
earlier sections with the epithelium growing gradually thicker, till finally
the dividing line is lost and the epithelium is found within the connective
tissue. This is of interest, since it commenced as pachydermia, during
which stage it was seen before it was a definite tumor and was watched
in its development; also in the fact that no recurrence has been observed
up to date, a period of 4^ years ; and lastly in the complete microscopic
examination with its accompanying series of sections.

' Lancet, Oct. 18, 1902. * Arch. f. Laryng., Bd. 13, 1902.

o98 DISEASES OF THE NOSE, THROAT, AND EAR.

Laryngeal Stenosis. — J. Price-Brown^ states that stenosis when
apphed to the larynx implies an amount of constriction within the cavity
itself sufficient to interfere with respiration. This interference may or
may not be sufficient to endanger life. A very large majority of the cases
of laryngeal stenosis which occur are due to conditions arising within
the larynx. The minority owe their origin to pressure from without,
occasioned by external pathologic conditions. The stenosis may be
variable in degree and in duration; the conditions being in some cases
temporary, in others permanent, or until relieved by medical or surgical
measures. Stenosis of the larynx may be either congenital or acquired.
The large majority of cases are of the latter character; while the former
or prenatal is exceedingly rare — so rare that in the Museum of the Royal
College of Surgeons, London, no specimen can be found. Congenital
stenosis : Nevertheless, the following forms of this condition may be
occasionally found: (1) Congenital syphilitic stenosis, as in the case re-
ported by Frankel; (2) vestibular stenosis, caused by the pressure of limp
and collapsible walls; (3) diaphragmatic or web stenosis. This is the
most common variety of this very rare condition. The usual attachment
of the prenatal web is between the anterior ends of the vocal cords, and
this diaphragm may extend various distances backward, until, as in Sir
Felix Semon's case, the passage is almost occluded. The congenital de-
formities of the posterior commissure are usually in the form of bifurca-
tions or dilations. Acquired stenosis may be classed according to its
cause, and may be the result of a large number of different pathologic
conditions. The situation may be above, between, or beneath the vocal
cords, or in two or all three localities combined. Wherever located,
respiration becomes involved, and the act of inspiration is usually more
affected than expiration. Except in cases of acute spasm, the onset is
usually gradual. One characteristic symptom, common to all cases of
laryngeal stenosis, is the increase of dyspnea during the hours of sleep,
owing to the fact that the cricoarytenoidei postici muscles, the dilators,
are withdrawn during that period from the control of the will. While the
existence of laryngeal stenosis may be easily diagnosed, to ascertain the
nature of the lesion which produces it is sometimes very difficult. If the
stenosis arises from contractions or adhesions, this may be discovered by
the use of the laryngoscope; but when edema is present, the cause of it
is more difficult to ascertain. The principal pathologic conditions which
produce laryngeal stenosis are the following: Neuroses, acute functional,
chronic functional, and organic. Acute functional neurosis is the form of
spasm of the cricoarytenoidei lateralis and the arytenoideus and is of fre-
quent occurrence in child life. It is usually caused by inflammatory
action in the respiratory tract, or as a reflex from some irritated portion
of the alimentary canal. The classical laryngismus stridulus or spas-
modic group is of this nature and is rarely fatal. Still, in rickety children,
the purely reflex spasm has in some instances proved immediately fatal.
Chronic functional neurosis occasioning laryngeal stenosis is a condition
of paresis of the recurrent nerve occasioned, it is supposed, by toxic
^ Ann. of Otol., Rhinol., and Laryngol., Aug., 1902.

DISEASES OF THE LARYNX AND TRACHEA. . 599

influence upon the nerve-centers. Organic neurosis of the larynx occa-
sions stenosis primarily by inducing paralysis of the abductor muscles.
That they are more vulnerable to organic nerve-lesion than the adductors
is generally conceded, and Semon lays it down as a law that paralysis
of the adductor muscle is always secondary to paralysis of the abductor.
A contribution to the study of toxic paralysis of the larynx, bearing
upon stenosis, is given by Heymann. It is a resume taken from fifty
papers on the subject. Lead-poisoning is responsible for a majority of
these cases. There are also instances of paralysis arising from the pres-
ence of copper, antimony, phosphorus, arsenic, cannabis indica, atropin,
morphin, and alcohol. In nearly all these instances the abductor muscles
were in the main affected. Edema, acute and chronic : Acute edema of
the larynx, although a rare condition, always gives rise to laryngeal
stenosis. It is sudden in development, and may be occasioned by frac-
tures of the cartilages, inhalation of irritating vapors, escharotics, etc.,
and even by sudden variations of circulation and external temperature.
Chronic edema of the larynx is usually secondary to some other laryngeal
condition, such as the pressure of perichondrial abscess, syphilis, carci-
noma, tuberculosis, myxedema, syringomyelia, Bright's disease, phleg-
mon of peritonsillar tissue, lupus, etc. Pseudomembranous stenosis is of
frequent occurrence, usually taking the form of laryngeal diphtheria.
Inferior chorditis hypertrophica of Gerhardt, being a condition of sub-
glottic hypertrophy, may be productive of a serious degree of laryngeal
stenosis, as likewise may the chronic blennorrhea of Stoerck, and also
that rare disease rhinoscleroma. Leprosy of the larynx is always at-
tended by stenosis. Phineas Abraham reports a case in which the lumen
of the glottis was reduced to the size of a duck-quill, necessitating trache-
otomy to prolong the life of the patient. Glanders, like syphilis, after
destruction of normal intralaryngeal tissue, may produce severe stenosis
by the inevitable cicatrization which follows. Gout is reported in several
instances to have produced severe stenosis by causing spasms. Benign
tumors, when intralaryngeal, sometimes occasion severe and dangerous
stenosis. Papillomas are the most frequent, and when multiple the
symptoms of stenosis are likely to be severe. This is more frequently
the case in children than in adults. It takes a larger growth to produce
stenosis in the supraglottic than in the infraglottic region; while tumors
situated on the vocal cords are particularly liable to produce spasm and
cough. Malignant tumors of the larynx produce stenosis in a similar
manner to the benign, but in an aggravated degree, owing to the systemic
cachexia and its increased pain. Foreign bodies within the larynx pro-
duce stenosis, not only from space limitation, but also from reflex spasm
and inflammatory action, which they are likely to induce. Laryngeal
stenosis may also arise from external pressure. The most common cause
is probably goiter, particularly when the isthmus is materially enlarged.
Abscess of the neck, enlarged scrofulous glands, and neoplasms in the
region of the larynx might also be mentioned as exciting causes.

Rapid Dilation and the Prolonged Use of Intubation-tubes in
Stenosis and in Cicatricial Occlusion of the Larynx. — J. Payson

600 DISEASES OF THE NOSE, THROAT, AND EAR.

Clark^ reports 2 interesting and somewhat rare cases of rapid dilation of
cicatricial and stenosed larynges. The first was that of a young man
with a cicatricial stenosis of the larynx resulting from syphilis, which
obliged the wearing of a tracheotomy-tube. The interest of this case lies
in the method employed to dilate the stenosis. This consisted in passing
female urethral sounds (under general anesthesia) through the tracheal
opening and through the stricture. A full-sized intubation-tube was then
introduced in the usual way. Unfortunately, after coughing this out one
day the patient refused further treatment and the tube had to be rein-
serted. The second case was one of complete cicatricial occlusion of the
larynx following diphtheria in a child 5 years old. The cicatrices in the
trachea and larynx were divided or stretched under general anesthesia
and an 8-10 intubation- tube introduced. The child wore this tube or
the size larger with occasional intermissions for nearly a year. Since
its removal, over a year, she has breathed naturally and there has been
no recurrence of the stenosis.

Myxoma of the Larynx. — P. Delobel^ reports a case interesting on
account of the size of the growth and the ease of its removal. It filled
the entire space of the glottis and completely concealed the vocal cords
even on deep inspiration. Oscillation during respiration seemed to indi-
cate attachment by pedicle, apparently in the region of the arytenoids.
This was confirmed during the operation, for the mass was easily separated
and extracted with Schroetter's forceps. The postoperative treatment
consisted in the application of silver nitrate to the remains of the pedicle
and the use of cold gargles and the sucking of ice. All symptoms disap-
peared within 4 days, and at the end of 2 months no evidence of the
growth could be seen.

Hysteric Edema of the Larynx. — Galzin^ describes a case of laryn-
geal edema coming on suddenly and associated with marked dyspnea,
which under inhalations of steam and compound tincture of benzoin
improved. The patient was a soldier, aged 21, of neurotic ancestry,
with a history of attacks of colic with vomiting and constipation. He
had also had swellings of the extremities. No cause for the attack could
be found, but on the third day a subaponeurotic swelling appeared on
his arm which proved to be an area of congestive edema. This suggested
a hysteric origin for the trouble, and this probability was confirmed by
the presence of cutaneous dysesthesia and the absence of the knee-jerks
and the conjunctival reflex. There were other similar swellings in the
body, and at no time was there any fever. The attack was repeated 7
months later without any apparent cause, and recovery was rapid.

Cancer of the Larynx Cured by the X-ray. — W. Scheppegrell*
reports a complete cure of a case of carcinoma of the larynx, in the
treatment of which rc-rays alone were used. The growth involved the
left laryngeal wall and vocal cord. High-tension Tesla coil was employed,
and in order to gain penetration a tube with a medium vacuum. The face

' Laryngoscope, Nov., 1902. ' Jour. Sci. Med. de Lille, Nov. 15, 1902.

3 Arch, de Med. et de Pharm. Militaires. Sept., 1902.
* N. Y. Med. Jour., Dec. 6, 1902.

DISEASES OF THE LARYNX AND TRACHEA.

601

and chest were thoroughly protected, but the neck was freely exposed
in order that any involved glands might be influenced by the treatment.
At first the anticathode was placed 15 inches from the neck, but this
was subsequently reduced to 7. The treatment was daily for a period
of 20 days and lasted for 10 minutes at each sitting. The anticathode
was brought to a dull red heat and the same degree of vacuum was main-
tained throughout the course of the treatment. At the end of 3 weeks
congestion seemed to be more marked and the tumor was unchanged,
but at no time did dermatitis develop, and after the second exposure
pain disappeared. About 10 days after the cessation of treatment it
was found that the tumor and most of the symptoms had disappeared;
treatment thereupon was resumed and carried on for 10 days, by which
time the ulceration had healed. The patient was in good condition 3
months later, and the aphonia due to loss of tissue of the left cord had
been partly overcome by compensatory overaction of the right cord.

Syphilis of the Larynx. — Charles M. Robertson^ reviews the symp-
tomatology, diagnosis, and treatment of this condition, and tabulates
diagnosis from carcinoma and tubercle as follows :

Syphius.
Pain usually slight.

Attacks any portion of
larynx and ulcerates
very rapidly.

Rarely seen in the stage
of induration. First
evidence usually a clear-
cut, deep ulcer.

Some induration around
the ulcer, but usually
very little edema.

Ulcer extends deeply,
often involving carti-
lage.

Surface of ulcer covered
with mucopurulent
secretion and necrotic
tissue.

Mucous membrane hyper-
emic and injected.

Laryngeal stenosis not
common till cicatriza-
tion occurs.

General health unim-
paired.

Frequently evidences of
syphilis in other tis-

Rapidly improves under
iodids.

Carcinoma.

Pain constant, lancinat-
ing.

Attacks any portion of
larynx and ulcerates
more slowly than sypli-
ilis.

First appearance is that
of a new-growth occu-
pying the laryngeal
cavity, no clear-cut ul-
cer.

The growth fills or en-
croaches on the larjm-
geal cavity.

Growth extends in all
directions, involving all
tissues in its course.

Surface of growth covered
by discharge.

Mucous membrane hyper-
emic.

Laryngeal stenosis com-
mon.

Early in the disease no
impairment of general
health; later a marked
cachexia.

In primary laryngeal car-
cinoma no other in-
volvement until later
in the disease.
'Not influenced by iodids.

Tubercle.

Pain severe on degluti-
tion.

Favorite site is the inter-
arytenoid space or the
base of the arytenoid
cartilages; ulcerates
slowly.

Usually the first appear-
ances are small spots of
induration which spread
rapidly, followed by
great edema.

Great edema of the ary-
tenoids.

Ulcer extends laterally,
but not deeply.

Surface of ulcer covered
with thick mucopuru-
lent secretion and ag-
glutinated mucus.

Mucous membrane pale.

Ivaryngeal stenosis rarely
occurs.

Health impaired previous
to laryngeal involve-
ment.

Previous and coincident
pulmonary trouble
common.

Not influenced by iodids.

39 S

'■ Jour. Am. Med. Assoc, Jan. 17, 1903.

602 DISEASES OF THE NOSE, THROAT, AND EAR.

Subglottic Sarcoma Removed Endolaryngeally with the Galvano-
cautery Snare. — J. W. Gleitsmann^ reports a case of a man of 52, whose
occupation necessitated his being constantly in the open air, and who
gave the history of pneumonia, moderate drinking, heavy smoking, and
negative history of gonorrhea and syphihs. He complained of rather
sudden onset of hoarseness on awaking one morning about 4 months
previously. He suffered from a severe dry laryngeal cough with occa-
sionally a little hemoptysis. There was no pain, no dysphagia, some
slight dyspnea on exertion . He lost 25 pounds and his voice could not
be raised above a whisper ; otherwise his functions were normal. Laryn-
goscopic examination, which was easily performed, showed that the
larynx was normal except for slight congestion of the cords, both of
which moved and approximated sufficiently to produce sound, which,
however, was not forthcoming. This was due to the presence of a growth
below the cords, which by contact with their lower surface interfered
with their vibration sufficiently to prevent voice-production. The tumor
filled the larger part of the tracheal lumen, leaving only a small posterior
opening for respiration. Its size appeared to be that of a small walnut,
and its surface was uneven and its density and compactness considerable.
There was no enlargement of the cervical lymph-glands. Its attachment
was evidently anterior and at the upper end of the trachea. It was
decided to attempt removal through the larynx and the following con-
siderations were borne in mind: (1) The possibility of lateral adhesions,
which would make an encircling of the tumor by the snare wire an im-
possibility. This was eliminated by thorough cocainization and explora-
tion. (2) The question whether the apparent density extended through
the whole tumor mass and the possibility of the separation and falling
into the trachea of a fragile portion. (3) The possibility of hemorrhage
in spite of the apparent nonvascularity of the growth. (4) The technical
difficulty of introducing through the glottis a sufficiently wide loop and
carrying it deep enough to slip over the lower surface of the growth.
(5) Great care had to be exercised, after the tumor had been strangulated
off, that it could be extracted through the glottis without slipping from
the snare. Preparations for a tracheotomy were made before the laryn-
geal operation was done. None of the anticipated possible difficulties
was met, and the operation was found to be simple, easy, and completely
successful. Several applications of cocain and adrenalin were made to
the larynx and trachea, and a length of shank and a size and shape
of the cautery loop necessary were determined. Schech's handle and can-
nula and iridoplatinum wire were used. The loop was tightened slowly
and the tumor extracted without difficulty, the base being immediately
thoroughly cauterized. The tumor on examination proved to be partly
small and large round-celled sarcoma, partly myxosarcoma, and partly
commencing alveolar in structure. A small remaining stump was re-
moved 3 weeks after the original operation and the base again cauterized.
Examination 5 months later showed nothing abnormal. The patient's
voice was as strong as originally, except for slight huskiness, and the

^ Med. Rec, July 5, 1902.

MISCELLANEOUS.

603

laryngeal structures had evidently been entirely uninjured by the two
operations and by the presence of the heated wire so close to the under
surface of the cords.

An Improved Syringe for Intratracheal Medication. — P. S. Don-
nellan* describes a syringe which consists of a graduated annealed glass
barrel of 2 drams (8.0 cc.) capacity. The barrel contains a glass piston
with an asbestos plunger at one end and a thumb-ring at the other. At
the thumb end of the barrel is a detachable metal collar with rings for
the insertion of the index and middle fingers. The cannula is metallic,
bent at a right angle, and has an olive-shaped closed tip with four fine

lateral openings, the advantage
of which is that they prevent too
free discharge of the injection
material and consequent cough-
ing (Fig. 124).

MISCELLANEOUS.

A New Form of Nasal Truss.
— W. J. Walsham,^ to obviate the
difficulty heretofore experienced
of the forehead plate of a nasal
truss slipping from side to side

Fig. 124. — Donriellan's syringe for intratracheal
mcdicutiou.

Fig. 125. — Walsham's nasal truss.

and upward over the forehead, has designed the one herein illustrated,
making the lower border of the forehead plate follow the contour of
the root of the nose and contiguous orbital margins. A rounded
notch (A) corresponding with the root of the nose is cut in the
plate and the margins of the lower part of the plate forming the sides
of the notch are bent backward in a blunt curve (BB), to almost a
right angle to the rest of the plate. The notch therefore embraces the

' Phila. Med. Jour., Feb. 7, 1903. ' Lancet, Jan. 24, 1903.

604 DISEASES OF THE NOSE, THROAT, AND EAR.

root of the nose, while the turned-back portions of the margins of the
plates catch under the orbital ridges at the internal angular processes
of the orbits. This prevents the truss from being displaced upward,
while the notch prevents any movement from side to side. The truss is
provided with the usual straps and head-band, and to the plate are fixed
the usual arms for making pressure upon, and fixing, the nasal bones or
cartilages (see Fig. 125).

Self-retaining Tongue-depressor. — H. P. Mosher^ describes an
apparatus which will retain the tongue in position during operations on
the throat. It consists essentially of a spring, one end of which presses
on the tongue and the other on the under surface of the chin. It is
adjusted and removed on the principle of any spring-clasp. Mosher
claims that by having the chin-piece pivoted so that it can catch on the
side of the chin it is possible to hold down the edge as well as the center.

Fig. 126.— Mosber's self-retaining tongue depressor, side view. Fig. 127. — Mosher's self-retaining

To open, press on the two finger-plates. tongue depressor. This cut shows the

pivoting of the chin-piece, so that it can
be placed at an angle in order to catch
on the side of the chin.

The blades are of different sizes and interchangeable (see Figs. 126, 127).
[This is an admirable instrument for operations under anesthesia, but is
not so practicable for office work.]

Some Points in Rhinologic Terminology. — George Fetterolf^ sug-
gests, with a view to the clarification of certain terms and the avoidance
of redundancy in others, that the following usage be adopted: "Tonsil-
lotomy" to mean incision into the tonsil and "tonsillectomy" to mean
removal of the tonsil, and to be modified by the words partial or complete
according to the operation performed. "Turbinate" to apply only to
the bone, and the word " epiturbinate " to apply to the soft tissue cover-
ing the bone, and the word " panturbinate " to the entire structure, both
bone and soft tissue. "Osteoseptum" to indicate the bony portion of
the septum, " chondroseptum" the cartilaginous portion, and "pansep-
tum" the entire septum.

' Boston M. and S. Jour., Aug. 7, 1902. ^ Amer. Med., Oct. 25, 1902.

miscp:llaneous. • 605

A Case of Nasal Vertigo Simulating Epilepsy. — Edward Woakes^
reports the case of a man, aged 40, who came to the Ear Department of
the London Hospital with the statement of having frequent "fits," which
according to his description seemed to be epileptiform in character. On
examination there was marked hypertrophy of the middle turbinated
bones, particularly on the right side. On being sent to a general hospital
and admitted as a medical patient the nasal condition was dissociated
from the symptoms, and the fits, regarded as epileptic, were referred to an
attack of sunstroke from which he had suffered 15 years previously. He
was treated for 2 weeks as an in-patient, and after being discharged was
treated as an out-patient for 7 weeks. The attacks now became more
frequent, — almost daily, — his memory became defective, and he wept
frequently. It was at this time that he came under the care of Woakes.
While the turbinate on the left side showed only slight enlargement, the
right presented a firm, nodulated tumor, occupying the anterior ethmoid
region of the nostril from its outer wall to the septum. So firmly did it
press against the wall that it was impossible to pass the loop of a snare
between the apposed surfaces. It was therefore removed by means of the
cutting ring forceps, the sections showing expansion of the intertrabecular
spaces, but no considerable cyst or cavity. This was in 1896, following
which he had not a single attack until July, 1901, when the trouble re-
turned with all the previous symptoms, though somewhat less severe.
On examination of the nose the ethmoid region had considerably changed
as regards the left middle turbinate, presenting much the same enlarge-
ment as that of the right side in 1896. It differed, however, inasmuch
as the enlarged osseous structures were covered with abundant soft pro-
liferation, especially on the inner surface adjacent to the septum. The
stump of the right turbinate had not materially changed since the opera-
tion. He was again admitted to the hospital, and the entire left middle
turbinate bone, as well as the stump on the right side, was removed.
On the third day following the operation the patient was up, entirely
free from symptoms, and returned to his home, since which time he has
seemed entirely well. Woakes mentions three symptoms found in this
case which he thinks sufficient to differentiate it from one of true epilepsy
and to transfer it to the group of vertigos due to disturbance of the equi-
librating apparatus of nasal origin — namely, (1) hyperacousis, indicated
by the distress occasioned to the patient b}^ the occurrence of loud noises
and evidencing implication of the cochlear portion of the octavus nerve;
(2) the tendency to uncontrollable weeping ; (3) loss of memory.

Clinical Report on the Use of Argyrol (Silver Vitelline) in Dis-
eases of the Nose, Throat, and Ear. — M. D. Lederman^ expresses
favorable conclusions from the use of this new silver preparation after
5 months of clinical observation. He used it to supplant the ordinary
indications for silver nitrate, and also in all forms of acute and chronic
inflammatory conditions of the nose, throat, and ear. He used various
strengths, from a 3 % to a saturated solution, and found that it possessed
the good qualities of silver nitrate without the unpleasant irritating

' Lancet, Aug. 16, 1902. ^ Med. Rec, Nov. 22, 1902,

606 DISEASES OF THE NOSE, THROAT, AND EAR.

features, especially in its application to the nasal, pharyngeal, laryngeal,
and aural mucous membranes. In attacks of acute pharyngitis solutions
of 30 % and 50 % strength Avere employed daily for 3 treatments with
prompt relief from the dysphagia and a decided change in the engorged
tissue, the applications being made with the usual cotton-wrapped ap-
plicator. The same effect was noticed in acute tonsillitis and in naso-
pharyngitis. Two cases of mucous patches of the pharyngeal and tonsil-
lar tissues were treated with a 50 % solution with rapid improvement of
the local soreness and disappearance of the lesions within 10 days. In
these latter cases internal medication was also used.

To Prevent Nose and Throat Complications in Scarlatina. — J. A.
Le Sage^ recommends the intermittent use of the following prescriptions
to relieve the purulent rhinitis complicating scarlatina, the result of
which is uncertain and rarely remains localized to the nasal mucous
membrane :

\i . Menthol 0.20 gm. ( 3 grains)

Boric acid 4.00 gm. (60 grains)

Petrolatum 30.00 gm. ( 1 ounce)

Mix and make an ointment

Or this:

K . Resorcin 0.30 gm. (4^ grains)

Petrolatum 30.00 gm. (1 ounce)

Mix and make an ointment.

Injections of the following oil are also recommended:

R . Essential oil of mint 11 drops

Resorcin 1 gm. (15 grains)

Sterilized olive oil 20 gm. (5 drams)

M. Ten drops to be injected into each nostril, night and morning.

"Cystoscopy" of the Nasopharynx. — A. Valentin^ has adopted a
modification of the ordinary cystoscope in the examination of the naso-
pharynx. The method was suggested by Reichert, who used a small
cystoscope to explore the maxillary sinus through an artificial opening.
With the modified instrument Valentin states that the walls of the naso-
pharynx, the posterior nares, and the openings of the eustachian tubes
can be inspected with greater accuracy than by the ordinary method.
The instrument (salpingoscope) is provided with an electric lamp of low
voltage, which is not perceptibly heated by the current. The instrument
is readily introduced along the inferior meatus, unless there be marked
deformity; and no matter upon which side it is introduced, a distinct
view of each lateral wall of the pharynx is obtained by rotating the in-
strument on its axis.

An Aseptic Cotton-holder. — C. Y. Hogsett^ furnishes an illustration
with description of an aseptic cotton-holder, which consists of a leaded
metallic base, upon which rests a double metallic cylinder 4 inches in length
and 2.5 inches in diameter. Through the center of this passes a square

* Union med. du Canada, Jan., 1903. ^ La Sem. med., Jan. 7, 1903.

3 Med. Rec, April 11, 1903.

MISCELLANEOUS. • 607

Steel rod, at one end of which there is a tap, at the other a small crank
for turning the rod. The outer cylinder is attached to the metallic base
below, is open at both ends, and at its upper part has an opening If inches
in width, extending through the entire length. The inner cylinder fits
within the outer, is closed at both ends, and has an opening corresponding
to that in the outer cylinder. Near the center of one side of the opening
there is a small metallic knob by which the inner cylinder can be moved
within the outer, thereby completely closing or opening both cylinders.
The receptacle for the cotton holds the amount that comes in the smallest
sized packages. By inserting one end of the roll of cotton into the opening
of the receptacle and then turning the crank the cotton will be wound onto
a roll on the central rod just as a bandage is wound on a bandage-roller.

Special Influences of the High Altitudes upon the Nose and
Throat. — S. E. SoUy^ makes some observations upon this subject based
upon many years' practice in Colorado. The high altitudes are intended
to apply to regions above 4500 feet elevation. The belief is expressed
that there are marked differences between the
climatic influence of a low and that of a high
altitude upon the upper respiratory tract; this
is due to the diminished air-pressure of the
high altitude, lessened humidity, and the in-
creased sensitiveness and energy of the ner-
vous system. These influences are temporary
and compensated for in normal persons, but
often continue to aggravate or improve patho-
logic conditions. The subject is treated in
some detail, especially in connection with
patients coming to high altitudes with partial

nasal stenosis. ,,.j„ i28._Hogsett's aseptic cotton-

Stammering and Its Treatment by the uoider.

General Practitioner. — H. W. LangwelP

describes at length Wyllie's method of treatment for this condition,
claiming that its advantage consists in that it can be easily explained
and carried out by the patient's ordinary medical adviser. Stam-
mering is taken to signify both the rapidly recurring enunciation of
a particular letter sound and also the tendencj^ to a sudden check in
the utterance of certain syllables or letter sounds. As regards the etiol-
ogy, the condition is more common in boys and is rarely acquired after
the second decade ; very commonly the period of onset is not when speech
is first acquired, but in the later years of childhood. Heredity is of
doubtful import, because in such cases imitation of another stammerer
is probably the essential factor. Imitation is unquestionably a frequent
cause. Some writers ascribe an etiologic factor to debilitating iUnesses,
and in many cases the condition is worse when the general health is
impaired. Another important factor is the nervousness and sense of
publicity present in reciting or answering questions in school. The

^ Abstr. of paper read before the Laryngol. Sect. Am. Med. Assoc., New
Orleans, La., May 6, 1903. " Practitioner, Jan., 1903.

608 DISEASES OF THE NOSE, THROAT, AND EAR.

affection is especially apt to occur in those of a sensitive, nervous, or
retiring disposition, but in such cases the nervousness is the result rather
than the cause. In the cases of those who "stutter" it may frequently
be observed that the patient is emptying his chest too rapidly, so that
the end of the sentence is often barely audible on account of the deficient
volume of air passing through the larynx. In the other variety, those
who "silently stick" (Wyllie), there is much less that is audibly notice-
able to the bystander, for in many of the less severe cases it is only by
looking at the patient that the fact of his stammering can be noticed.
It may sound as if the speaker were simply grouping his words peculiarly,
whereas his utterance is involuntarily checked at intervals. This variety
of stammering produces, as Wyllie puts it, in saying the word "poor,"
for example, one big initial " capital P," instead of the stutterer's several
"little p's." Other symptoms associated with this form are congestion
of the face and puffing out of the cheeks in a patient's endeavor to enun-
ciate, which is sometimes finally accomplished with an explosion of saliva
as well as of air. In some of the severer varieties there are seen involun-
tary contractions of the facial muscles and jerking movements of the
head or even of the limbs; these last may be so severe that the patient
appears exhausted by his endeavors to overcome his difficulties. In
addition to these movements there are others of a purposive kind, for
it occasionally happens that the impediment is more easily overcome
if some other muscles are thrown into play; c. g., by tapping the foot
or swaying the body. Another variety of voluntary action, which is
sometimes met with, is the enunciation of a difficult word during inspira-
tion instead of expiration, so that the patient really sucks in the word
and produces thereby a peculiar see-saw mode of speech. This action is
primarily voluntary, although from habit it may finally become involun-
tary. It is noticed that stammering is more apt to opcur upon letters
occurring at the beginning than in the middle of a word, that this is
most marked when patients are speaking in their ordinary conversational
tone, and that it is generally absent when they are singing. In beginning
treatment patients should be instructed that in the production of normal
speech there are three separate, closely coordinated and interdependent
mechanisms: (1) A current of air must be expelled from the lungs by
the ordinary expiratory apparatus; (2) this column of air passing through
the larynx produces vibration of the vocal cords which results in certain
sounds ("vocalization"); and (3) these sounds, initiated in the larynx,
are capable of various modifications ("articulation") by the action of
the lips, tongue, palate, etc. The important fact for the stammerer to
understand is that while the importance of expiratory function is un-
doubtedly great, his difficulty arises from a want of the proper harmony
or prompt cooperation between the functions of vocalization and articu-
lation. Wyllie illustrates this by using as a simile a violin player who
with one hand produces the sounds and with the other modifies these
into music ; vocalization represents the former and articulation the latter
part of the performance. The stammerer's error usually lies in the fact
that his vocalization is defective both in promptitude and amount, and

MISCELLANEOUS.

609

he seeks to make up for this by excessive attempts at articulation. The
trouble is produced by giving more attention to articulation than to
vocalization, and the chief aim in treatment is to emphasize the vocal
element in words. The importance of this is seen when it is remembered
that scarcely ever does one stammer in singing, because attention is
directed to the proper vocalization or the correct sound to be produced,
and when speaking or reading in a monotone the predominance of the
vocal element will frequently enable a stammerer to overcome his trouble,
as in the case of Charles Kingsley, who, though a bad stammerer all his
life in ordinary conversation, was enabled to preach well by delivering
his addresses in a musical monotone. If in treating a stammerer he is
directed to adopt the voice or tone of some one familiar to him, he can
get over his most troublesome stumbUng-blocks with the greatest ease,
because his attention is so directed to the accurate production of the
correct sound that articulation becomes as easy as in singing. In those
who do not possess this faculty of imitation, this little therapeutic measure
cannot, of course, be adopted. After the patient has thoroughly grasped
the importance of proper coordination of his vocalization and articulation
apparatus, he should be taught how to deal with the various letters of
the alphabet, and for the instruction of such Wyllie has constructed the
following physiologic alphabet:

A PHYSIOLOGIC ALPHABET.— (Wyllie.)

I. VOAVELS.

Y— I E A O U— W.

These should be pronounced in the Latin manner as w, eh, ah, oh, oo ; y and
w are consonants, not vowels, but are placed here for reasons given in the text.

II. — Consonants.

Voiceless Oral,

Voiced Oral.

Voiced Nasal
Resonants.

Labials.
(First stop-position.)

(W)

B
W

Labio-Dentals.

Linguo-Dentals.

Th^

Th'
Z

Linguo-Palatals.

(Second stop-position.)

Sh
T

(T-)

Zh
D
L
R

Posterior
Linguo-Palatals.
(Third stop-position.) *

H or Ch

G
Y

(R)

The voiceless W and voiceless L have been given in brackets, the former being
now almost confined to Scotland, the latter being peculiar to Wales. The uvular
(burring) R is also in brackets.

610 DISEASES OF THE NOSE, THROAT, AND EAR.

The vowels are, of course, produced in the larynx, and therefore generally
cause little trouble. The patient should be instructed, however, to give
each one its full vocal emphasis, and for this purpose the following sen-
tence is very convenient, as it produces each of the vowels in the physio-
logic order in which they are produced in the oral mechanism: "Eels ail
amid ocean ooze." This does not include the w and y, which are grouped
by Wyllie with the vowels. These letters are of great importance, be-
cause, when they occur as initials, they are frequently a source of great
difficulty, as the patient generally attempts to produce them without
vocalizing. An initial w is phonetically equivalent "to a tight oo, with
a slight fricative element added," as, for example, in the word "water,"
which is phonetically "oo-ater." An initial y really represents ee; e. g.,
the word "j-'ard" really is "ee-ard." The word "yes" is a frequent
source of difficulty, partly because it so often stands alone, but mainly
because of the attempt to pronounce the initial letter voicelessly as "yeh" ;
but when once the patient is made to understand that it is equivalent
to "ee-es" and that it should be pronoimced almost as if one were spelling
it into two syllables, he will find it comparatively easy and that he has
the key to the enunciation of a large number of troublesome words.
Each consonant is considered "as it is pronounced during the enunciation
of a syllable containing it"; e. g., the letter F is regarded as the initial
sound in the word "far" and not as "eff." The consonants are grouped
in Wyllie's alphabet according as they do or do not possess the vocal
element, and the important guiding rule is that in speaking or reading
all consonants which normally contain voice should have their full vocal
element given to them, while those that are normally voiceless should
be touched off as lightly as possible, the voice being brought out with
emphasis in the ensuing vowel or voiced consonant. For instance, in
saying "Tom Davidson" the voiceless T is merely given sufficient com-
pression of the air to supply to the fully sounding "om" the explosive
character of the voiceless T, while, since D requires voice, the initial letter
must have the voice thrown into it and emphasized. The patient should
be thoroughly instructed as to the vital distinction between these two
classes of consonants, and must be made to prove to himself the fact.
In order to effect familiarity with this distinction it is often useful to
give him sentences and tell him to underline in each word the letter in
which the voice is first to be thrown, as: "Ask Kate to carry &ack my
Tartan shawl." In case the pupil sticks at a w^ord, the teacher should
be able to tell by listening whether the letter is voiced or not, for if he
is giving the full vocal element to all the voiced consonants the pre-
liminary laryngeal sound should be audible. With the preceding princi-
ples firmly established, the teacher should then go on with the various
letters of the physiologic alphabet, requiring frequent practice so as to
convince the student of the presence or absence of voice. (1) The voice-
less oral consonants. The general rule in these is that they should be
no more than formed in the oral mechanism, and that all the emphasis
should be thrown into the ensuing voice letter. In the early stages of
treatment the following method of teaching how such voiceless initials

MISCELLANEOUS. • 611

are to be touched off will be of value : In such a sentence as "Peter caught
ten fish," let the student practise emphasizing the voiced portions of the
word, viz.: ''eter aught en ish." After this is fully produced it is easy
to show that the very smallest possible P will convert the "eter" into
"Peter"; the same can then be done with the remaining words of the
sentence. A practical point as illustrated in the second and third words
of the sentence just given is that when the voiceless initial of any word
in the sentence is a terminal letter of the immediately preceding word,
no attempt should be made to reproduce it again as an initial. The dis-
tinction should be taught between the voiceless "th" in "thin" and the
voiced "th" in "thine." K represents "C hard" just as S represents
"C soft," and hence the absence of the letter itself in the alphabet. (2)
Voiced oral consonants. As a general rule all words commencing with
two or more consonants are especially likely to cause difficulty, and in
this respect those commencing with "wh" are no exception. This diffi-
culty is met by treating the "W" as a vowel and therefore fully vocalized
and the "H" placed before the "W," so that "which" is pronounced as
if it were phonetically spelt "hoo-ich." The compound letter sound
"zh" is the phonetic equivalent of the letter "S" as it is pronounced,
for example, in the word "measure." L and R are frequently difficult
of pronunciation, and the patient should be taught to vocalize them
thoroughly from the full chest. (3) Voiced nasal resonance. M and N
are the only ones of these occurring as initials and the patient should
be taught to vocalize each as much as possible so that a loud continuous
hum is produced. For example, the word "Newmarket" would be spelt
phonetically "(un)new" "(um)-market." As regards the rest of the
alphabet, capital Q is equivalent to "kw," and X to "ks." Capital J
and "soft" capital G are equivalent to "dzh," as in the words "Jim"
and "gin." A valuable aid in impressing upon the patient the distinction
between the voiceless and voiced letters is the following series of sen-
tences devised by Wyllie :

A. — Initials that contain voice. (In the pronunciation of these the voice is
to be thrown boldly into the initial) : —

1. "Even ancient elves are awed over oozing."

2. "We visit the Zulus like ramblers yearly."

3. " My nephew."

4. "Best gold dust."

B. — Initials that do not contain voice. (These are to be touched off lightly,
the voice being promptly brouglit out in the ensuing vowel or voiced consonant) : —

1. "Far shores seem thinly hazy."

2. "Two poor comrades."

For further exercise upon the more difficult initials the following additional
sentences are also reproduced : —
A. — Voiced Initials: —

1. "Billy Button bought a buttered biscuit."

2. "Davy Doldrum dreamt he drove a dragon."

3. "Gaffer Gilpin got a goose and gander."

4. "Mother, make more mustard: no, no, not now."

B. — Voiceless Initials: —

. 1. "Peter Piper picked a peck of pepper."

2, "Tiptoe Tommy turned a Turk for twopence."

3. "Kimbo Kemball kicked his kinsman's kettle."

C12 DISEASES OF THE NOSE, THROAT, AND EAR.

The teacher should notice which letters cause the greatest difficulty in
reading these sentences and should construct similar ones containing these
letters, which should be systematically practised. In all his lessons the
patient should stand up and speak in a full voice. He should cultivate
the habit of full and regular inspiration in order to have a plentiful
supply of air for full vocalization, and should alw^ays avoid abrupt or
hurried speaking, cultivating deliberate and musical utterance. The
daily lesson should consist of reading the sentences given above, then
other sentences containing exercises upon the consonants causing the
greatest difficulty. This should be followed by a short reading lesson
in poetry and subsequently prose. Treatment should be daily and per-
sistent, and the age at which it should commence depends entirely upon
the aptitude of the particular patient.

Constitutional Manifestations Due to Infectious Processes in the
Adenoid Structures of Children. — D. Braden Kyle^ states that this
structure is known to be readily susceptible to inflammation with which
there are usually associated high fever and other constitutional mani-
festations in children, the slightest infection being accompanied by con-
stitutional symptoms out of proportion to the local changes. When the
adenoid tissues are removed there is very little constitutional disturbance
even though slight local infection should occur. In those children who
are subject to attacks of fever for which no definite cause can be readily
found, examination should be instituted for the presence of adenoids,
and they will usually be found present. After recovery from the acute
infection the adenoids should be removed, and the usual result is the
absence of recurrence of the febrile attack and often the rendering of the
child less susceptible to the acute infectious diseases.

Spasmodic Torticollis Following an Adenoidectomy. — John M.
Ingersoll^ reports the case of a well-nourished boy, 7 years old, who had
been operated on for adenoids. The operation was complete and in no
way unusual. About 3 hours after the operation he developed a typical
right-sided torticollis, which was considered to be a reflex neurosis and
was treated by suggestion; the spasmodic condition disappeared in a few
days. The irritation caused by the operation in the nasopharynx pro-
duced reflexly, through the glossopharyngeal and spinal accessory nerves,
the spasm of the sternomastoid muscle. Cases of spasmodic torticollis
which were cured by an adenoidectomy have been reported. All such
cases suggest, at least, the advisability of careful examination for adenoids
in patients with spasmodic torticollis, and the possibility of a cure in
some cases.

A Case of Defective Speech Due to a Form of Spinal Cord Disease
Resembling Disseminated Sclerosis. — G. Hudson Makuen^ reports the
case of a patient, 26 years of age, who was apparently healthy until he
began to learn to walk, when it was found that his legs and ankles were
weak, in consequence of which he was obliged to wear braces for several

^ Med. News, Aug. 30, 1902.

^ Ann. Otol., Rhinol., and Laryngol., Aug., 1902.

3 Proc. Phila. Co. Med. Soc, March 31, 1903.

MISCELLANEOUS. , 613

years. He did not try to talk until he was 4. At the time he applied for
treatment for his defective speech respiration was obstructed, owing in
part to an ecchondrosis of the nasal septum, but chiefly to his general
muscular disability. The septal defect was remedied. A sHght intention-
tremor was roticeable throughout the entire body, he was awkward in
the use of his hands, and wrote with great effort. His walk'was unsteady,
there was a tendency to drag the feet, and in coming down-stairs his
poise was very insecure. He had great difficulty in learning to ride a
bicycle, and succeeded only indifferently well; he never could learn to
skate or dance. He did not succeed well in school, and his mentality was
about on a par with his physical development. He spoke in a halting
manner, somewhat as he wrote and walked. There was no stammering,
but there was a slight hesitation as if he were thinking how to say the
word. Treatment consisted chiefly in the application of various forms of
physical training, especial attention being given to development of speech.

The Influence of Catarrhal Diseases of the Nose and Throat in
Producing Speech-defects in Children. — G. Hudson Makuen^ states
that catarrhal conditions of the upper respiratory tract interfere with the
normal development of speech to an extent that is not fully appreciated,
and it is the object of this paper to point out the various ways in which
this is brought about. It is generally during the second and third years
that these catarrhal affections of the nose and throat do the damage.
It is then that the faculty of speech is being acquired, and at this time
even the slightest deviation from the normal condition, whether it be in
the nasal, pharyngeal, or oral cavity, may be responsible for grave defects
of speech. The writer claims that faulty breathing is one of the most
common causes of defective speech, and anything that blocks the normal
respiratory tract interferes with the normal respiratory rhythm, and
brings about a muscle imbalance. He also descril^es the action of the
respiratory muscles in vocalization, and urges the practitioner to look
carefully for enlarged tonsils, lingual, faucial, and pharyngeal, and also
for obstructions in the nasal passages of all infants.

The Development of the Faculty of Speech. — G. Hudson Makuen^
calls speech the tool of the mind, the thing with which the mind works, and
draws attention to our dependence upon the faculty of speech, and to the
fact that it is acquired by unconscious imitation; and therefore, to have
good speech, a child must have good surroundings and good speech models.
Important causes of the development of faulty speech are ill health, and
the influence of abnormalities of structure on the organs of speech. The
first form of expression is crying, which begins at birth. Different cry-
ing sounds are soon used to denote special needs. Laughing, smiling,
and other forms of facial expression are followed by grunting. Then
come babbling and crowing. Soon the child will begin to repeat the last
sound of a sentence that it has heard — echolalia. Then comes mimic
reading. The child begins to understand spoken language at about 11
months of age, and begins to use words of its own invention. Finall}^
the child acquires intelligent speech.

' Intemat. Med. Mag., Feb., 1903. - Intemat. Med. Mag., July, 1903.

6M DISEASES OF THE NOSE, THROAT, AND EAR.

Congenital Cleft of the Palate. A Further Report upon the
Operative Technic and Its Results. — James F. McKernon^ states that
since the publication of his article on this subject in 1899, he has some-
what modified the method, based upon the experience of 24 later opera-
tions. In this article he repeats the method as described at that time
and adds a few modifications from the standpoint of both operative
technic and after-treatment which he finds beneficial. In the first place,
on the day before the operation he does a preliminary tracheotomy under
cocain-anesthesia, which he finds a comparatively easy matter, since
most of his cases were adults. If, however, the patient be a young child,
he then advises tracheotomy just prior to beginning work on the palate.
In administering the chloroform he prefers to drop it on an inhaler
directly over the tracheotomy-tube rather than through a long rubber
tube as first described. The large, flat, thick pieces of gauze with strings
attached are still used to cover the entrance to the larynx and esophagus
as described in the earlier operations. In preparing the edges of the
cleft, a long-handled mouse-tooth forceps is used to grasp the edge of the
tissue, the cutting being done with long-handled curved scissors, except
in cases where the edges cannot be pared with the scissors further than the
junction of the hard and soft palate, as here the edge of the cleft is firmly
adherent to the palate process of the superior maxillary bone, in which
a knife is used, a thin margin of the flap is cut directly down to the bone
upon which it rests and can then be easily removed with a periosteal ele-
vator. Especial care is advised to save as much of the tissue of the
uvula as possible, Avhich will unite when only a very small area of it is
freshened. Before proceeding as in the former operation he now intro-
duces the sutures through both sides of the soft palate, and through as
much of the hard palate as overlaps the bone, provided the overlapping
be of sufficient width to allow the introduction of the suture; otherwise
they are merely passed through to the hard palate. Silver wire is used.
After the alveolar incision care should be taken to have that portion of the
flap situated just behind the front teeth left with as broad a margin of at-
tachment as possible, in order to preserve the circulation between the flap
and the adjacent tissue, since in one instance he observed that the point
was narrowed down to a small attachment, and on the sixth day parted, but
fortunately closed later by granulation. Where formerly a curved incision
was made in the tissue of the soft palate internal to the hamular process, it
is now extended downward, keeping well to the outer attachment of the
soft palate, until in some cases the incision stops just before the fibers of the
pillar are severed, which furnishes an absolute safeguard against tension,
and also prevents the arching of the palate after healing has taken place,
which is a valuable adjunct when the patient begins to articulate. This
incision can be made either before or after suturing the edges, though
usually it is partially done prior to suturing; and then, after the edges
are united, it is extended downward in the manner referred to. In all of
his cases operated upon during the past 2 years he has had little trouble
from hemorrhage while operating, and this was easily controlled by gauze
' Laryngoscope, Feb., 1903.

MISCELLANEOrS. . 615

sponges wrung out of hot sterile water. Formerly the introduction of
the sutures was begun just behind the teeth in the hard palate, but he now
inserts them first in the soft palate and then works forward rather than
from before backward. In closing the cleft and twisting the wire great
care is taken not to draw the sutures too tight, otherwise they may cut
through the edges of the flap on the second or third day and allow a
separation of the edges. As an aid in drawing the sutures just tight
enough to give moderate approximation, a shield is used while twisting
the wire, which enables one to see just how tight the suture is drawn.
After the wire sutures are in place the ends should all be bent forward to
prevent irritation of the tongue as much as possible. The lateral incisions
are packed quite firmly with sterile gauze and left in position for at least
24 hours, which tends to push the flaps together and also aids in checking
hemorrhage. In all the more recent cases operated upon the second
dressing was done from 12 to 15 hours after operation, instead of 24 as
was first practised, since the salivary secretion is more profuse after
anesthesia and the dressings are saturated quite as much as they are
later by allowing them to remain the full 24 hours. The best results he
obtained by dressing the whole operative field twice a day for the first
6 days after the primary dressing, the dressings being applied moist, pre-
viously wrung out of hot sterile water. In accord with the suggestion
that lead clamps would help here and act as splints, he is having some
constructed with this end in view. The lateral alveolar incisions should
not be packed after the first 24 hours, since even when repacked during
the second 24 hours there will be a tendency to a curling over of the edge
which has been severed, and this curling takes place toward the median
line rather than toward the tissue from which it was severed. Instead
of nourishing by the rectum during the whole period of convalescence as
formerly advised, he now allows the i:>atient to have a glass of pe])tonized
milk after the third day, while dressing, which is followetl by a glass of
warm, sterilized water to cleanse the jmrts. This quantity of nourish-
ment is later increased to a pint of milk at each dressing as the days go
on, the rectal nourishment being in no way diminished on this account.
In this way, he claims, very little weight is lost and the strength is well
maintained. A point in rectal nourishment which he emphasizes is that
after the nutritive enema has l)een placed in the bowel the nurse should
always hold a pad firmly over the anus for from 20 minutes to half an
hour to prevent its expulsion. The sutures are left in much longer than
in his earlier operations, which gives firmer imion. The tracheotomy-
tube is usually allowed to remain 10 days. In answer to the numerous ,
criticisms which have been made against the use of the tracheotomy-
tube, he states that he operated upon 3 cases, those of 2 adults and 1
child 7 years of age, following the technic as described in every detail with
the exception of tracheotomy. The results at the end of 5 days were that
he had nothing but ragged flaps in the adult cases, and at the end of the
second day in the child's case there was not a stitch intact. As regards
the final result of the other 24 cases, he states, however, that all were not
successful; 16 closed by primary union in botli hard and soft palate; in

616 DISEASES OF THE NOSE, THROAT, AND EAR.

2 there was a slough at the junction of the hard and soft palate, that
looked on the eighth day as though there was going to be a large hole
left permanently; but under stimulation these closed completely, though
in doing so caused the arch of the soft palate to become somewhat higher
than in those which healed by primary union throughout. In 2 cases the
wound united by primary union except just behind the front teeth,
where a small but permanent sinus was left which was closed 3 months
later by a small flap operation. In one case, that of a boy 16 years of age,
a large hole was left permanently by the sloughing of the attached end
of the flap on the right side next the alveolar border. He believes the
reason for this was that the cleft in the hard palate was an unusually
wide one, and in trying to close the cleft completely there was an in-
sufficient attachment of the flap on that side with insufficient circulation
brought to the flap to nourish the tissue properly. The other 3 cases,
those of a child 5 years of age and 2 adults, were almost complete failures.
The cause of failure in the child's case he attributes to the child's working
the tongue back, and in some way getting it beneath and behind the new
palate, thus forcing the dressing out of the mouth and pulling the stitches
out of the soft palate. A portion of the hard palate united. In one of
the adult cases the failure was ascribed to a secondary hemorrhage
occurring on the second day caused by the removal of a large group
of adenoids 2 days before the operation on the palate. The bleeding
was so profuse that all efforts to stop it failed until packing was
done beneath the newly formed palate, and this so disturbed the sym-
metry of the flap that sloughing followed. Failure in the other case he
is unable to attribute to any definite cause, except possibly that of in-
fection, since one of the assistants at the time of the operation was suffer-
ing from a suppurating tonsillitis of which the operator was unaware.
Of the 24 cases with operation, the ages ranged from 3 to 36 years.
From the standpoint of surgical results as well as for the function of speech
the author advocates operation at an early age.

DISEASES OF THE EAR.

Functional Tests of Hearing : Some of the Principles on which
They Are Based. — William L. Ballenger,^ emphasizing the great value
of functional tests of hearing in the large and oftentimes perplexing group
of diseases of the nonsuppurative type which affect the middle ear and
labyrinth, states that there is not time within the limits of this paper to
enter into a discussion of the relative merits or significance of the various
tests, so confines his remarks to certain major principles on which they are
based. Under the first major principle he groups two secondary principles
which only serve the purpose of elaborating or elucidating it: (1) Any-
thing which disturbs the normal tension of the drumhead and ossicular
chain will diminish or abolish the hearing for the two or three lower octaves.
(2) Any disease affecting the perception apparatus will diminish or abol-
lish the hearing for the upper tones of the range of hearing. He states
' Jour. Am. Med. Assoc, April 11, 1903.

DISEASES OF THE EAR. 617

under this heading that the range of hearing in adults under 55 years of
age is approximately 16 to 48,000 vibrations per second. After the fiftieth
or fifty-fifth year the hearing for the upper tones is somewhat reduced,
as has been shown by Zwardemaker, Bezold, and others. The very aged
do not, as a rule, hear tones higher than 37,000 vibrations per second.
Under the second major principle it is stated that hearing by bone-conduc-
tion is approximately one-half as long as hearing by air-conduction. The
rule is subject to considerable variation in normal ears, but for practical
purposes in the study of these principles we do not need to make a closer
analysis. Under this head are also two secondary principles: (1)
Hearing by bone-conduction is increased in those affections of the middle
ear which disturb the normal tension existing between the drumhead
and ossicular chain. (2) Hearing by bone-conduction is diminished or
abolished in affections of the labyrinth or perception apparatus. As a
third major principle he states that the intensity of hearing by bone-
conduction is either increased or diminished by morbid conditions within
the middle ear or labyrinth. Two secondary principles may also be
given in this connection: (1) Any disturbance of the normal tension
existing between the drumhead and ossicular chain will increase the
intensity of hearing by bone-conduction. (2) Any disturbance of the
perception apparatus wiU diminish the intensity of hearing by bone-con-
duction. On these principles he discusses their application in diagnosis
and prognosis of cases. After having made a careful history of the case,
including all subjective and objective phenomena, the author states that
it is his custom in private practice to test the range of hearing with
tuning-forks for the lower 7 octaves, and with the Galton whistle for the
remaining or higher limit of hearing. If the lower tones are not heard,
middle-ear or tubal disease is probably present; and if the upper tones
are not heard, there is presumptive evidence of labyrinthine disease.
Hence the examination as to the range of hearing is of great value in
determining whether the deafness is due to middle-ear or to labyrinthine
involvement. An exception to these conclusions is found in those well
advanced in years, when the upper tone-limit is normally reduced; and
another when there is marked retraction of the drumhead, forcing the
foot-plate well into the oval window. The tension of the intralabyrin-
thine fluid is thereby increased, and may give the usual functional signs
of true labyrinthine disease. The signs will quickly disappear, however,
on inflation of the tympanic cavity, and thus clear the diagnosis. In the
application of the second major principle he gives the following example:
If in a given case bone-conduction in the affected ear is relatively longer
than hearing by air-conduction, the disease is probably within the middle
ear. If the Weber test is performed, the sound will lateralize to the
affected side; or if the Rinne test is made, the result will be negative;
that is, hearing by bone-conduction will be longer than by air-conduction.
If, on the other hand, bone-conduction in the affected side is relatively
diminished in duration, it is probably one of labyrinthine involvement.
The Weber tests will lateralize to the good or better ear rather than to
the more affected side, while the Rinne and Schwaback tests will show
40 S

618 DISEASES OF THE NOSE, THROAT, AND EAR.

a relatively diminished hearing by bone-conduction on the affected side.
In this way may be classified all the functional tests of the ear under the
various principles which they elucidate.

The Treatment of Chronic Suppuration of the Middle Ear. —
James F. McKernon/ in a study of the many methods advised at .the
present date in the treatment of chronic suppuration of the middle ear,
summarizes the methods which he thinks most advisable, treated clini-
cally under the two heads, namely, the dry and the irrigation or wet treat-
ment. In the treatment of all cases three objects are kept in view:
(1) Cure of the otorrhea; (2) improvement of the hearing; and (3) relief
of the subjective sounds when present. In the beginning of treatment
in any case a careful examination of the nose and nasopharynx should
be made for the detection and removal of obstructions in either one or
both localities. At the outset the first cardinal principle in treatment
as regards the ear itself is to secure and maintain cleanliness of the au-
ditory canal and the parts adjacent; next, to determine just what struc-
tures of the middle ear are involved, since this will have a decided bearing
upon the progress of the case; and, finally, to locate the opening in
the drum membrane and ascertain whether the present opening is
draining the cavity sufficiently, and, if not, to enlarge it. Ascertain at
the first examination and before treatment is begun whether any caries
of the ossicles or the adjacent structures exists, which can easily be made
clear by cocainizing the point of the perforation and using the silver probe
to palpate with; but the mistake should not be made of calling every
particle of exposed bone "dead bone." Under dry treatment he con-
siders the following methods: The hands of the person who is to treat
the case are first made sterile; then sterilized cotton is used on a carrier
to wipe the canal thoroughly dry. After this drying process a fine
powder is insufflated over the drum surface as well as the canal walls;
the powders commonly used are xeroform, nosophen, boric acid, acetan-
ilid, aristol, and iodol; following this a small wick of gauze, iodoform,
borated or plain sterilized, is passed up and, if possible, into the perfora-
tion, and the canal loosely filled to the meatus. If the opening in the
drum is too small to admit the end of the gauze, the canal is loosely packed
from the drum to the meatus, which acts as a siphon to carry away the
discharge. As soon as this becomes thoroughly moistened with the dis-
. charge it should be removed and the process of cleansing carried on as
before. He states that the chief objection to this method of treatment is
the absence of a trained nurse to carry it out on antiseptic lines ; he thinks,
however, if this could be arranged for, it might become the ideal way of
treating this disease. The irrigation or wet treatment, which is the one
ordinarily used to-day among the majority of aurists, consists in sjrring-
ing the ear with one of the following solutions : mercuric chlorid, 1 : 8000-
1: 4000; boric acid, 20 grains to the ounce of boiled water; carbolic acid,
from 1 % to 2 % solution ; a weak solution of formalin and a solution of
potassium permanganate ; a normal saline solution. The author believes
that all but the latter could be dispensed with in a great majority of cases
1 Med. News, Jan, 17, 1903.

DISEASES OF THE EAR. 619

did we but try. When the patient is seen by the surgeon and the parts
cleansed in the manner described, a good solution to further sterilize the
parts is composed of equal parts of the solution of mercuric chlorid,
1: 1000, and absolute alcohol; to this can be added boric acid, from 10
to 20 grains to the ounce. Granulations may be destroyed by silver
nitrate or chromic acid, the parts being cocainized before either is used.
If polyps are present they can be saturated with a solution of cocain or
eucain and adrenalin and be removed by the curet or snare, cauterizing
the base after their removal. The canal now being clear, the irrigations
may be used, first every 2 or 3 hours, depending upon the profuseness of
the discharge, lessening their frequency as the discharge diminishes.
After the canal is cleansed and just prior to stimulating the parts, direct
the patient to perform Valsalva's method of inflation to expel retained
secretion through the opening in the drum. In case the patient is unable
to do this, perform gentle inflation by means of the catheter; then remove
the secretion thus displaced before the final application is made to the
surface for stimulation i Later the patient may be instructed to use one
of these cleansing solutions by placing from 5 to 8 drops in the ear morn-
ing and evening. As to the use of hydrogen dioxid there is a wide diversity
of opinion, the author favoring its use only in cases in which the perfora-
tion in the drum is a large one, though he thinks a better and more stable
preparation in all cases would be hydrozone. When the discharge is
persistent and there is an area of exposed bone complicating the simpler
condition, he finds the use of carbolic acid of great value. With the head
placed in a horizontal position the canal is partially filled with pure
carbolic acid and allowed to remain about 30 seconds, when the canal
is syringed with pure alcohol. The alcohol counteracts any escharotic
action which the acid would have upon the normal tissues and yet at the
same time allows the diseased parts to be thoroughly cleansed and
stimulated. When, after all the ordinary methods of treatment, a small
perforation exists with little or no moisture, the method suggested and
practised by Blake, of fitting a very thin piece of sterile paper over the
existing opening, will oftentimes heal the perforation. Flexible collodion
may also bring about the same result. To improve the existing tinnitus
after the otorrhea has ceased, inflation or vaporization of tube and
middle ear may be practised, with internal administration of strychnin
in tonic doses, as well as small doses of iodid of potassium.

Reflex Movement of the Auricle of the Ear. — E. Donaldson^ states
that among the reports of skin reflexes he is not aware that a reflex move-
ment of the auricle has been mentioned. The case he reports is that of a
man aged 54 years who came under his observation in May, 1902, with
suppuration of the right middle ear with polyp. The discharge first began
when he was 8 years of age and continued 17 years, since which time
there had been no recurrence until the beginning of April, 1902, when the
discharge was observed accompanied by considerable pain. The polyp
was removed by means of a snare. He was very deaf in this ear, not
being able to hear a watch on contact. As a part of the treatment

' Lancet, Aug. 23, 1902

620 DISEASES OF THE NOSE, THROAT, AND EAR.

powdered boric acid was insufflated through an ear speculum without
holding the auricle. At each puff the auricle was observed to move dis-
tinctly forward to the extent of about i inch; afterward at different
sittings he observed that this reaction could be produced by blowing air
from a small india-rubber bag into the auricle in the localitj^ of the ex-
ternal meatus, the best result usually occurring from the first puff. The
movement of the auricle would sometimes not occur after 3 or 4 puffs in
rapid succession, though in no sitting did he fail to get the reaction. In
making the observations he states that he was careful to exclude volun-
tary movement, and a movement that was only a part of a more general
scalp movement. The patient was unable to prevent the reflex from
taking place, nor was he able to produce the movement voluntarily,
though he was quite conscious of the reflex movement. The left ear was
normal and this reflex was only slightly observed in a backward direction.

Ozone in Chronic Middle-ear Deafness. — George Stoker^ reports
satisfactory results in the treatment of what is popularly known as throat
deafness, or technically chronic dry catarrh of the middle ear. It is
generally believed to be due to stenosis of the eustachian tube, which
may arise from interference with nasal respiration due to congenital mal-
formation or to hypertrophy of the mucous membrane of the nose or
nasopharynx. The symptoms are progressive deafness with tinnitus
of various kinds and of varying intensity. The tympanic membrane is
retracted and usually opaque. There are no signs or symptoms of the
auditory nerve being involved, and of all forms of deafness this may be
considered the most common and the most intractable, and it is no ex-
aggeration to describe it as the opprobrium of otology. The stenosis
of the eustachian tube affects the mucous membrane lining the middle
ear by preventing the free ingress and egress of air, and by confining the
secretions, thus setting up inflammatory conditions, which lead to thick-
ening of the mucous membrane and consequent deafness. The nasal
stenosis may be relieved and the eustachian tube may become more
patulous, but the deafness stiU increases ; this points to a remaining un-
healthy condition of the middle ear. The effect of oxygen, and more
particularly of its allotropic form, ozone, in restoring a healthy condition
to diseased nasal mucous membrane led to a trial of the latter in chronic
progressive deafness. The ozone was generated by means of an electric
current acting on a Ruhmkorff's coil to which the ozonizing tube was
attached. The ozone thus generated was pumped into the middle ear
through a eustachian catheter for about 3 minutes from twice to four
times a week, according to opportunity. In the 4 cases reported ex-
tremely gratifying results were obtained and in a remarkably short period
of time. A particularly interesting feature is the disappearance of the
tinnitus after a few applications. Stoker thinks it reasonable to suppose
that the results would be even better if the ozone could be used every-
day.

Perforation of the Membrana Tympani from Lightning Stroke. —
H. McNaughton-Jones^ reports the case of an officer who, while sitting

1 Lancet, Nov. 1, 1902. » Med. Eec, Aug. 23, 1902.

DISEASES OF THE EAR. ' 621-

in his tent drinking from an iron cup during a storm, received a shock
from a thunderbolt which rendered him unconscious for a time. He
was paralyzed, except in the left arm, and various burned areas were
scattered over his body. The hearing of the left ear was seriously af-
fected, and on examination a few days later the membrane was found
to be perforated in two places, with marked injection and of a deep red
color. Considerable tinnitus was present. With the application of a
weak silver solution, protection of the ear with gauze, and an occasional
inflation a gradual recovery was made.

Chloroform in Earache. — The "Journal of the American Medical
Association"^ quotes an abstract in the " Courier of Medicine" of a simple,
harmless, and infallible cure for earache. A small funnel of stiff paper
is inserted into the ear and in the larger end is placed a pledget of cotton
saturated with chloroform. With a long breath blow through this, carry-
ing the fumes of the chloroform into the ear. Instant relief is claimed.

Nonoperative Measures for Preventing and Combating Inflam-
mation of the Mastoid Cells. — Samuel Theobald,^ while fully recogniz-
ing the importance of operative measures for inflammatory and infective
conditions of the mastoid cells according to the generally recognized
indications, believes that far too little attention is given to other measures
which may not only alleviate the painful symptoms, but prevent and
even cure those cases which have developed. In expressing his opinions
he calls attention to an article which he published 20 years ago, and
states that his views are still in accord with those set forth at that time,
since in a large experience the results obtained are sufficient justification.
He divides his nonoperative measures for the prevention of inflammation
of the mastoid cells into what pertains to mastoiditis occurring as a con-
sequence of chronic inflammatory processes of the ear and to that occur-
ring as a complication of otitis media acuta. In regard to the first, the
object is to control the inflammation in the tympanum and thus avoid
the risk of its extension to the antrum and mastoid cells, accomplished
by means of building up the system with suitable tonics, eliminating
habitual constipation if present, and the use of antiseptic solutions to
control the suppuration. The antiseptic which he finds most efficacious
is mercuric chlorid, 1 : 8000 or 1 : 4000, or as his second choice boric acid
in saturated solution. Contrary to the more universal teaching, he
advocates the use of the syringe by the patient himself, with an occasional
inspection of the ear by the aurist. To avoid implication of the mastoid
cells in acute inflammation of the middle ear, energetic measures should
be employed to control the otitis and, if possible, to abort it in its incip-
iency, in which one must be guided by the cause of the attack and the
stage of the disease at the time the case comes under observation. For
this he expresses an abiding faith in the antiphlogistic value of energetic
purgation, especially with calomel; aside from the use of this drug as
a purge, he advocates its employment in small doses for its specific
effect upon the infection. Bearing in mind the peculiar characteristics
of the membrane which lines the mastoid cells — a periosteal as well as
> Dec. 20, 1902. ^ N. Y. Med. Jour., Sept. 13, 1902.

622 DISEASES OF THE NOSE, THROAT, AND EAR.

a mucous membrane — in inflammatory conditions involving the walls of
these cells, especially in their early stages, mercury, of all remedies, should
prove efficacious. Another remedy which he strongly recommends is the
pyrophosphate of sodium administered in liberal doses, 20 grains for an
adult or 10 to 15 grains for a child, every 2 hours. The same antiseptic
solutions for cleansing the ear are indicated in each condition, though
in the latter, owing to the profuseness of the discharge,, more frequent
irrigation is required.

Mastoiditis Due to the Gonococcus. — Charles Trow^ reports the
case of a man aged 22 years, admitted to the Toronto General Hospital
suffering from a somewhat diffuse swelling about the mastoid process
with moderate degree of pain. The patient was of a poorly nourished
type, never having been really well, though he had had no definite illness,
with the exception of a chronic diarrhea which had occurred intermit-
tently for 10 years, being diagnosed 5 years ago as being of tubercular
origin; had suffered from slight attacks of the grip for several winters,
and denied absolutely ever having had gonorrhea or other venereal
trouble. The present trouble originated about 5 months ago, following
exposure to wet and cold, when a small lump appeared in the submaxil-
lary region near the greater cornu of the hyoid bone, and at the same
time he experienced a sore throat. This was followed a week or two
later by a sharp pain in the right ear which lasted for several weeks,
being followed by slight swelling behind the ear, with a yellow discharge
from the ear and right nostril. In this condition he was admitted to the
hospital, with a temperature about normal, never higher than 100°. On
examination a diffuse swelling in the mastoid region was apparent, which
seemed to extend some distance below the tip of the process. Pressure
showed pitting with but little tenderness, the discharge moderately
abundant with no bulging of the posterior wall of the external meatus,
while the drum showed marked congestion with a perforation about the
size of a pin's head at the lower anterior quadrant. On operation the
whole mastoid region was carious, with the lateral sinus bathed in pus
and an opening through the posterior inferior part of the process into
the tissues of the neck. After thorough curetment and packing with
iodoform gauze the patient recovered without subsequent discharge, with
perfect hearing. The interesting feature of this case lies in the examina-
tion of the discharge from the ear and nose, which showed by the ordinary
stains abundant pus-cells, in which, clustered about the nucleus, were
many diplococci morphologically and in point of size identical with the
gonococcus. Furthermore, the microorganism was decolorized by Gram's
solution; cultures were made on nutrient agar-agar and on Loffler's
blood-serum, but no growth could be obtained. Loffler's blood-serum
was then smeared with blood carefully drawn with antiseptic precautions
from the ear of another patient and inoculations from this discharge.
Incubation at the body-temperature for 36 hours showed a growth which
on staining proved to be a noncapsulated diplococcus. The discharge
from the nasal cavity showed the same form of diplococcus, as did also
' Canad. Pract. and Rev., March, 1903.

DISEASES OF THE EAR. 623

that taken from the mastoid during the operation. Examination of nasal
discharge and material from mastoid cavity 2 months later did not show
gonococci. The wound had nearly healed and the patient had gained 10
pounds in weight.

Salient Points in the Treatment of Catarrhal Deafness. — Sargent
F. Snow^ states that without question the successful handHng of a case
of chronic catarrhal deafness means more careful consideration and more
broad, painstaking work than any other condition which aurists are
called upon to treat. He believes that while local intranasal factors bear
an important relation to the ear and must be taken care of before em-
barking upon the treatment of deafness itself, the mistake is often made
of attributing to them undue importance in the causation of disease,
with an unwarranted hope of cure from their removal. However, if
closer attention be paid to the general systemic conditions, to clothing,
diet, exercise, the bath, — in fact, any hygienic measure which will pro-
mote a healthy action of the excretory apparatus, especially the skin, —
he believes that a good prognosis should be given much more frequently
than we have been accustomed to in the past. As regards local treat-
ment, he believes the most effective method of handling chronic cases
of catarrhal deafness is by jets of stimulative vapor, made by passing
air under pressure over a supersaturated solution of gum-camphor in
tincture of iodin, through the eustachian tube to the middle ear.

Otomycosis in the Malay Archipelago. — D. J. Galloway,^ of Singa-
pore, reports an exceedingly interesting parasitic affection — otomycosis —
prevalent in the Malay Archipelago. In studying a series comprising
hundreds of cases of ear-diseases this affection was found in 70 %, and,
contrary to most tropic parasitic affections, it is found most frequently
in Europeans and next in persons of mixed parentage ; it is very rarely
found in Arabs and Malays, and in the Chinese scarcely at all. The sub-
jective symptoms may be pain of a subacute character or there may be
only a slight discomfort with itching of the meatus. The anatomic
changes are proliferative and not inflammatory, some solution of con-
tinuity being necessary in the membrane lining the meatus to convert
a pure otomycosis into a meatitis. The primary cause of the disease is
a fungus, Mucor mucedo being the most frequent, though occasionally
Aspergillus fiavescens is found. The marked preponderance of Mucor
mucedo is peculiar to the locality, other species being found in China, Siam,
and the Dutch East Indies, while in Europe the Aspergillus fumigatus
is most common. Among predisposing factors sea-bathing is particularly
mentioned, certain bathing resorts having gained special notoriety from
the frequency with which the disease develops. The presence of the
parasite alters the character of the cerumen, general debility favors the
invasion, and at times healthy secretions and the presence of the parasite
are noted in the same case. After having advanced for a time, however,
all normal cerumen disappears. Pathologic changes are dependent upon
the depth of tissue-involvement, a thin pellicle of the parasite closely

' Buffalo Med. Jour., Jan., 1903.

'Jour, of Rhinol., Laryngol., and Otol., Feb., 1903.

624 DISEASES OF THE NOSE, THROAT, AND EAR.

adherent to a part of the meatus and tympanic membrane only being
found in uncomplicated cases; in the mildest form of the disease only the
sebaceous glands are affected, producing increased secretion, which forms
with the mycelium a thin covering limited to a cartilaginous meatus.
More advanced irritation produces an infiltration of the deeper layers of
the integument, a sodden condition of the horny layer, accompanied by
serous exudation. In all varieties there is exfoliation of the pavement-
cells, while in the moist variety there is a denudation not unlike eczema.
Occasionally trauma effects a portal of entrance to the deeper layers,
which may be followed by an acute diffuse meatitis. There is tumefac-
tion or perichondritis, and the membrana tympani may participate in
its whole thickness with a certain amount of hyperemia of the middle
ear. No pus is formed. The objective signs of the disease are character-
istic, there being in the dry variety abnormal cleanness of the meatus,
absence of cerumen, and in its place a few yellow scales, dry and easily
detachable. In the deeper parts may be seen a light mother-of-pearl-
colored pellicle extending over the membrane and outward over the
canal. In another variety the canal walls are covered by a dense, dull
membrane of a yellowish- white color with large detachable flakes; this
membrane may be removed as a hollow cast by the syringe, frequently
leaving a red oozing surface. In the moist variety the canal is filled by
a grayish-white mass resembling white blotting-paper, the most per-
sistent symptom being itching, which remains as long as there is a trace
of the parasite. Deafness varies with the type of the disease, there
being little interference with the conduction of sounds in the dry variety,
while in those cases in which a firm thick membrane covers the deeper
meatus and membrana tympani the deafness may be considerable. A
sensation of moisture in the meatus is usually felt and there is an extru-
sion of particles from the meatus during movements of the jaw; this may
be scaly, membranous, or soapy, according to the type of the disease.
In the treatment GaUoway states that any good antiseptic may be
employed, such as mercuric chlorid or silver nitrate, which may be used
in considerable strength unless there is desquamation of the epithelium
lining the canal.

Deafness. — M. Marage^ makes some interesting deductions from
articles which have been read during the past 7 years before the Academy
of Medicine, the Biological Society, the Academy of Science, and the
Society of Physics. These works consist mostly of competitive essays
on the study of auditive acuity, the functions of the ossicles of the ear,
and of the composition of the liquid of the internal ear and of the otoliths.
From suggestions in these works Marage has been able to make some
practical conclusions with reference to diagnosis and treatment of dis-
eases of the ear. In one series he has taken up cases of deafness accom-
panying old age, excluding any that required surgical interference. In
experimenting on these cases he found that the acoumeters in present
use give very unreliable tests. With reference to the diapason, it is as
yet impossible to obtain a definite degree of sonority of the various
' Bull, de I'Acad. de Med., July 1, 1902.

DISEASES OF THE EAR. ' 625

forks, or the force of the stroke necessary to set them in vibration. How
then can we measure the time when a sound ceases or when the patient
stops hearing it? He finds also a marked difference in the ability to
hear musical sounds in contrast to those of ordinary conversation. Fol-
lowing these experiments he was led to devise an instrument, by means
of a siren fitted with a sounding board, that will produce vowel-sounds;
their intensity being regulated by air-pressure. With reference to the
ossicles of the ear, while well understood in their essential mechanism,
he believes that their motility has been very largely overestimated, since
instead of the vibratory movements of the drum membrane being capable
of one-tenth of a millimeter displacement, the actual movement probably
does not amount to a thousandth of a millimeter. The consequence is
that in the practice of massaging the t3nnpanum extreme pressure may
become dangerous by transmitting to the bony chain too much in excess
of that received under physiologic conditions. In his cases he has not
found that those with the greatest loss of hearing are the least responsive
to treatment. With reference to the liquid of the internal ear he has
not been able to obtain it in sufficient quantity for a thorough chemic
analysis, though he finds it to be of a very high density. By means of the
radiograph he has been able to detect in frogs otoliths in suspension in
this liquid. An analysis of these bodies shows their composition to con-
sist of bicarbonates of lime and magnesium with an excess of carbonates.
Their function is likely to assist in maintaining a constant degree of
density of the liquid in which they are suspended. They are found to
be soluble in certain acid quinin salts, from which fact Marage thinks
that we have an explanation for the buzzing in the ears when a large
amount of quinin is administered. He thinks that we may give credence
to this, since ethyl carbonate of quinin, which has no effect on the otoliths,
may be administered without producing buzzing in the ears.

Observations on Anesthesia of the Drum Membrane. — George B.
McAuliffe^ states that while the majority of clinicians do not believe in
trying to obtain local anesthesia of the membrana tympani, their deduc-
tions have been drawn in the main from the futility of using cocain for
this purpose in the external meatus. This difficulty, as is well known, is
produced by the dermal layer of the drum membrane, a skin without
glandular elements, acting only as a shield for the layers beneath, an
effort of nature to protect the tympanic cavity from fluids dropped by
chance or design into the external canal. Jacques, by utilizing the
selective action of methylene-blue, mapped out the nerve plexus in the
middle layer of the drum membrane. In the deeper portions of the
dermal layer detached bundles run in different directions and end in
apparently sensory end-tips. The mucous membrane of the eustachian
tube and that of the tympanic cavity receive their main nerve-supply
from the glossopharyngeal, which facts show that the external dermal
layer has very little to do with sensitiveness of the drum membrane, and
that most of the solutions dropped into the ear have little effect until
they nullify the shield-like action of the skin covering. The various
' Canad. Pract. and Rev., Dec, 1902.

626 DISEASES OF THE NOSE, THROAT, AND EAR.

methods of freezing by means of ethyl chlorid have been found impracti-
cable, since it does not desensitize deeply enough, nor can the area be
localized, besides the pain which always accompanies both the freezing
and the thawing. Thus he concludes that the best method we have is
the application of cocain after the preparation of the membrane by the
use of other applications which will aid in its absorption; in other words,
fluids which disturb the osmotic equilibrium of the membrane and produce
minute solutions of continuity in the dermal layer, thereby allowing
cocain to reach the nerve filaments. The conditions favoring the appli-
cation of cocain are the removal of foreign substances and loose scales
from the dnmi membrane and canal, dehydration of the outer layer of
the membrane, and the induction of endosmosis. The first condition is
met by the use of hydrozone, which he thinks better than any other kind
of hydrogen dioxid; while the second and third conditions are met by
the use of alcohol and anilin oil. By the use of solutions of 5 % to 20 %
cocain with equal parts of absolute alcohol and anilin oil anesthesia is
gained in from 10 to 15 minutes. The disadvantage of the solution is
that the anilin oil is toxic and obscures the field, which difficulty, how-
ever, may be obviated by making the application on a small cotton
pledget. He states that during the past 6 years he has experimented
with tubal injections of cocain, but without satisfactory results. He
draws the following conclusions: (1) The dermal layer need not be con-
sidered in local anesthesia of the membrane, and does not play so great
a part in sensation as the mucous layer, since palpation of the skin
surface does not elicit pain, although it reaches only the mucous mem-
brane. (2) The pain does not result from a local impact, but from the
excitation of the whole sensory apparatus of the tympanic cavity, in-
duced, no doubt, by the sudden abnormal inward movement of the
contents. (3) The pain of incision depends on the impression made on
the drum membrane by the knife as much as on the cutting, hence the
advisability of making a minimum amount of pressure by using as sharp
and as thin a knife as is practicable. This explains why incision in the
membrane is made so much easier by the use of the Graefe knife than
by the poor knives made especially for the work, knives whose smallness
of blade precludes sharpness of edge. (4) In order to produce the best
results isotonic or isoosmotic solutions of cocain should be used in order
to avoid edematization of the tube and subsequent transient otitis media.
Cardiac Reflex of Auricular Origin.— ^Massier,^ of Nice, reports
a case of auricular reflex in which indurated and impacted cerumen pro-
duced an intermittent action of the heart. The case reported is that of a
physician who for a long time had suffered from an intermission of the
pulse followed by a few painful palpitations. On auscultation at various
times and by different physicians no organic heart-lesion was found and
all the other organs were in apparently good condition. The symptoms
mentioned occurred in any position of the body and were not influenced
either by fatigue or by active exercise. His attetion being attracted to
his ears by the occurrence of tinnitus, the patient consulted Massier,
• Ann. des Mai. de TOreille, etc., Oct., 1902.

DISEASES OF THE E.\R. ' 627

who discovered and removed an accumulation of impacted cerumen.
Following this the palpitations were diminished, but the canals wera
left in an inflamed and sensitive condition for some weeks, when more
wax was removed and the heart became regular and no further discomfort
was experienced. The author naturally concludes that the cardiac
irregularity was due to reflex irritation, since the ear-canal is supplied with
its sensory branch from the pneumogastric, which through irritation
gave rise to an inhibitory impulse affecting the heart.

A Case of Delayed Healing of Extensive Mastoid Wound Treated
by Means of Skin-grafting. — Wendell C. Phillips^ reports favorable
results following skin-grafting to close a large wound following a mastoid
operation. Since the primary operation for the mastoid disease in
February, 1901, 3 additional operations had been performed, the last
one in April, 1903, all for the removal of small pieces of diseased bone.
The repeated operation had left such an extensive wound that it was
determined to use the method herein referred to for its closure, which
after 2 attempts proved very successful. PhiUips thinks this method
might be utilized to advantage in the delayed healing of many extensive
mastoid wounds.

Influence of Acute Mastoiditis on Audition. — J. F. McCaw,'
in a study of this subject, comes to the following conclusions: (1) Great
reliance can be placed on abortive measures in the hemorrhagic variety
of acute tympanomastoiditis following influenza, with a reasonably good
prognosis of normal hearing. In no other form of the disease can this
be done. (2) The period of the disease at which appropriate treatment
is applied influences the ultimate functional result. (3) In all cases re-
quiring operation, the earlier the surgical treatment is resorted to, the
greater will be the amount of hearing preserved. (4) The dry method
of postoperative treatment seems to influence the function of audition,
but to a less extent than early surgical interference.

Beer Yeast in Otology. — L. Sune y Molist^ has reported satisfactory
results following the use of beer yeast administered by the mouth for
otitis media, mastoiditis, and otitis externa furunculosa. He uses a
special preparation compounded from the formula of Fita, known as
cerevisina-Fita, a teaspoonful being given every 4 hours. In a case of
mastoiditis the pain subsided and the swelling markedly decreased upon
the day following administration ; and by the fourth day the inflammation
had entirely disappeared. He obtained equally good results in a case of
acute suppurative otitis with perforation of the tympanum and involve-
ment of the mastoid cells. He thinks there is no question but that this
substance exercises a specific effect upon pyogenic organisms in sup-
purative conditions.

Operative and Other Treatment of Chronic Suppuration in the
Middle Ear. — Charles J. Heath* lays great emphasis on the avoidance
of using the syringe for cleansing purposes and the importance of drying
the ear with suitable wool mops and then passing the fluid remedy through

1 Med. Rec, Nov. 1, 1902. ' Larjmgoscope, April, 1903.

* Rev. Cien. Med. de Barcelona, xxviii, No. 7, 1902. ' Lancet, Feb. 21 , 1903.

628 DISEASES OF THE NOSE, THROAT, AND EAR.

the perforation of the membrane and into the eustachian tube to the naso-
pharynx so that it can be tasted. Frequent apphcations are advised,
and since the patients must use it at' home, a nonpoisonous is insisted
upon. He uses spiritus vini rectificatus and thinks that if apphed in the
manner stated and pumped through to the nasopharynx, using the tragus
as the pump, it will cure 30 % of all cases. Removal of ossicles and
membrane when diseased does not as a rule stop the discharge, since
generally, if the bones are diseased, the attic and antrum are also affected
and the complete postaural mastoid operation should be carried out.
The presence of granulations and bare bone in the tympanum does not
show that the antrum is diseased, and these conditions are often rendered
healthy and the discharge entirely stopped by the treatment referred to.
After the radical operation he strongly recommends the glycerin and
iodoform emulsion as an antiseptic application to the cavity. In sewing
up the wound completely behind the ear he allows the anterior flap to
overlap slightly the posterior, thus securing a better scar and preventing
the ear turning outward or becoming depressed into the large meatus.

Diagnosis and Treatment of Tuberculous Disease of the Middle
Ear and Its Accessory Cavities. — W. Milligan^ treats the subject in
detail and summarizes as follows: (1) In all cases of middle-ear disease
of suspected tuberculous origin search should be made for tubercle bacilli
either in the discharge, in tufts of exuberant granulation-tissue, or in
enlarged periotic. (2) Inoculation experiments (either subcutaneous or
intraperitoneal) afford a ready and trustworthy means of proving or
excluding the tuberculous nature of the disease. (3) A final and exact
diagnosis is imperative both from the point of prognosis and from that of
treatment. (4) Tuberculous disease of the middle ear and accessory
cavities is frequent among infants and young children. (5) The disease
is most frequently found as secondary to tuberculous processes in other
regions of the body. (6) Primary tuberculous disease of the middle ear
is probably of more frequent occurrence than has usually been supposed.
(7) The prognosis is always grave, but in a certain proportion of cases
suitably planned surgical intervention would eradicate the disease. (8)
In many of his cases it was advisable to conduct the operative treatment
in stages. (9) When less than 10 % of hearing power remains, no
attempt should be made to preserve the organ as an organ of special
sense. (10) When more than 10 % of hearing power remains in a patient
in otherwise apparent health, a definite attempt should be made to pre-
serve the hearing power which still exists. (11) When the tuberculous
origin of the disease has been scientifically demonstrated, the case should
be regarded as infectious and precautions taken accordingly.

Microscopic Examination of the Discharge in lOo Cases of Middle-
ear Suppuration, with an Analysis of the Results. — Wyatt Wingrave^
presents the following points of interest: (1) Acid-fast and alcohol-fast
bacilli were found in a large proportion of chronic purulent ear discharges.
(2) In 17 cases they were presumably tubercle bacilH in so far that they
conformed to the recognized morphologic and staining characteristics,
and were for the most part associated with trustworthy clinical evidence
1 Lancet, Feb. 21, 1903. ' Lancet, Feb. 21, 1903.

DISEASES OF THE EAR. . 629

of tuberculosis. (3) In 7 cases, while conforming in a greater or less
degree to the staining requirements, they were morphologically unlike
tubercle bacilh, yet 5 of them had either a family or a personal history
of phthisis. (4) The success in their demonstration in a great measure
depends upon the method of collecting and staining, together with
perseverance in search. (5) In the peculiar selective action of the
squames — a property specially attributed to certain bacilli — they had a
possible source of error in diagnosis and an explanation of the pecuhar
affinity of other bacilli or fuchsin.

Ossiculectomy. — Edward B. Bench, ^ in summing up the indications
for the operation of ossiculectomy, divides the cases into 3 classes: (1)
Those cases in which the patient suffers from what is commonly known
as chronic nonsuppurative otitis media, in which the membrana tympani
has always been intact, and for which operative procedures are under-
taken either for the improvement of the function of the organ or for the
improvement of certain symptoms, such as subjective noises and vertigo.
(2) Those in which an operation is undertaken primarily for the relief
of chronic suppuration. Here the principal object is to remove all dead
bone from the tympanic cavity and cause a cessation of the discharge.
Incidentally, the surgeon may also aim to improve the hearing; likewise
to relieve subjective symptoms. (3) Those in which there has been pre-
vious suppuration, but which is at present so slight as to cause the patient
no inconvenience and constitutes practically no menace to life. In this
class the ossicular chain is bound down by adhesions, and the function
of the organ impaired as the result of the changes which have taken place
within the middle ear. The author enters fully into the consideration of
each of these classes, giving indications for operation, technic, with the
dangers which may be encountered. The results obtained, according to his
statistics, seem to show a larger percentage of cases cured and improved
than has heretofore been reported. Out of 88 cases of chronic non-
suppurative otitis with operation for the improvement of function, 76
were improved, 10 were unimproved, 1 grew worse after the operation,
and in 1 the result was unknown. In those cases with operation for the
relief of suppuration, out of 92 cases 53 were cured, 25 improved, 2
unimproved, and in 12 the result was unknown. He states that the
effect upon the hearing in those cases of operation for suppuration has
not been accurately determined in every case, though nearly all showed
improvement, and in no case was the hearing made worse.

A New Method of Treating Suppurating Catarrh of the Middle
Ear. — Albert A, Gray,^ following his experiments, which were published
a few years ago in the "Lancet," in the use of solutions of cocain in anilin
and alcohol in order to produce anesthesia, gives the result of treating
chronic cases of suppuration with a saturated solution of iodoform in
anilin. The cases reported range in age from 3 to 38 years, in one case
the discharge having continued for more than 30 years. Owing to the
toxic effect of anilin, he finds that it is not safe to use more than 5 drops
of the solution at one time. His technic is the same as that usually
adopted : first cleansing the ear with hydrogen dioxid or alcohol, and after

' Med. News, Feb. 28, 1903. ^ Lancet, April 18, 1903.

630 DISEASES OF THE NOSE, THROAT, AND EAR.

drying carefully with a cotton-wrapped probe he inserts a small tampon
moistened with the solution. In conclusion he emphasizes the following
points: (1) The solution should be measured before use. (2) The
dr5dng out should be done with the same care as is required in the present
methods of treatment. (3) Granulations should be removed, though
this is not quite so imperative as it is in other methods of treatment.
(4) The applications should be made by the surgeon himself. (5) The
use of the solution is particularly indicated in those cases which do not
do well when treated in the usual ways — that is, in foul-smelling and
presumably tuberculous cases.

The Ear from a Medicolegal Standpoint. — W. ScheppegrelP ex-
plains the importance of making a careful examination of the patient, and
of not being guided too much by the history given. In illustration of
this, he cites a case in which the patient accused the defendant in a suit
for damages of having been the cause of injury to the ear, when the clinical
examination had demonstrated that the real cause of the injury was due
to an infected toothpick which the patient had used to remove a foreign
body, the toothpick having caused a perforation of the drum and
an infection of the middle ear. The evidence of Scheppegrell, from
notes which he had taken of the case, at once secured the release of the
defendant in the suit. He also calls attention to the importance of
making careful notes in cases of injury, as these may afterward become
the subject of court cases.

Tobacco Deafness. — Wyatt Wingrave^ states that there seems to
be an undoubted tobacco element in the etiology of certain cases of deaf-
ness. He divides the cases into 3 classes, as follows^ (1) Mechanical
or pneumatic; (2) irritative or catarrhal; and (3) toxic or nerve-deafness.
In this last group he alludes to 17 cases and adduces the following points:
They were all marked cases of nerve-deafness unattributable to other
causes and occurring in heavy smokers. The loss of low tones in 50 %
suggested an auditory equivalent for a recognized ocular lesion. There
was definite scotoma in 4 cases and impaired sensation of vision in 8. The
disease was symmetric ; and 80 % showed marked improvement on abstin-
ence from tobacco, and with supplementary drug-treatment 3 were cured.

Aural Bougies.^— G. L. Richards' describes some medicated bougies
for the relief of earache and otitis externa. They can be wrapped in tin-
foil or dispensed in lycopodium powder, and after dipping in warm water
are inserted into the external auditory canal. They are the size of a
quill and half an inch long, and in the experience of Richards have been
instrumental in aborting earache in more than one-half of the cases
occurring in children. Their formula is a modification of Gruber's, and
is as follows :

R . Carbolic acid ni^\ (0.004)

Fluid extract of opium n\.f (0.0085)

Cocain gr. i (0.015)

Atropin sulfate gr. t'4 (0.004)

Add sufficient water, gelatin, and glycerin to make a mass which will dissolve
at the body-temperature.

» Amer. Med., June 28, 1902. ' Med. Press and Circ, Feb. 11, 1903.

» Med. News, Aug. 3, 1902.

DISEASES OF THE EaR. • 631

The Radical Operation for Chronic Suppurative Otitis Media.—

Chevalier Jackson^ advocates the radical operation for chronic suppura-
tive otitis media in the absence of mastoid symptoms when suppuration
has failed to yield in 3 months after ossiculectomy followed by wick
treatment. Kis results in hearing are very much better in cases in which
he has healed the posterior wound from the bottom, removing the poste-
rior bony wall, but not incising the fibrous canal, this having also the
advantage of avoiding the deformity of the concha necessary to an
adequate meatal opening for efficient after-treatment in the usual Staacke-
Schwartze operation with Korner or Pause flaps. When both ears are
affected he advises invariably against these operations, and in favor of
posterior healing from the bottom on
account of conserving the hearing. He
describes a method of posterior skin-flaps
to hasten healing, also a new chisel tre-
phine, mallet, and otologists' rule for
Reed's base-line.

Powder Insufflator. — H. Grey
Brown- has designed an insufflator which ^ig. i29.-Browu's powder insufflator,
can be sterilized either by dry heat or by

boiling (Fig. 129). It is on the principle of what is known as Bart's puff,
but with the following alterations: (1) The pipe unscrews at c. (2) The
top, h, is made of spring metal. (3) For introducing the powder the
screw-top at a is removed. (4) The aperture of the pipe inside is
covered with a piece of gauze to prevent large pieces of powder being
blown through. (5) There is no solder used, allowing the insufflator to
be sterilized by dry heat, in which way, if desired, the powder may be
sterilized inside the instrument.

A Wire Loop for Aural Snares. — Harold Wilson,^ to obviate the
difficulty which often arises in having to rethread an aural snare several

Fig. 130. — Wilson's wire loop for aural snares.

times during a single operation, has devised a loop with the ends of the
wire twisted so that it may be inserted into any snare with a single open
cannula with very little trouble. A piece of malleable steel wire. No. 36
or No. 40 (about one foot in length for the Blake snare), is doubled and
twisted (best in a small lathe, holding the loop end between the fingers),
leaving the loop of any desired size. These loops are so very easy to
make and so inexpensive that they may be made up and kept on hand
in sufficient numbers to have them always ready (see Fig. 130).

An Improved Otoscope. — J. B. Ball^ states that instruments in which

'Ann. of Otol., Rhinol., and Laryngol., Nov.. 1902.

2 Brit. Med. Jour., Jan. 10, 1003. ' Jour. km. Med. Assoc, Nov. 15, 1902.

* Lancet, May 23, 1903.

632

DISEASES OF THE NOSE, THROAT, AND EAR.

a speculum, a reflector, and a magnifying lens are combined in one piece
have long been used for inspection of the ear. On this plan he has had
constructed an otoscope, small and very portable (Fig. 131). The inte-
rior of the otoscope and speculums, instead of being bright, as in the
otoscopes at present most in use, is black, thus bringing out by contrast
the image of the parts to be examined with striking clearness. It can be

Fig. 131. — Ball's improved otoscope.

used with good daylight, sunlight, or artificial light. It is fitted with
three speculums of different sizes, which can be used separately with the
frontal mirror if desired. The interior of the speculums is first bronzed,
then blacked, so that they may be sterihzed by boihng; the exterior
of the instrument is heavily plated so as not to tarnish.

ANATOMY.

By C. a. HAMANN, M.D.

OF CLEVELAND, OHIO.

BONES, JOINTS, AND MUSCLES.

Os Metopica. — Rauber^ discusses the presence of an os metopica, or
OS interfrontalis according to his nomenclature, and an os supranasalis
in the corresponding fontanels. On the external surface of the frontal
bone and 20 mm. above the nasion he found distinct traces of sutures,
which he believes to have been continuous with two corresponding sutures
on the internal surface. These sutures appear on the lateral surface of
a small narrow plate of bone, which is termed by the author os inter-
frontalis. Schwalbe claims that proof is lacking of the separation of these
bones at the upper and lower extremity, and that the formation might
have been irregular, having been developed from above and below instead
of laterally. Schwalbe has never observed an os metopica although
they have been reported by E. Fischer. Above the root of the nose the
author has observed an elongated piece of bone, surrounded by the re-
mains of the supranasal sutures first described by Velpeau in 1837, and
later by Schwalbe. This bone he considers an os fontanellse supranasalis,
although Schwalbe declares that this area of bone is the result of irregular
suture formation.

The Amount of Fluorine Contained in the Bones and Teeth. —
Jodlbauer^ found that herbivora and carnivora show no great difference
as to the quantit)'' of fluorine, although it does vary considerably in some
animals. The flat bones of some animals contain less fluorine than the
long bones, although the percentage is not constant in the different long
bones. The humeras contains more fluorine than the femur. Whether
the function or the nutrition of the bone has any relation to this ele-
ment remains to be seen. The teeth contain a greater quantity of fluorine
than the bones. The enamel is responsible for this large percentage.
The back teeth contain more than the front. The tooth germs contain
more than the first teeth. The relatively small quantity of fluorine at
this early period would give the impression that the lower jaw sacrifices
its fluorine at this period for the embryonic teeth.

Histology and Histogenesis of Cartilage. — Srdinko^ has found in
the cartilage of mammalian and human embryos cells with protoplasmic
prolongations. These cells are devoid of a capsule and divide by the

1 Anat. Anz., Oct. 24, 1903. ^ Zeit. f. Biol., N. F. xxvi, p. 259, 1902.

3 Anat. Anz., Jan. 30, 1903, p. 437.

41 S 6.33

634 ANATOMY.

formation of a great many daughter-cells. Many of these cells in their
youthful state are bound together by protoplasmic anastomoses, which
have been demonstrated by various methods. The ground-substance is
homogeneous or fibrillary. The fibrillation is due to the penetration of
the nutrient fluid. Embryonic cartilage changes directly to hyahne
cartilage, in which the cells lose their protoplasmic prolongations and are
surrounded by a capsule. A portion of the ground-substance is prob-
ably derived by the direct transformation of the cells. In mature hyaline
cartilage of mammals and the human species the cells do not send forth
the processes as in the embryo. In the ground-substance one can often
see fine fibers, passing from cell to cell; these fibers are not artefacts.
The nutrition of cartilage is effected by nutrient fluids which leave the
vessels and enter the cartilage along these fine fibrillas.

The Role of Atmospheric Pressure in the Hip-joint. — Since the
contribution of the Weber brothers in 1836 on the anatomy and phys-
iology of the hip-joint, calhng attention to the negative air-pressure as
an important factor in supporting the head of the femur in the socket,
various authors have held tliis to be one of the main supports. Seabury
W. Allen ^ overthrows this theory and beheves that the cotyloid hgament
is the principal support, then the capsular Hgament, and the air-pressure
need not be considered.

A New Muscle of the Eye (Musculus papillae opticae). — G. Nicolai*
has observed at the head of the optic nerve of man and several animals
a muscle consisting of circular, longitudinal, and radiary fibers. Further
investigation upon this subject will inform us whether the author did not
mistake the mesodermal structure of the elastic coat of the artery for
muscular fibers.

Congenital Absence of Both Inferior Recti Muscles. — Edw.
Stieren^ reports the case of a child who when asked to look down flexed
his head upon the chest, the eyes not moving below the horizontal plane.
Operative interference disclosed the absence of the inferior rectus of the
right eye. Although the left side was not operated upon, the author con-
cludes that this case was one of binocular congenital absence of the in-
ferior recti. He was unable to unearth a similar case in the hterature.

A Complete Absence of the Superficial Flexors of the Thumb
and Concurrent Muscular Anomalies. — W. S. Hall* records the case
of an anomalous condition of the muscles of the thumb. The thenar
eminence was less prominent than usual, which was due to the complete
absence of the abductor polUcis, the opponens polUcis, and the super-
ficial head of the flexor brevis polUcis. After removing the skin the
entire metacarpal bone of the thumb was exposed. Moreover, the short
stout branches of the median nerve and the superficial palmar arch were
absent. The tendon of the extensor ossis metacarpi polHcis was double
and from the external tendon a small quadrilateral muscle 15 mm. square
passed transversely inward and was implanted in the superficial aspect
of the anterior hgament. This sHp together with the extensor ossis

» Boston M. and S. Jour., April 9, 1903. ^ Ann. d'Oculist., Nov., 1902,

^ Amer. Med., April 11, 1903. * Jour. Anat. and Physiol., April, 1903.

BLOODVESSELS AND LYMPHATICS. ' 635

metacarpi muscle provided a functional compensation for the missing
group.

BLOODVESSELS AND LYMPHATICS.

Notes on the Topographical Anatomy of the Operation of Making
an Anastomosis between the Portal Vein and the Ascending Vena
Cava. — G. Russo-Travali^ directs as follows: The abdomen being
opened, the edge of the liver is Hfted up and the colon pushed down,
The cysticoduodenal ligament is then exposed, and the part of the
duodenum looked for which embraces the head of the pancreas. The
hepatoduodenal ligament is next sought. The anterior layer of this
peritoneal structure is then divided and the ducts and hepatic ar-
tery are then pushed aside to expose the portal vein, which is freed
as far as possible from the margin of the pancreas to the hepatic
sulcus. The vena cava is situated on a deeper plane, being exposed
by pushing aside the hepatoduodenal ligament and the duodenum,
and is covered by the posterior layer of the peritoneum. The portion of
the vena cava between the renal veins and the spermatic or ovarian vein
is the best for the anastomosis. On the right and externally, this portion
is in relation with the right kidney and ureter, internally with the aorta,
in front with the third portion of the duodenum, and behind with the
lumbar vertebras. The lumbar veins which enter the vena cava from
behind should be remembered when applying forceps to .the wounded
vena cava. Sometimes the right renal vein is inserted in front of the vena
cava.

The Existence of an Unknown Blood-supply to the Embryonic
Stomach. — Broman,^ in his studies on the development of the omental
bursa and neighboring structures, observed one, two, or more branches of
the ductus venosus arantii running through the attachment of the omen-
tum minor into the mesodermic stomach-wall, in which they form a dense
network. Those branches of the celiac axis, which anastomose with
this plexus, seem to be sHghtly developed at this period. They were
never found in older embryos, probably obliterating with the spreading
and thinning out of the lesser omentum. He considers these vessels"
of great importance in the development of the stomach, and gives the
following reasons: (1) an organ shows the greatest growth when its nutri-
tion is the best; (2) that during the existence of these veins the stomach
displays its greatest growth (the time that its breadth increases beyond
that of the other parts of the alimentary tract) ; (3) the ductus venosus
supplies the most nourishing blood (direct from the placenta) ; (4) these
branches from the ductus venosus are short and direct. He has found
these veins in the embryo of the pig and cat, also chicken, turtle, and
Necturus embryos, and is under the supposition that they exist in all
vertebrates with well-developed stomachs.

The Branches of the Superior Mesenteric Artery to the Jejunum
and Ileum. — Thomas Dwight* states that the number of branches of the

' Riforma Medica, April 15, 1903. ^ Ar.atom. Anz., July 30, 1903.

3 Anatom. Anz., May 15, 1903, p. 184.

636 ANATOMY.

superior mesenteric artery from the left side is very variable ; there may
be 20, but of these only 6 or 7 are of considerable size. The first one is
generally small and is followed by 4 to 6 larger ones, arising near to-
gether and supplying the upper half of the small intestine ; the remainder
are smaller. The first two or three divide into an ascending and a de-
scending branch, each of which inosculates with the corresponding branch
of the neighboring artery, thus forming a single row of arches, from which
the straight vessels descend to the border of the intestine. Near the be-
ginning of the small intestine we notice a frequent modification of the
plan of the arches, small loops connecting them near their origin. The
parallel vessel is formed chiefly by the subdivisions of the primary
branches, and slightly by the connecting-links. The next modification
to occur is that branches may give off secondary branches from their
sides, which subdivide and at their ends anastomose with the primary
branches. Lower down in the intestine secondary loops of bifurcation
become more frequent, and near the beginning of the second quarter
of the small gut we often find an approach to a second tier of arches.
While the vessel diminishes in size the arches become more complex.
Toward the end of the ileum the arrangement is uncertain. There is a
free anastomosis between the termination of the superior mesenteric
artery and its ileocoUc branch. The system of straight vessels extends
throughout the jejunum and ileum from the parallel vessel to the gut.
At the jejunum they are numerous and large, having a length of 45 cm.
and occasionally branch. Anastomoses practically never occur between
them in the mesentery. Most frequently the entire vessels are distrib-
uted alternately to one side or the other of the gut, although they may
divide at the gut, sending one branch to either side. After the first third
of the small intestine the straight vessels are smaller and shorter, but
still characteristic, although at the end of the ileum they become small
and very irregular.

Topographic Anatomy of the Bronchial and Tracheal Lymph-
glands. — W. Sukiennikow^ states that the appearance and arrangement
of the tracheal, bronchial, and pulmonary lymph-glands are subject to
, certain regular rules. The synoptical relations of the trachea and bronchi
produce 3 inclosed spaces which are filled with tracheobronchial lymph-
glands. The bronchopulmonary lymph-glands are always found in the
angles of the bronchi or their branches, the same as in the bronchotracheal
glands. From their relation to the trachea, the bronchi and their
branches, and to the lungs, and from their absorption of the lymph from
these organs, two main systems of lymph-glands are recognized: (a)
Tracheobronchial lymph-glands, subdivided into right, left and inferior
or bifurcational tracheobronchial glands; (6) bronchopulmonic, sub-
divided into the eparterial, ventrales dextra I, ventrales sinistra I, ven-
trales dextra II, etc., corresponding to the bifurcation. Enlargement
of the right tracheobronchial glands will push the right vagus toward
the lung. The left vagus is not closely related to its respective set
of glands. The inferior laryngeal nerve is affected by the swollen gland
1 Berl. klin. Woch., April 6, 1903.

BLOODVESSELS AND LYMPHATICS. 637

under the aorta and under the thyroid gland. The predominance of the
anterolateral position of the lymph-glands, especially of the tracheo-
bronchial glands, makes percussion a doubtful factor in the diagnosis of
enlarged glands.

The Relations between the Lymphatics and the Connective
Tissue. — The question of anastomoses between the lymphatics and the
lymph-spaces, " Saftkanalchen," is considered by W. G. MacCallum,^ who
comes to the conclusion of Ranvier, that the lymphatics end bhndly and
present no stomas. The Saftkanalchen are not spaces, but are due to the
separation of cells and intercellular substance, and these tissue-spaces
are variable instead of being definite cavities Hned with endothehum.
By injecting the lymphatics with silver the endothehal lining behaves
similarly to that of the bloodvessels, presenting no pores or holes, except
some artefacts due to trauma. Sohd matter is taken up by the lymph-
atics through the agency of phagocytic leukocytes, which have the power
to enter or leave the bloodvessels or lymph- vessels by their independent
mobility. The lymphatic system is produced by long-continued sprouting
of bUnd tubules from the bloodvessels. Lateral branches are formed
from a single row of endothehal cells by sprouting of swollen and divid-
ing end-cells.

Relation of the Lymphatics of the Peritoneal Cavity in the Dia-
phragm and the Mechanism of Absorption of Granular Materials
from the Peritoneum. — W. G. McCallum^ concludes from his study on
the diaphragm of dogs that the peritoneal endothelium is a complete and
unbroken layer of cells, not presenting stomas as described by v. Reck-
Unghausen, but the cells have power to retract from one another, as
Muscatello, Kolossowo, and others have shown. The lymphatics of the
diaphragm form a dense layer beneath the endothelium. The radial trunks
are embedded between the musculature of the diaphragm and anastomose
freely with the pleural lymphatics. This leaves only a continuous layer of
endothehum between pleura and peritoneum. Granules, however, enter
the lymph-channels of the diaphragm, later appearing in the medias-
tinal lymph-glands. After injecting granules into the peritoneal cavity,
there appeared in a short space of time phagocytic leukocytes, each laden
with a granule, forcing their way between the cells, then Uning the lymph-
channels of the diaphragm into the mediastinal glands. This process
is somewhat accelerated by the respiratory movements. After exclud-
ing all Hfe from cells by heat or chemicals, there still occurred some ab-
sorption, which was demonstrated by the outhne of granules around
the epithehal cells.

Lymphatics of the Ureter. — The investigations of K. Sakata^ upon
the lymphatics of the bladder and kidney, which are of importance re-
garding the theory of ascending infection, brought him to the conclusion
that the organs have no direct lymphatic connections, but through the
anastomosing of the glands or through the lymphatics of the ureters.
The lymphatics of the ureter are situated apparently only in the muscular

* Bull. Johns Hopkins Hosp., Jan., 1903. ^ Anatom. Anz., May 6, 1903, p. 157.
« Arch. f. Anat. u. Phys., 1, p. 1, 1903.

638 ANATOMY.

coat and on the surface. The lymphatics of the lower ureter lead to the
hjrpogastric glands or to the lymphatics of the bladder. Those of the
middle ureter run to the lumbar glands, wliile those of the upper part
are seen to take a course toward the aorta or anastomose with the lymph
of the kidney.

VISCERA.

Liver-cell. — Schlater^* gives his version of the architecture of the
liver-cell. Browicz and the author are of the opinion that the Hver-cell is
a comphcated morphologic structure analogous to an organ. The paren-
chjTna is made up of a structureless ground-substance through which
fibrillas run and granules (cytoblasts, Arnold) are found. The fibrillas
contracting on the parenchyma of the cell move the erythrocytes and
hemoglobin toward the nucleus through the ground-substance. Schlater
considers the nucleus to be made up of two ellipsoid bodies having
a common axis ; the smaller body being contained in the larger one. This
internal body presents a clear unstained space, whose function he is not
able to state. Between the surfaces of the two ellipsoids 6 nuclear
granules are constantly found, which have fixed positions. One granule
is found at each end of the common axis, the other 4 being situated at
the comers of a square, perpendicular to the long axis and through the
center of the ellipsoid.

Lymph-canaliculi of Cells of Liver and Suprarenal Body. — Emil
Holmgren^ discusses the " Saftkanalchen" (lymph-canaHcuH) of the Hver-
cells and of the epithelial cells of the suprarenal body. In an earlier essay
he considered that the canalicuU belonged to a trophospongiosiun, and
that the intracellular canals are not connected with the bile-capillaries.
Browicz, and the author both called attention to these intracellular
structures. The bile-capillaries possess tail-pieces. From the epicellular
spaces canals penetrate the cell more or less ; some of these reaching the
nucleus, but never penetrating it. Browicz claims that the bile-capil-
laries have their origin in the nucleus. They can easily be distinguished
from one another; the nutrient canals are of a light color and are continu-
ous with the perivascular interstices and never in direct contact with the
intercellular bile-capillaries. The bile-capillaries can easily be recognized
by their tails. Holmgren has also demonstrated the lymph-canaliculi
in the suprarenal body. Holmgren is of the opinion that in these
nutrient canals fermentative processes occur whose products are granules
or drops (vacuoles).

The Cardiac Glands of Mammals. — R. R. Bensley' concluded
from his examinations of the cardiac glands of man, pigs, and gnawing
animals that the cells were mostly mucous with few chief or parietal
cells, contrary to the opinion of the German school. Toward the fundus
the chief and parietal cells grow still scarcer. He believes that the cardiac
glands are regressive fundus glands in which the most essential parts have

» Anatom. Anz., Nov. 24, 1902, p. 249. ^ Anatom. Anz., Sept. 20, 1903.
3 Am. Jour. Anat., p. 105, 1902.

VISCERA. . 639

degenerated. This degeneration he attributes to the mechanical irri-
tation from the entrance of food.

The Relations between the Suprarenal Body and Growth of the
Body. — P. Linser^ reports the case of a boy 5^ years old of gigantic
structure who gave the appearance of a youth of 16 to 18 years. An
inoperable tumor was found in the left renal region which at autopsy
proved to be a maHgnant tumor of the suprarenal body. The author
beUeves that the glands of the blood, under which are included the thyroid,
hypophysis, thymus, suprarenal bodies, and genital organs, have a certain
close relation among themselves. They can influence the function of
one another and also the growth of the body. In giants we generally
observe tumors of these glands, while in dwarfs hypoplasia or aplasia
is observed.

Gallbladder. — In liis article Brewer^ states that in the lower portion
of the S-shaped curve of the gallbladder Hartmann has described a large
semilunar fold attached to two-thirds of the circumference of the wall,
the center of attachment being on the right. Beneath this, arising from
the left side or promontory, at the upper arm of the curve, is another
but smaller valve. Between these two valves a space called by Hartmann.
" le bassinet de la vesicule," or the pelvis of the gallbladder, is found.

The Form of the Human Spleen. — R. K. Shepherd^ recalls the fact
that the normal spleen shows enormous variations in size and shape.
The parietal surface, the surface next to the diaphragm, is quite constant
in its form, but the visceral surface, which contains a number of areas,
usually 2 or 3, the renal, the gastric, and the basal or coUc surfaces of
Cunningham, varies considerably. Two chief types of spleen are met
with in hardened subjects. In the first type, the segmental, it is shaped
Hke the segment of a pear with a parietal surface and two visceral areas,
the renal and gastric. In the second type this organ is shaped Hke an
irregular tetrahedron having a parietal surface and three visceral areas,
the gastric, the renal, and the,cohc areas, which meet at a point, the inter-
mediate angle or the apex of the tetrahedron. The gastric and renal
areas are always separated by an intermediate border. The gastric area
is marked off from the parietal area by a distinct border, while the renal
area is separated from the parietal surface by a border, the posterior.
These are the only borders found in the segmental type. In the tetrahe-
dral type three secondary borders are met in addition to those described
above. The types are due to the state of distention of the surrounding
organs. When the stomach is distended and the colon is empty, we have
the segmental type; when the conditions are reversed, we have the tet-
rahedral type. A tubercle is often found on the intermediate border;
when found, the border below is very much flattened. This tubercle
is probably due to the relationship of the tail of the pancreas. A process
of peritoneum is seen in the tetrahedral type passing over the anterior
angle of the spleen, the origin of which is unknown. In some spleens
a Henophrenic Hgament is observed.

* Beitr. zur klin. Chir., xxxvii, p. 282, 1903. ^ Med. News, May 2, 1903.

* Jour. Anat. and Phys.,1.0ct., 1902, p. 50.

640 ANATOMY.

The Position of the Gallbladder. — S. Carmichael^ finds that the
generally accepted statement that the gallbladder is found lying op-
posite the ninth costal cartilage is erroneous in 75 % of cases. The
position of the ninth costal cartilage itself varies on account of differences
in its length and direction. He beHeves that the gallbladder should be
located by a vertical line, dropped from the middle of the clavicle,
which will generally cross some part of the fundus. The fundus lies from
1 cm. to 9 cm. outside of the right lateral line described by Addison in
90 % of the cases observed by Carmichael.

Division of the Left Auricle of the Heart by a Fibrous Band. —
T. Waldrop Griffith^ in his description says that the left auricle was
divided into 2 compartments by a broad fibrous band, which started
from the auricular septum, where it was continuous with the tissue of the
valvula foraminis ovalis, from which it arose by several spurs. This
band passed upward and forward below the upper right pulmonary vein,
then along the anterior and left walls of the auricle and below and in front
of the left pulmonary vein, and becoming narrower, was lost on the pos-
terior wall of the auricle. The concave margin formed about two-thirds
of the aperture between the two auricles, which admitted 2 fingers. At
the auricular wall several small apertures were observed. Griffith is of
the opinion that this anomaly is due to the failure in the complete amal-
gamation of that part of the auricle which is supposed to be formed
from the confluent portions of the pulmonary vein and that derived from
the left-hand division of the common auricle of the embryonic heart.

Anatomy of the Pancreas. — The surgical importance of the pancreas
at the present time renders a consideration of its anatomy, embryology,
and anomahes of practical interest. E. L. Opie^ has always found two
ducts present. The common duct always joined the duct of Wirsung,
while the duct of Santorini emptied into the intestine above. In 10
cases out of 100 the ducts failed to anastomose with each other in the
gland, and in 4 only minute anastomoses ej^sted. In 28 instances the
duodenal end of the duct of Santorini was not patent; therefore in one-
third of cases this canal cannot act as an accessory duct, if the duct of
Wirsung is occluded. In 11 cases out of 100 the duct of Santorini was
as large or larger than that of Wirsung. The head is composed of two
lobes, an anterior and lower one, tributary to the ductus Santorini, and
a posterior lobe, tributary to the duct of Wirsung. They are divided
by a cleft, fiUed by adipose tissue. HeUy has found within the papilla
of the ductus Santorini lobules of pancreatic parenchyma situated imme-
diately below the duodenal mucosa; they constitute a true accessory
pancreas. Helly found this pancreatic tissue to develop very early in
embryonic life from lateral branches, which bud from the duct as it
passes through the mesoblastic layers of the intestinal wall. Opie be-
lieves this process to be responsible for aberrant pancreatic tissue em-
bedded in the wall of the stomach or intestine. He has found this
anomaly in 10 out of 1800 cases. Opie is of the opinion that at a very

ijour. Anat. and Physiol., Oct., 1902.

2 Jour. Anat. and Physiol., April, 1903. ^ Amer. Med., June 20, 1903.

VISCERA*'^ • 641

early period of embryonic life a lateral branch of the pancreatic duct
entangled in the mesoblastic layer of the intestinal wall is carried by
longitudinal growth of the intestine away from the pancreas and a new
duct is formed. The pancreas consists of two functionally diverse ele-
ments, cells of secreting acini which supply to the intestine important
digestive ferments and cells of the islands of Ijangerhans, which have
no communication with the ducts of the gland, but are in intimate
relation to the bloodvessels, through which medium they exert their
effect upon carbohydrate metabolism.

The Development of the Islands of Langerhans in the Human
Embryo. — Richard M. Pearce^ made observations on embryos varying
in age from 7 weeks to 7 months. In 7 weeks' embryos there is seen on
the periphery of the tubules a distinct proUferation and differentiation
of cells. These areas lie in the concavity of the tubules and show at
8 to 10 weeks evidences of vascularity. At the end of 3 months these
processes are separated from the acini, and a solid mass of cells connects
the islands with the gland acini. There is distinct vascularity, the
vessels coming from all sides. This stage is followed by complete separa-
tion of the island from the gland by connective tissue. In a syphiUtic
embryo of 3 months the connective tissue showed great development,
probably arresting the development of the gland.

The Normal Appendix : Its Length, Its Mesentery, and Its Posi-
tion or Direction, as Observed in 656 Autopsies. — George H. Monks
and J. Bapst Blake^ give statistics the results of which form the following
conclusions: The average length of the appendix in men, women, and
children is 7.9 cm., the extremes being 1 cm. and 24 cm. No relation
exists between length of body, age or sex, except that children are apt
to have an appendix proportionately larger than adults. Fully one-half
of all appendixes have a mesentery which reaches nearly to the tip. The
other half have mesenteries reaching as far as the middle of the appendix
or beyond. Occasionally an appendix is devoid of any mesentery. The
commonest position for the appendix is down and in, that is, toward
the pelvis, the appendix frequently hanging over the brim of the pelvis.
After this it is most frequently found behind the cecum, then in a down-
ward direction, and then inward. The appendix is in one of these
positions in three-fourths of all cases.

Determination of the Duodenum by the Glands of Brunner. —
Konrad Helly' gives a new method of determining the length of the
duodenum by the glands of Brunner. There may be difficulties in
recognizing the boundary between the duodenum and jejunum in the
cadaver due to abnormalities in this situation, among which may be
mentioned the occurrence of a so-called free duodenal mesentery, and
an opposite condition, the fixation of the beginning of the jejunum to
the posterior abdominal wall, and the formation of abnormal duodenal
loops. Normally the attachment of the suspensory muscle of the duode-
num and the crossing of the superior mesenteric artery and the small

» Med. News, April 4, 1903. ' Boston M. and S. Jour., Nov. 27, 1902.

^ Anatom. Anz., Jan. 19, 1903.

642 ANATOMY,

intestine occur in the same location and indicate the duodenojejunal
junction. In the absence of this duodenojejunal flexure, Broesicke, His,
Toldt, and Oppel have determined the length of the duodenum by
different methods. Oppel, Gegenbaur, Henle-Merkel, Langer-Toldt,
Stoehr, Rauber, and v. Ebner have given various distributions to the
duodenal glands, most of them finding them to be distributed tliickly
around the pylorus, diminisliing in number in the descending loop, past
which they are seldom found, Boehm and Davidoff state that the entire
duodenum is lined with Brunner's glands. In 14 normal duodenums
Helly has always obtained the same constant result. The glands of
Brunner, thickly distributed at the pylorus, decrease in number up to
the entrance of the bile-duct, from where they grow scarcer, and cease
at the duodenojejunal flexure. In his fifteenth case he found a duode-
num with a free mesentery and no attachment to the posterior abdominal
wall. Only a superior horizontal and a descending portion could be
recognized. The suspensory muscle of the duodenum was absent.
Measurements gave no satisfactory results. Upon liistologic examination
it was found that the lowest glands were found at a point 14 cm. from
the pylorus, which point corresponded to an artificially produced duodeno-
jejunal flexure. He suggests, therefore, that the lowest limit at which
the glands of Brunner can be found be regarded as the end of the duo-
denum.

The Nature and Anatomy of Enteroptosis (Glenard's Disease). —
Arthur Keith^ from an anatomic standpoint assumes that enteroptosis
is the result of a vitiated method of respiration, either from yielding
of the thoracic support or the weakening of the abdominal. The muscles
of the cms of the diaphragm whose spinal attachments tend to pull
this organ down, are most important factors in producing ptosis. The
diaphragm has 3 supports — the abdominal, thoracic, and costal, of which
the thoracic is of more importance than is generally believed. It sup-
ports the center of the diaphragm by the attachment of the cms muscles
to the heart, pericardium, great vessels, and lungs, which directly or
indirectly attach the upper surface of the diaphragm to the structures
at the root of the neck and to the whole extent of the thoracic wall.
Each contraction of the diaphragm has to overcome the thoracic support.
Too much importance is given to the passive bands wliich fit the viscera
to the abdominal wall. The extrusion of viscera from the subdiaphrag-
matic space is attributed to the constricted thorax pressing on the epigas-
tric region, which prevents the stomach and liver from swinging forward,
and depression of the ribs, which displaces the costal fibers of the dia-
phragm vertically, exerting a downward pressure upon the abdominal
viscera. The disused abdominal muscles are not able to counteract the
diaphragm after the constriction is released.

1 Lancet, March 7, 1903.

NERVOUS SYSTEM. ' 643

NERVOUS SYSTEM.

Nucleus Salivatorius of Chorda Tympani. — Kohnstamm^ was able
to demonstrate in the dog degenerative changes in a group of cells in
the medulla after section of the fibers of the chorda tympani which pass
to the submaxillary gland. He suggests the name ''nucleus salivatorius"
for these cells, inasmuch as they are to be regarded as the origin of
fibers ending in the submaxillary ganglion. This group of cells extends
from just in front of the posterior extremity of the nucleus facialis to
the anterior extremity of the motor root of the fifth nerve; they are
distributed over a considerable area. The cells resemble the motor cells
of the anterior horns and of the cranial nerve-nuclei. The fibers issuing
from them decussate and leave the brain as the nervus intermedins
Wrisbergii. This nucleus salivatorius is supposed to innervate all the
salivary glands. It would seem proper to regard the nervus intermedins,
whose peripheral portion is called chorda tympani, as an independent
sensorimotor cranial nerve.

Structure of the Choroid Plexuses. — Catola^ has investigated the
choroid plexuses by the Weigert method of staining and finds 2 kinds
of neurolgia fibers entwined in a ring-like manner about the bloodvessels.
He describes 3 layers of tissue in the plexuses An epithelial layer, a
layer of neuroglia, and the connective-tissue and bloodvessel layer. The
first two are remnants of the original brain tissue, while the third is
derived from the pia mater; the arachnoid does not enter into the forma-
tion of the plexuses according to the author J. Mamura,^ however,
describes the arachnoid as taking part in the formation of the plexuses.

A Study of the Cerebral Cortex in a Case of Congenital Absence
of the Left Upper Limb. — Macroscopic comparison of both hemispheres
of a man whose left lower arm was congenitally absent disclosed no greater
difference than exists between normal hemispheres. Moorehead* beheves
that the differences found by Gowers, Bastian, and Hornby were within
the normal variations.

The Extent of the Surface of the Cerebellum. — Kreuzfuchs^ finds
that the total surface area of the cerebellum is 84,246 sq. mm.; of this
area the concealed portion is 4 times as great as the free area. In the
cerebrum the concealed area is about twice as great as the free area.
The number of Purkinje's cells was estimated at over 14,000,000.

Structure of the Dura Mater Cerebri. — S. Nose^ finds that the
outer layer of the dura is covered with a layer of large cells, which are
to be looked upon as modified connective-tissue cells. In the child there
is a single layer of these cells, whereas in the adult there are several.
Directly beneath these cells is an elastic membrane, which increases in
thickness up to the twentieth year. Nose confirms the statement that
the dura is rich in elastic fibers. The vessels of the dura show a pro-

* Anatom. Anz., xxi, 1902. ' Riv. di patol. nerv. e mentale, 1902, No. 9.

' Arbeit, aus Prof. Obersteiner's Laborat., 1902, Heft 8.

* Jour. Anat. and Physiol., Oct., 1902.

* Arbeit, aus d. Neurolog. Institut. a Wiener Univ., ix, 1902, p. 274.
' Arbeit, aus Prof. Obersteiner's Laborat., 1902, Heft 8.

644 " ANATOMY.

gressive thickening of the media, beginning at the thirtieth year. The
dura is more vascular in adults than in children, the parietal layer being
more vascular than the visceral. Nerves are also abundant. The pac-
chionian bodies are more numerous in adults than in children, the nuclei
are less abundant, and the connective tissue has proliferated.

A Further Note upon the Prepyramidal Tract (Monakow's Bun-
dle).— After destroying the tract between the optic thalamus and the
crossing of the pyramids in apes and cats, E. H. Fraser^ concluded that
the fibers of Monakow's bundle (descending motor cortico-tegmental
fibers) have their source in the red nucleus of the tegmentum. In apes
it is narrower and less diffuse than in the cat, in which the fibers of the
crossed pyramidal tract intermingle quite freely with those of Monakow's
bundle. The collaterals of the bundle fibers enter on the sides of the
anterior horn in the gray substance, and end in the cells of the anterior
horns. Fraser did not observe any ascending fibers in Monakow's
bundle.

A Study of the Brain-weights of Men Notable in the Professions,
Arts, and Sciences. — Edward Anthony Spitzka^ says that heavy brains
of idiots, imbeciles, and others of that class, and of ordinar}'- laborers
can nearly always be explained by pathologic hypertrophy, either con-
genital or acquired, as abnormal development of the neuroglia with
diminution of ganglion-cells, or abnormal gyral development. The recent
studies on the brains of scientists, including the brains of Hugo Gylden,
Kovalewski, Helmholtz, the composer Lentz, Gambetta, and others,
show that the index of an individual's prominent characteristics is to be
found in certain individual pecuHarities in the development of one or
another cortical region. The higher developed the individual, the greater
power of association will be possessed by the mind, and superior develop-
ment and arrangement of the gyri and special cortical fields will be
observed. The weight of the brain is influenced by senile atrophy,
fluid in the ventricles, blood, etc., at the time of autopsy. The average
weight of 96 brains of eminent men was greater than that of 100 ordinary
brains. Donaldson calls attention to the fact that the decrease of brain-
weight in senile persons is deferred a decade in the highly intellectual
class. Men of exact science have the heaviest brains, then the natural
scientists, followed by men of fine art, philosophy, etc., then "men of
action," government employees, poUticians, military men, etc.

The Cerebrum of a Microcephalic Idiot. — N. C. McNamara^ reports
the case of a microcephalic idiot whose cranial development was of a
low type and whose cerebrum was insignificant. He was unable to
speak, but expressed his wants by signs. He was entirely devoid of
intelhgence, but seemed to appreciate the sound of music. His sight
and sense of smell and hearing were good. His head measured 7^ inches
from the glabella to the occipital protuberance, and 8i inches from the
tip of one mastoid to that of the other. The brain weighed 12^ ounces,
and the cerebellum projected f inch beyond the occipital lobe. The

' Jour, of Phys., Sept. 12, 1902. ^ Phila. Med. Jour., May 7, 1903.

^ Jour. Anat. and Physiol., April, 1903, p. 258.

GENITOUllINARY TRACT. • 645

stems of the sylvian fissures and their posterior horizontal limbs are
alone present. The posterior ramus of the sulcus of the right side is
nearly at a right angle with the cerebrum; on the left side it has an
angle of 65°. In the left hemisphere the orbital and frontal opercula
are wanting and the frontoparietal operculum is imperfectly developed.
In the right side this condition of the opercula was marked. The island
of Reil consists of a small smooth nodule presenting no gyri or sulci
except a semblance of a longitudinal fissure. The frontoorbital sulcus
is well defined, and forms the anterior Hmiting sulcus of the island of
Reil, the same as in anthropoid apes; in fact, the cerebrum resembles
that of a full-grown chimpanzee. That portion of the cerebrum posterior
to the central sulcus shows the most marked anomalies. The calloso-
marginal sulci cut into the superior border of the hemispheres posterior
to the upper end of the central fissure. The intraparietal sulci are of
an ape-Hke character. The parietooccipital sulci, especially the left one,
pass into fissures corresponding to the " Affenspalte" of the ape's cere-
brum, but there is no occipital operculum. The temporal lobes project
but little beyond the inferior terminal portion of the great Hmbic lobe;
they present only 2 distinct sulci. This brain corresponds more to that
of an adult chimpanzee than to a human cerebrum. The absence of
speech can be attributed to the presence of only rudiments of the oper-
cula of the third frontal gyrus of the left hemisphere and the insula.

GENITOURINARY TRACT.

Two Cases of Complete Bilateral Duplication of the Ureters. —

In A. H. Gould's^ cases of this rare anomaly the kidneys of both sides
presented 2 pelves, from each of which 2 distinct patent uretere ran
and were separate throughout their entire course. Each ureter had a
separate orifice in the bladder.

The Curve of the Fixed Portion of the Urethra. — Many authors
have endeavored to give accurate mathematic descriptions of this portion
of the urethra, among them Kohlrausch, Engel, Henle, and Testut, all
of whom differ. Fr, Merkel,^ investigating the literature upon the
subject, could not find the reasons for this variance. Testut de-
scribed 3 portions of the fixed urethra, one portion anterior, another
posterior, to the urogenital diaphragm, and that part inclosed by the
diaphragm. That portion anterior to the diaphragm is controlled
by the hgaments of the penis and the amount of fat in this region. The
part posterior to the diaphragm is also quite mobile, depending upon
the fulness of the bladder and rectum. Garson demonstrated that filling
the rectum raises the bladder. As the urethra remains fixed in the
diaphragm, the intrapelvic portion stretches as the bladder rises, and
the prostate is elongated. The more the bladder is pushed forward, the
more the prostate will be displaced, consequently the angle of the urethra
will be more acute. When the rectum is empty, the fluid in the bladder
plays an important role. If the bladder is empty, the curve is fiat;

' Am. Jour. Med. Sci., March, 1903. ' Anatom. Anz., June 24. 1902.

646 ANATOMY.

on the other hand, if it is filled, it presses on the prostate and the urethra;
the gland is flattened while the urethra is shortened. In cases of simul-
taneous dilation of both the rectum and bladder the curve remains the
same as if the organs were empty. A curve of the urethra in the position
described above will correspond to the arc of a circle whose radius is
25 cm, long, and whose center is located on the posterior surface of
the symphysis pubis, at the upper border of the lower quarter. The
greater portion of the arc is included in the intrapelvic portion, which
flattens out to a slight degree posteriorly near the bladder. The true
stationary urethra does not lie under the symphysis pubis, but in a line
corresponding to a tangent to the posterior surface and 15 mm. below
the symphysis. He . claims that it is impossible to give an accurate
length of the posterior portion as Sappey and Testut have done.

I A Case of Genuine Hermaphroditism. — Aside from the malforma-
tion of the external genitalia, this case, reported by Garre,^ presented
a hernia-Hke protrusion of the left inguinal region, whose contents con-
sisted of a testicle, epididymis, spermatic cord, ovary, tube, and par-
ovarium. These organs were recognized microscopically. Rectal ex-
amination revealed a band, extending from the urethra to the left linea
temporalis, where two bodies the size of pigeon-eggs could be palpated,
probably ovary and testicle. This is most hkely a case of true bilateral
hermaphroditism. JVIicroscopic examination of the testicle showed the
characteristics of a retained inguinal testicle, retrograde changes, and the
absence of spermatogenesis. In the ovary primary follicles could be
observed.

True Hermaphroditism. — W. Simon^ reports the case of an indi-
vidual 20 years old growing up as a boy who desired to develop into
one of the male species. His breasts were well developed, and during
the last 3 years they became swollen at intervals. At regular periods of
4 weeks blood would appear at the genitals. For a number of years he
had become sexually excited by females, having erections and a discharge
of semen containing no spermatozoa. At the symphysis a cylindric
penis-Uke body of 4 cm. length and 6.5 cm. circumference with a distinct
nonperforated glans existed. From the end of the glans to its base there
was a Hnear ridge with plainly visible canal. From this organ two
labia-like bodies covered with hair, which were united at the base by
a broad commissure, descended. A narrow strip of skin was found be-
tween these elevations, in the middle of which on a sagittal summit
the orifice of the urethra was observed, leading into the bladder. An
incision in the right inguinal region revealed a tumor consisting of testicle,
epididymis, ovary, tube, and parovarium,

MISCELLANEOUS.

Note on the Framework of the Thyroid Gland. — Flint^ is of
opinion that large septums of framework do not divide the thyroid

* Anatom. Anz., March 17, 1903, p. 27.

2 Virchow's Archiv, clxxii, 1, p. 1, 1903. ^ Johns Hopkins Bull., Feb., 1903.

MISCELLANEOUS. • 647

gland into lobes or lobuli. The bloodvessels and connective tissue make
up the largest portion of supporting framework. The organ is made up
almost entirely of follicles, which are embraced by the connective tissue,
retaining their form and relations. The follicular membrane is a fine
delicate structure, with a suggestion of fibers. It is somewhat thickened
where 2 folHcles meet, while at nodes where 3 follicles come together a
pyramid of framework is found. Small arterioles, venules, and capillaries
can be observed in the interfolHcular network. The reticular membrane
is traversed by small fibrils outUning the fascicular spaces. Between
them considerable interfollicular connective tissue, which is distributed
chiefly around large vessels, is found. The fasciculi accompanying these
vessels are generally parallel to them, although many interlacing and
circular fibrils are given off to give strength and elasticity to the gland.

Hibernating Gland in Human Embryo. — Hatal^ has discovered in
human embryos a gland corresponding to the hibernating gland of lower
mammals. This organ, termed provisionally interscapular gland, was
found only in embryos. It can be divided into (1) an enlarged anterior
portion, beginning below the parotid gland under the sternocleidomas-
toid muscle, and running downward and backward along the neck, be-
tween the internal jugular vein and the levator scapulae and splenius
capitis muscles to the superior border of the scapula; and (2) a lower
narrow portion, running downward beneath the scapula or near its verte-
bral border. The gland is composed of lobes and lobules, which contain
2 constituents, an outer fatty tissue and an inner lymphoid structure,
which is surrounded by a thick fibrous membrane. The lymphoid struc-
ture contains adenoid tissue, between which blood and lymph-sinuses
run. This organ corresponds in some respects to the so-called hibernating
glands, and also to the hemolymph organs.

The Submaxillary Gland. — v. Smirnow^ states that the human sub-
maxillary gland is a seromucosalivary gland, consisting of serous glands
between which are distributed islands of mucous alveoli and saccules. The
mucous glands are in the minority, therefore it should be considered as an
albumin-producing gland. The loose connective tissue of the lower jaw
surrounds the gland, following the vessels and ducts from the hilum, and
giving off septa, which divide the parenchyma into lobes. Through the
interlobular spaces we find the connective tissue dense and plentiful. The
cell-elements observed among the connectve-tissue fibers include plasma
and mast-cells, fat-cells, " Wanderelemente" of the blood and lymph, and
smooth muscle-cells in the wall of the main excretory duct of the gland.
Elastic fibers are present in the connective tissue of the excretory ducts
and the accompanying bloodvessels and lymph-vessels, also around the
glandular alveoli and canaliculi, but especially around the larger inter-
lobular ducts. Here the fibers generally run parallel to the duct. Around
the ducts the elastic fibers are observed next to the epithelium and in
the adventitia. Along the salivary canaliculi elastic fibers are observed
in great quantities in the connective-tissue formation of the walls, of
which the greater portion is found subepithehal, running parallel to the

'Anatom. Anz., July 4, 1902. * Anatom. Anz., March 17, 1903, p. 11.

648 ANATOMY.

canaliculi. Around the canaliciili anastomoses a rather firm plexus of
elastic fibers is formed. In the smaller salivary canaliculi the connective
tissue consists mainly of collagenous material, in which are found scat-
tered elastic fibers, which have the same location and direction as the
above. Ai'ound the mucous alveoli is found much elastic tissue, to
which fact Livini called attention. He ascribes the presence of such a
large quantity to the increased amount of power required to empty the
thick slimy mucus.

Papillas in the Normal Conjunctiva. — Nakagawa^ has constantly
observed in horses, cattle, sheep, and pigs real papillas in the neighbor-
hood of the cornea; beginning near the limbus from 5 to 10 are found.
They begin at the outer border of the annulus conjunctivae, where the
epithehum of the cornea goes over into the thick epithelium of the con-
junctiva and separates itself from the lower layer of the sclera. They
may number from 4 to 13 and are placed about 2 mm. below and 1.5 mm.
above the hmbus in the conjunctiva bulbi. They are, on an average,
120 mkm. high and 80 mkm. broad. The human papillas can be differ-
entiated from those of the domestic animals by their size and height.
They consist of a dense superficial connective-tissue layer containing
few muscles, while internally a loose fibrillary connective tissue is found
which is rich in muscle. Each papilla contains a bloodvessel. The
epithelium of the conjunctiva covers them and fills up the ridges between.
These papillas have to be differentiated from papillary growths and
foUicles. The first are irregular swellings of the subepithelial adenoid
conjunctival tissue; the follicles are subepithelial neoplasms having the
appearance of lymphatic glands.

Structure and Development of the Posterior Layer of the Iris,
Particularly the Sphincter Iridis. — v. Lenhossek^ determines that the
entire musculature of the iris, i. e., both the sphincter and dilator pupillse,
are of epitheUal (ectodermal) origin. The sphincter begins to be formed
in the beginning of the fourth month and the dilator in the seventh
month.

Nerve Terminals in the Extrinsic Muscles of the Eye. — Levinsohn'
found that in the majority of specimens examined the terminal nerve-
fiber on approaching the end-plate divided into a considerable number
of end-fibrillas each of which supplied a single primitive muscle-bundle.
These end-fibrillas are inclosed in the sheath of Henle and have a diameter
of 6 to 9 micromillimeters. They often pursue a tortuous course and
may form several loops around a muscle-fiber. Often each end-fibrilla
forms a separate end-plate, which does not fuse with adjacent ones.
The nerves are very numerous; this is explained by the fact that the
ocular muscles are in more constant use than other muscles.

Gland Tubules and Hassall's Corpuscles in the Thymus. — Scham-
bacher,* after examining carefully the thymus gland of numerous fetuses
and of individuals dying at various ages, determined that there are to

' Arch. f. Augenheilk., xlvii, I, p. 51, 1903.

' Aus dem I Anatom. Institut. der Konigl. Ungar. Univ. zu Budapest.

^ Aus dem Anatom. Institut. in Berlin. * Virchow's Archiv, Bd. clxxii, p. 368.

MISCELLANEOUS. • 649

be found remnants of excretory ducts in this gland. He regards the
concentric corpuscles of Hassall as formed from the epithelial contents
of these gland tubules.

Transitory Epithelial Structures Associated with the Mammary
Apparatus in Man< — H. E. Walter^ discusses the epitheHal thickenings
discovered by Hugo Schmidt, which he interpreted as supernumerary
mammary "Anlagen" on account of their distribution, their form, the
time of their appearance, and no other plausible explanation. These
thickenings have also, been described by Schmidt, Strahl, Lichtenstein,
V. Bardeleben, and others. In the cases of Schmidt and Walter, 40 of
these "Anlagen" have been found, which is a greater number than in
any known mammal; therefore the hypothesis of atavism can be ex-
cluded. Their arrangement to the mammary Hue, as also their con-
figuration, speak against their being mammary Anlagen. A clew as to
their origin can be obtained from the studies of Bresslau, who finds
in the opossum that the development of the marsupial pouch is preceded
by the formation of marsupial pockets around each milk point. These
pockets appear at first as an irregular ring of thickened epithelium.
Walter beHeves these pockets to be analogous to the structures of Schmidt,
for the time of the appearance and disappearance of the temporary
epithelial structures connected with the mammary apparatus in man,
their grouping around the milk points, their arrangement \vith reference
to relative width and length, and, lastly, their individual form, can be
more clearly explained by the hypothesis that such structures are the
remains of ancestral marsupial pockets than by considering them as
"Anlagen" of supernumerary mammae.

The Subclavian Triangle. — WaFdeyer^ calls attention to the fact
that upon full inspiration the structural relations vary. When the apices
are pressed closely under the skin, as they are at full inspiration, the
lungs are better approachable for diagnostic purposes. On account of
the varying relations during respiration the bloodvessels are more easily
injured at the height of inspiration, especially those on the left side,
where the thoracic duct enters the subclavian vein. The thoracic duct
not infrequently divides into several branches before emptying into the
vein. In deep inspiration the apices of the lungs in the floor of the
triangle are pressed closely against the skin, thus making them very-
approachable for diagnostic purposes. If clinicians would take advan-
tage of these phenomena, fewer failures would occur in finding physical
signs in incipient phthisis.

A Case of Siren Formation. — S. Abraimow and M. Rjesanow^ de-
scribe a case of footless siren fonnation of a child 36 cm. in length,
which expired 4 minutes after birth, and made several pendular move-
ments with the legs. The skeleton" presented the following anomalies:
The spinal column was short, due to the absence of sacrum and coccyx.
The pelvis was rudimentary. The ischii formed one bony mass, which

' Antom. Anz., Oct. 10, 1902, p. 97.
''Bonn, 1903; Med. News, June 13, 1903.
' Virchow's Archiv, vol. clxxi, 1903, p. 284.
42 S

650 ANATOMY.

filled up a great portion of the pelvis. The ascending rami of the ischium
were absent, while the descending rami of the os pubes were synostosed.
The ossa illei were flattened. The hmbs were fused, the leg being short,
while the feet were missing. The internal genitalia and rectum were
rudimental. The external genitaha, bladder, ureter, and umbilical artery
were absent. Instead of the latter a well-developed omphalomesaraic
artery was found; hydronephrosis existed, due to the absence of the
ureter. He attributes the malformation to a narrow caudal fold of the
amnion.

A new method of staining the medullary sheath is described by
V. Schrotter.^ The sections, which are best hardened in IMiiller's fluid, are
placed from 15 to 20 minutes in a freshly prepared cold solution of gallein
(Griibler), which is prepared by boiling with well-water. Then differ-
entiate in a 5 % solution of soda or weak sodium hydrate solution, then
for a moment in a light violet permanganate solution. Wash with
water, absolute alcohol, carbolxylol. The medullary substance will have
a violet appearance, likewise the red blood-corpuscles; the gray sub-
stance and connective tissue will remain unchanged.

A Carmine Stain for Axis-cylinder. — Chilesotti^ gives this formula :
Mix 1 gm. sodium acid carmine (Griibler) with ^ grain uranium nitrate
and boil 12 hours with 100 cc. water. Filter and before using add 1 %
hydrochloric acid. Sections from Midler's fluid will stain in 5 to 10 min-
utes; those from formalin, freezing paraffin, and celloidin in 15 to 20 min-
utes; from Weigert's neuroglia fluid in ^ to 1 hour; from Marchi in 2 to 4
hours. Then treat with water, alcohol, carbolxylol.

» Cent. f. allg. Path. u. path. Anat., 1902, p. 299.
' Cent, f. allg. Path. u. path. Anat., 1902, p. 193.

NDEX.

Abbe (R.) on tic douloureux, 276.

Abbott (E. G.) on liypertrophy of
synovial fringes of knee-joint, 253.

Abbott and Shattock on niacroglossia
neurofibromatosa, 33.

Abdomen, gunshot wounds of, 112,
327, 328, 330; wounds of, in war,
treatment, 329.

Abdominal contusions, diagnosis and
treatment, 114; contusion, intestinal
injury following, diagnosis, 115; in-
cision, suppurating, 499; pregnancy,
380; pregnancy, secondary, 382; sec-
tion, 493; section, complications during
and after, 498 ; section, drainage after,
11; section, parotiditis after, 500.

Abortion, 376; recurrent, 377.

Abrams (E. T.) on relation of thyroid
to eclampsia, 393.

Abscess, cerebellar, 265; duodenal,
79 ; ischiorectal, acute dilation of
stomach after operation for, 89;
of appendix, 163; of brain, 266; of
liver, 179; of liver in child, 178; of
liver, tropical, 179; of prostate, pre-
rectal curvilinear incision for, 317;
subphrenic, in appendicitis, 162, 163;
tonsillar, death from bursting of,
586; tropical, of spleen, 207.

Accommodation, pupil in, 566.

Accouchment force, 373.

Actinic rays, Cleaves's lamp for, 336;
for anesthesia, 334.

Adenitis, tuberculous cervical, treat-
ment, 243.

Adenocarcinoma of nose, 574; of rec-
tum, 137.

Adenoid structures of children, constitu-
tional manifestations due to infectious
processes in, 612.

Adenoidectomy, spasmodic torticollis
after, 612.

Adenoma, nasal, with sarcomatous
metamorphosis, 578 ; of rectum, 137.

Adenomyoma of uterus, 476.

Adnexa uteri, surgery on, conserva-
tive, 493.

Adnexopexy, 500.

Adrenalin anil atropin as mydriatic,
569; as local anesthetic, 52; in glau-
coma, 562; in metrorrhagia, 454.

Agglutinin subconjunctival, injections
and, 569.

Air-passages, upper, and esophagus,
direct endoscopy of, 594; lymphoid
tissue of, infections originating in,
594.

Albargin in gonorrhea, 260.

Aldrich (C. J.) on eyestrain, 524.

Alexander on prostatic hypertrophy,
322.

Allen (S. W.) on myxofibroma of nose,
35.

Allen and Cotton on brachial paralysis,
281.

Allport's modification of Panas's opera-
tion for ptosis, 533.

Alter (F.) on paraffin in saddle-nose,
333.

Althorp on perforated gastric ulcer,
73.

Altitudes, high, influence of, on nose,
607; influence of, on throat, 607.

Amberg's modification of Farlow's ton-
sil punch, 587.

Ametropia, 523.

.\mputation, 13; avoidance of shock
in, by cocainization of nerve-trunks,
14; for traumatism, 15; hip-joint,
under medullary narcosis, 14 ; inter-
.scapulothoracic, for sarcoma of
brachial plexus, 17; of leg, after
intraneural injection of cocain, 51.

Amyl nitrite, eye burn with, 563.

Amyloid degeneration of conjunctiva,
538.

Amyx on gunshot wound of abdomen,
330.

Anal fissure, 131.

Anastomosis between portal vein and
ascending vena cava, topographical
anatomy, 635; end-to-end, of poplit-
eal artery, for gunshot injury, 232;
intestinal, Lundholm's method, 121,
122, 123; nerve, in facial paralysis,
278; ureteral, 301; ureteroureteral,
in female, 449.

Anatomy, 633.

Anderson (W.) on congenital absence
of vagina, 432.

Andrews's method of infrapubic section
in prostatectomy, 319.

Andrews on foreign body in bronchus,
220.

Andrews on hernia into fossa duodeno-
jejunalis, 171.

651

652

INDEX.

Andrews (A. H.) on diagnosis of frac-
tures, 244.

Andrews (E. W.) on fecal vomiting
in operations for intestinal obstruc-
tion and septic peritonitis, 100.

Andrews (J. G.) on cerebellar abscess,
266.

Anesthesia, accidents of, prevention,
and treatment, 44; actinic rays for,
334; bad and difficult subjects in,
43; local, in radical cure of inguinal
hernia, 168; management and prepa-
ration of patient for, 42; of mem-
brana tympani, 625 ; recent improve-
ments in, 46; spinal, 40; spinal,
excision of superior maxillary bone
under, 50; spinal with cocain, am-
putation of leg after, 51 ; ultra-
violet ray, 336.

Anesthetic, 42; anesthol as, 46; bra-
chial paralysis after, 281 ; chloroform
as, in operations on throat and nose,
45; ethyl bromid as, 48; ethyl chloric!
as, 46; ethyl chlorid as, in labor,
387; local, adrenalin as, 52; local,
cocain as, poisoning after, 51 ; mor-
phin-scopolamin as, 48.

Anesthol as anesthetic, 46.

Aneurysm, gelatin in, 231 ; Matas's
operation for, 227 ; of innominate
artery, treatment, 230; of innomin-
ate, right subclavian, and right
common arteries, 229; of subclavian
artery, 231; traumatic, 231.

Angioneurotic erythema, 283.

Angiotribe, Downes's, 487; Downes's
electrothermic, 487 ; Downes's elec-
trothermic in producing hemostasis,
11.

Angus on ruptured duodenal ulcer, 79.

Anilin-iodofomi treatment of catarrhal
otorrhea, 629.

Anisocoria, diagnostic value, 566.

Anning on carcinoma of pylorus, 85.

Antisepsis, intravascular, 20.

Antitoxin, hay-fever, 578; tetanus, pro-
phylactic injections of, inwounds from
toy pistols, 19.

Antral empyema, diagnosis, 582; treat-
ment, 582.

Antrum, maxillary, disease of, 582.

Anuria, surgical treatment, 291.

Anus and rectum, surgery of, 130;
artificial, in colitis, 125.

Aorta, perforation of, 226.

Aphasia, puerperal, 417.

Appendicitis, 142; acute, 147; blood
examination in, 144; cholecystitis
after, 145; diagnosis and treatment,
149; gangrenous, in hernial sac,
161; hematemesis in, 158; hemor-
rhagic, 157; in pregnancy, 164;
mortality in, 151; mortality in, treat-
ment to reduce, 152; operations for,
154, 160; operations for, early, 144;

operations for, mortality, 153; puer-
peral, 164; subphrenic abscess in,
162, 163; thrombosis of. portal vein
in, 158; toilet of peritoneum in, 155;
transposition of cecum in, 156; treat-
ment, 148, 149, 150, 152; with geiieral
peritonitis, 162; with symptoms like
typhoid fever, 164.

Appendicostomy, 126.

Appendicular black vomit, 157.

Appendix, vermiform, abscess of, 163;
vermiform, anatomy, 641; vermi-
form, anatomy and pathology, 142;
vermiform, and cecum, strangulation
of, 174; vermiform, carcinoma of,
162; vermiform, carcinoma of, pri-
mary, 149, 150; vermiform, elongated
and adherent, strangulation of small
intestine from, 161 ; vermiform, fetal,
relation of meconium to, 346; vermi-
form, foreign bodies in, 155; vermi-
form, removal of, advisability, when
abdomen is opened for other reasons,
146; vermiform, removal of, forceps
for, 145; vemiiform, removal of,
tumor of cecal wall after, 161; vermi-
form, strangulation of, in right fe-
moral ring, 174.

Aqueous humor, secretion of, 550.

Argyrol in diseases of nose, throat, and
ear, 605; in gonorrhea, 259.

Arm, orthopedic surgery of, 505.

Armstrong (G. E.) on perforation in
typhoid fever, 101.

Arnott on abscess of liver, 178.

Arterial degeneration, retinal hemor-
rhage in recognition of, 553.

Arthritis, acute suppurative, drainage
of knee-joint for, 253; rheumatoid,
520.

Asch operation for deviations of nasal
septum, 578.

Ascites due to cirrhosis of liver, Talma's
operation for, 184.

Ash (A. E.) on typhoid perforation of
gall-bladder, 200.

Ashby and Stephenson on acute amau-
rosis, 559.

Ashell (J.) on constipation as factor in
eclampsia, 393.

Aspergillus flavescens cause of otomy-
cosis, 623.

Asphyxia neonatorum, 419.

Asthenopia, 524; association of, with
malaria, 525.

Astigmatism, 525; subconjunctival ten-
otomy in, 525.

Atmospheric pressure, role of, in hip-
joint, 634.

Atrophy, optic, hereditary, 558; in
retrolDulbar neuritis, pathology, 558.

Atropin and adrenalin as mydriatic, 569 ;
bromid of methyl, as mydriatic, 569.

Attitude, faulty, roimd shoulders and
508.

INDEX.

653

Aural bougies, 630; snares, Wilson's
wire loop for, 631.

Auricle, reflex movement of, 619.

Auricular reflex, heart and, 626.

Autointoxications of pregnancy, 363.

Axis-cylinder, carmine stain for, 650.

Axis-traction forceps, Tarnier's, Fried-
man's modification, 409.

Baber's tongue-depressor for exposing
tonsil, 588.

Bacilli of diphtheria in atrophic rhinitis,
574.

Bacteriolysin, subconjunctival injections
and, 569.

Bag, kolpeurynter, in placenta prsevia,
372.

Bailey on perforating gastric ulcer, 73.

Bailey and Thorndike on tuberculosis
of testicle, 304.

Bainbridge on duodenal abscess, 79.

Baker (A. R.) on eyestrain, 524.

Baldwin (J. F.) on deciduoma malig-
num, 348; on intraabdominal omental
torsion, 117; on knife-blade in lung,
220 ; on ])regnancy following nephrec-
tomy, 364.

Baldy (J. M.) on cancer of uterus, 482;
on myoma of ovary, 503.

Ball (C.) on adenoma and adenocar-
cinoma of rectum, 137.

Ball (J. M.) on corneal fistula, 546.

Bair.s otoscope, 631.

Ballance on aneurysm of innominate,
subclavian, and carotid arteries, 229;
on thrombosis of lateral sinus, 266.

Ballance and Stewart on facial paralysis,
278.

Ballcnger (W. L.) on tests orf hearing, 616.

Ballock on cancer of male breast, 38; on
pruritus vulva;, 429.

Baner (W. L.) on formaldehyd in septi-
cemia, 20.

Barber (C. F.) on multiple ulcers of
stomach, 75.

Barbour on inflammation of uterine
appendages, 492.

Barker (A. E.) on nonmalignant disease
of stomach, 65; on strangulated and
gangrenous hernia, 174; on trans-
sacral removal of an intussusception
complicated by malignant growth, 95.

Barnard on drainage of knee-joint for
acute suppurative arthritis, 253.

Barnard on simulation of acute peri-
tonitis, 93.

Barnes (J. T.) on vision in railway em-
ployees, 542.

Barrett (J. W.) on antral empyema, 582;
on cataract, 551.

Barrett and Orr on double optic neuri-
tis, 558.

Barrows (C. C.) on formaldehyd in
acute septicemia, 19.

Bartlett (W.) on middle cranial fossa,
275.

Barwell (H. S.) on goiter in abnormal
thyroid gland, 242.

Basedow's disease, 240. See also Ex-
ophthabnic gjiter.

Bassini operation in femoral hernia, 165.

Baths during puerperium, 390.

Battle on peritonitis, 94.

Baumm on prolapsus uteri, 460.

Beatson on oophorectomy for inoperable
cancer of breast, 22.

Beaumont and Houseman on rupture
of spleen, 209.

Beer yeast in otology, 627.

Belfield (W. T.) on weight-wave of
menstruation, 451.

Bell (J.) on foreign bodies in vermiform
appendix, 155.

Bell (W. B.) on appendicular abscess,
163 ; on cancer of male breast, 38.

Benedict (A. L.) on diminished birth-
rate, 339.

Benjamin (A. E.) on radical cure of
hernia, 169.

Bennett (W. H.) on varicose veins of
lower limbs, 235.

Bensley on cardiac glands of mammals,
638.

Berg (A. A.) on perforating gastric and
duodenal ulcers, 73.

Bevan on anuria, 291; on stomach
surgery, 57.

Beyea (H. D.) on adnexopexy, 500.

Beyea's operation for gastroptosis, 80.

Bierhoff (F.) on renal calculus, 292.

Bile-ducts, diseases of, diagnosis, differ-
ential, 189; surgery of, 184.

Bilharziosis, surgical view, 309.

Billington and Nuthall on neurofibroma-
tosis, 34.

Binocular magnifier, Jackson's, 570.

Bird on sarcoma of stomach, 86.

Birth injury, suture of brachial plexus
for, 505; paralysis, surgical treat-
ment, 281.

Birth-rate, lessened, 339.

Bishop (E. S.) on prolapse and true
ligaments of uterus, 461.

Bissell (J. B.) on tuberculous cystitis,
307.

Black (N. M.) on squint, 530.

Bladder, diseases of, 307: diseases of,
pathology and prognosis, 310; ex-
.cision of, with implantation of ure-
ters into rectum, for papillomatous
growth, 314; exstrophy of, trans-
plantation of ureters into rectum for,
309; female, after hysterectomy, 446;
female, cystoscopy of, 444; female,
examination of, direct, 443; in her-
nial sac, 169; injury of, 313; removal
of, complete, 314; rupture of, intra-
peritoneal, 310, 311, 312; suture of,
after suprapubic cystotomy, 313;

654

INDEX.

tumors of, 314; wounding of, in
operation for hernia, 169.

Bladder-wall, perforation of, by calcu-
lus, 313.

Blake (J. B.) on varicose veins, 237.

Blake and Monks on vermiform appen-
dix, 641.

Blanchard (W.) on genu varum and
genu valgum, 514.

Bleeding polyp of nasal septum in
pregnancy, 579.

Blindness, acute, after infantile convul-
sions, 559; color-, Holmgren test for,
545; color-, relation of, to railroad
transportation, 542; color-, test for,
545.

Blood and amniotic fluid of mother and
fetus, comparative investigations of,
344; examination of, in appendicitis,
144; maternal g,nd fetal, serum of,
345.

Bloodgood on angioneurotic erythema,
283; on medullary giant-cell sarcoma
of tibia, 244.

Blood-pressure changes in surgical cases,
14; decrease in, glaucoma and, 560;
in diagnosing typhoid perforation, 109;
means of controlling, 234.

Blood-supply, unknown, existence of,
to embryonic stomach, 635.

Bloodvessels and lymphatics, anatomy,
635.

Blumer (F. M.) on rupture of bladder,
312.

Bodine (J. A.) on local anesthesia in
inguinal hernia, 168.

Bone-grafting, Morton's method, 243.

Bones, amomit of fluorine in, 633;
anatomy, 633; diseases of, 243;
fragility of, 243; in children, tubercu-
losis of, treatment after Lannelongue
method, 519; tuberculosis of, treat-
ment, general, 521.

Bordley (J. R.) on tuberculosis of con-
junctiva, 538.

Bossi dilator, 373.

Bottini operation for prostatic hyper-
trophy, transvesical cauterization as
substitute for, 318.

Bougies, aural, 630.

Bovee (J. W.) on complete nephroure-
terectomy, 449 ; on shortening utero-
sacral ligaments, 469.

Bowen (W. S.) on hydrorrhoea gravida-
rum, 353.

Bowlby on intestinal obstruction, 99;
on primary nerve-suture, 283 ; on
typhoid perforation. 111.

Box and Wallace on appendicitis, 164.

Boyd and Unwin on cancer of tongue,
25.

Brachial paralysis after anesthetic, 281 ;
plexus, sarcoma of, interscapulothora-
cic amputation for, 17 ; plexus, suture
of, for birth injury, 505.

Bradford (E. H.) on subtrochanteric
osteotomy, 511.

Brain, abscess of, 266; and skull, gun-
shot injuries of, 326; diseases of, 262;
tumors of, from neurologic stand-
point, 264; tumors of, trephining for,
262.

Brain-weights of professional men, 644.

Branham (J. M.) on vaginal incision,
498.

Breast, affections of, 428; carcinoma
of, glands in, 434; carcinoma of, in-
operable, oophorectomy for, 22, 37;
carcinoma of, subdural cervical car-
cinoma secondary to, 37 ; endotheli-
oma of, 37 ; male, carcinoma of, 38.

Brewer on abdominal contusions, 114;
on anatomy of gall-bladder, 639; on
diseases of gall-bladder and ducts, 189.

Briggs (C. E.) on typhoid perforation,
108.

Briggs (W. G.) on rectal approach in
obstetrics, 346.

Bright's disease, surgical treatment,
288.

Brimhall (J. B.) on injuries to elbow-
joint, 505.

Brockbank on ultra-violet ray anesthe-
sia, 336.

Brodel's method of passing suture in
fixation of kidney, 296, 297.

Brokaw on foreign body in bronchus,
220, 221.

Bromid of methyl atropin as mydriatic,
569.

Bronchial lymph-glands, topographic
anatomy, 636.

Bronchotomy for foreign ])ody in bron-
ch-us, 220."

Bronchus, foreign body in, 220, 221.

Bronner on Mules's operation, 564; on
removal of lens in myopia, 526.

Brooks and Greene on diseases of blad-
der, 310.

Brown (S. T.) on diabetes with movable
kidney, 300.

Brown-Pusey on metastatic ophthal-
mia, 567.

Brown's powder insufflator, 631.

Brunner, glands of, determination of
duodenum by, 641.

Buck (A. H.) on operation for acute
hematemesis, 83; on postoperative
hematemesis, 83.

Bull (C. S.) on iridectomy for glaucoma,
561 ; iridochoroiditis, 549.

Bull (J. G.) on tenotomy in astigma-
tism, 525.

Bullard on congenital hernia of liver
into umbilical cord, 178; on head in-
juries, 268.

BuUer on suppuration of cornea, 546.

Bullock on intestinal obstruction, 98.

Burdick (G. C.) on radiotherapy in
tuberculosis, 334.

INDEX.

655

Bums, 325.

Burns (H. D.) on phlyctenular ophthal-
mia, 536.

Bursa, iliopsoas, surgical importance,
284.

Burtenshaw on anatomy of pelvic floor,
435.

Bushong on cervix uteri, 438.

Butlin on carcinoma of tongue, 31.

C.A.BOT (A. A.) on strangulation of

. testicle, 305.

Cabot (F.) on instructions for patients
Avith venereal diseases, 257.

Cabot (H.) on ureteral anastomosis, 301.

Calcaneoastragaloid and scaphoastraga-
loid joints, compound dislocation
at, 255.

Calcaneum, greater process of, frac-
tures through, 249.

Calcium chlorid in metrorrhagia, 454.

Calculus in ureter, 293; pancreatic,
203; perforation of bladder-wall by,
313; renal, 292; renal, method for
diagnosing, 292.

Campbell (W. F.) on anatomy of in-
ternal saphenous vein, 238.

Canac-Marquis's method of anchoring
floating kidney, 299.

Canaliculi, lymph-, of cells of liver
and suprarenal body, 638.

Cancroin for eye cancer, 569.

Carcinoma and nerve or trophic areas,
relation, 25; development of, in old
cicatrix, 24; epibulbare planum,
539; inoperable, formalin .solution
in, 23; moperable, treatment, 21;
inoperable, x-rays in, 39; laryn-
gectomy for, 213; metastatic, of
choroid, 549; of appendix, 162; of
breast, glands in, 434; of breast,
inoperable, oophorectomy for, 22,
37; of breast, male, 38; of breast,
subdural cervical carcinoma second-
ary to, 37 ; of choroid, metastatic,
549; of esophagus, 54; of hepatic
duct, 197; of kitlney, nephrectomy
for, 288; of larynx, diagnosis, 213;
of larynx, pachydermia and, 597;
of larynx, x-rays in, 600; of lips, 32;
of liver, 181; of pharynx, 590; of
pylorus, 85; of rectum in pregnancy,
366; of rectum, sigmoidoproctectomy
for, 141; of rectum, treatment, 139;
of rectum, .r-rays in, tube-shields
and s])eculums for, 142; of stomach,
diagnosis, early, importance of, 83;
of stomach, pylorectomy for, 86;
of stomach, treatment, 87; of stom-
ach, treatment, surgical, 84; of
tongue, 25; of tongue, diagnosis,
early, 31 ; of tongue, excision for,
29; of tonsils, 590; of uterus, age-
limit in, 478; of uterus, clinical

aspects, 480; of uterus, condition
of pelvic lymphatics in, 479; of
uterus, hemostasis in treatment, 487,
497; of uterus, inoperable, Jabou-
lay's treatment, 483; of uterus, in-
operable, ligation of hypogastric and
ovarian arteries in, 483; of uterus,
inoperable, treatment, 482 ; of uterus,
mortality, 482; of uterus, Sampson's
operation for, 485; of utervis, statis-
tics on, 477 ; of uterus, treatment,
operative, 483; of uterus, x-rays in,
488 ; of vermiform appendix, primary,
149, 150; primary, of fallopian tube,
488 ; primary, of female urethra, 443 ;
recurrent, of female urethra, 443; re-
current, x-rays in, 39; .r-rays in, 39,
40, 41. ■

Carcinomatosis of stomach and intes-
tines, 85.

Carcinomatous change in an area of
chronic ulceration, 23.

Cardiac disease, valvular, in pregnancy,
358; disturbances in menopause,
457 ; glands of mammals, 638 ; reflex
of auricular origin, 626.

Cardiorrhaphy, 226.

Cardiospasm, treatment, 118".

Cardiotomy, 226.

Cargile membrane to prevent nasal
adhesions, 574.

Carless and Mayou on fractures through
greater process of calcaneum, 249.

Carmichael (S.) on position of gall-
bladder, 640.

Carmine stain for axis-cylinder, 650.

Carotid arteries, right common, in-
nominate, and right subclavian,
aneurysm of, 229.

Carstens (J. M.) on operation during
pregnancy, 370.

Cartilage, histology and histogenesis,
633; semilunar, at knee-joint, luxa-
tion of, 514.

Cas.selberry (W. E.) substituting medi-
cine dropper for spray, 596.

Cataract, artificial production of, 550;
causes of, unusual, 551 ; eyestrain
and, 524 ; medical treatment, 551 ;
operation for, 552.

Catarrhal diseases of nose and throat,
influence of, in producing speech-
defects in children, 613.

Catgut, preparation of, by Claudius
method, 9; sterilizing, 9.

Catheters, sterilization of, 10.

Cauterization of prostate through
rectum, for obstruction due to hyper-
trophy, 319; transvesical, as sub-
stitute for Bottini operation in hyper-
trophy of prostate, 318.

Cautley and Dent on stenosis of pylorus,
72.

Cavanagh (W. J.) on posterior-occipital
positions, 404.

656

INDEX.

Cecal wall, tumor of, after removal
of appendix, 161.

Cecum and appendix, hernia of, 174;
artificial valvular fistula in, for chronic
colitis, 125 ; lipoma of, 39 ; transposi-
tion of, in appendicitis, 156.

Celiotomy during pregnancy, 369.

Cell, liver-, anatomy, 638.

Cells of liver and suprarenal body,
lymph-canaliculi of, 638.

Cellulitis, orbital, scarlatina and, 565.

Cerebellar abscess, 265, 266.

Cerebellum, extent of surface of, 643.

Cerebral cortex in congenital absence
of upper limb, 643 ; localizations, 262.

Cerebrospinal rhinorrhea after fracture
of skull, 245.

Cerebrum, dura of, structure, 643; of
microcephalic idiot, 644.

Cerevisina-Fita in otology, 627.

Cervical adenitis, tuberculous, treat-
ment, 243; spine, acute osteomyelitis
of, 245; sympathetic, resection of, for
glaucoma, 561.

Cervix uteri, conditions of, 438; lacera-
tion of, 438; new form of dilator for,
438.

Cesarean section for puerperal eclamp-
sia, 398; Fritsch's incision in, 411 ; in
placenta prtevia, 375; vaginal, 412.

Champneys on tubal gestation, 384.

Chance (B. K.) on eye in infectious
fevers, 565 ; on staphylomas in myopic
eyes, 526.

Chandler (H. B.) on glaucoma, 561.

Chase (H. M.) on fractures of hip in
children, 245.

Cheatle on relation between carcinoma
and nerve or trophic areas, 25.

Chest, gunshot wotmds of, 328, 330.

Chetwood (C. H.) on hematuria, 292.

Cheyne (W. W.) on cancer of rectum,
139.

Childbirth, importance of careful exam-
ination and treatment of women after,
387.

Chloroform as anesthetic in operations
on nose and throat, 45; in earache,
621 ; in labor, 386.

Cholecystectomy, 195; indications for,
193.

Cholecystitis after appendicitis, 145;
gangrenous, 198.

Choledochotomy, duodenal, 192; mor-
tality of, 192.

Cholelithiasis and glycosuria, pancrea-
titis with, 205; relation of, to acute
pancreatitis, 206.

Chorda tympani, nucleus salivatorius
of, 643.

Chorea, eyestrain as cause, 524.

Chorion-epithelioma, 348.

Chorionic villi, transmission of, 350.

Choroid and iris, congenital defect of,
548; diseases of, 548; metastatic

carcinoma of, 549; plexuses, struc-
ture of, 643; tuberculosis of, 549.

Christ on relations between pregnancy
and operations, 370.

Christian (H. M.) on argyrol in gonor-
rhea, 259.

Christian and Lehr on appendicitis, 162.

Christopherson (J. B.) ■ on imperfect
descent of testicles, 305.

Chromatopsia following labor, 528.

Cicatricial ectropion, operations for, 534.

Cicatrix, old, development of cancer in,
24.

Ciliary arteries, anterior, dividing of,
for glaucoma, 561.

Circumcision, 305, 306.

Cirrhosis of liver, 183; ascites due to,
Talma's operation for, 184; surgical
treatment, 183.

Clark (J. G.) on postoperative femoral
thrombophlebitis, 238.

Clark (J. P.) on hay-fever, 577 ; on sten-
osis of larynx, 599, 600.

Claudius method, preparation of catgut
by, 9.

Clavicle, fracture of, in spontaneous
labor, 418.

Claybrook on laceration of bowel, 113.

Cleaves's lamp for actinic rays, 336.

Cleft palate, congenital, operative tech-
nic, 614.

Club-foot, 510.

Cobb (C. M.) on acute coryza, 581.

Cocain as anesthetic for membrana tym-
pani, 625, 626; as local anesthetic,
poisoning after, 51 ; intraneural in-
jection of, amputation of leg after,
51; used externally, danger of, 51.

Cocainization of nerve-trunks, avoidance
of shock in amputations by, 14.

Coe (H. C.) on pregnancy complicated
by fibroid tumor, 368.

Coffey's operation for gastroptosis, 81.

Cohen and Gibbon on tropical abscess
of liver, 179.

Colectomy in malignant disease of
colon, 127.

Coley on inguinal and femoral hernia,
164; on z-rays in malignant tumors,
40.

Coley and Lambert on embolism of
mesenteric artery, 233.

Colitis, artificial anus in, 125; chronic,
artificial valvular fistula in cecum for,
125; right lumbar colostomy in, 126.

CoUargolum in puerperal sepsis, 412.

Collier on double congenital hernia, 170.

Collier on relationship between nasal
obstruction and deformities of upper
jaw, teeth, and palate, 331.

Collins (J.) on spinal cord tumor, 287.

Collins (W. J.) on unusual hernia, 173.

Colon, irrigating, 126; malignant dis-
ease of, colectomy in, 127.

Color-blindness, Holmgren test for, 545;

INDEX.

657

relation of, to railroad transportation,

542; test for, 545.
Colored vision, 528.
Color-perception, central, detection of,

545.
Colostomy, right lumbar, in colitis, 126.
Columnization of vagina for metritis,

458.
Conant (W. H.) on umbilical hernia,

170.
Conjunctiva, amyloid degeneration of,

538; carcinoma of, 539; diseases of,

536; growths of, 537; moUuscum

contagiosum of, 538; papillas in, 648;

papilloma of, 537 ; tuberculosis of, 538 ;

tuberculosis of, x-rays in, 568
Conjunctivitis due to larvas of Wohl-

fahrt's fly, 536 ; sozoiodolic acid salts

in, 568.
Connective tissue, lymphatics and, rela-
tions between, 637.
Connell (F. G.) on gastrointestinal per-
forations, 75 ; on through-and-through

intestinal sutures, 120.
Connor (L.) on magnet for foreign bodies

in eye, 563.
Constipation as factor in puerperal

eclampsia, 393.
Contagious diseases, prophylaxis, in

ophthalmology, 541.
Contracted pelvis, 399; treatment, 399.
Contusions, abdominal, diagnosis and

treatment, 114; intestinal injury fol-
lowing,'diagnosis, 115.
Convulsions, infantile, acute amaurosis

after, 559.
Cook (F. R.) on Gibney adhesive plaster

dressing for sprains, 255.
Cornea, diseases of, 546 ; endothelium of,

546; epithelium of, detachment, 546;

fistula of, 546 ; suppuration of, acute,

546; tumors of, 547; ulcers of, 547;

ulcers of, iodin-vasogen in, 547.
Corpuscles, Hassall's, gland tubules and,

in thymus, 648.
Corset, evil effects of, 421; for movable

kidney, 297.
Cortex, cerebral, in congenital absence

of lower limb, 643.
Coryza, acute, transillumination of ac-
cessory sinuses in, 581.
Cotton (F. J.) on empyema in children,

217.
Cotton and AUen on brachial paralysis,

281.
Cotton-holder, aseptic, 606.
Coutts on acute ependymitis, 267.
Crandon on enlarged prostate, 316.
Cranial fossa, middle, surgical anatomy,

275.
Craniotomy, instrument for protecting

brain in, 273.
Cred6 on collargolum in septic infections,

412.
Crile (G. W.) on blood-pressure in diag-

nosing typhoid perforation, 109; on
hot-water mattress, 12; on means of
controlling blood-pressure, 234 ; on
x-ray picture of calcified aorta mis-
taken for foreign body, 337.

Crooked nose, treatment, 332.

Crookes (W.) on emanations from
radium, 335.

Crouse (H.) on windowing plaster casts
in compound fractures, 244.

Cryoscopic examinations, 303.

Crystalline lens, ablation of, in high
myopia, 526.

Cullen (T. S.) on uterine adenomyoma,
477.

Cullen's cystoscope, 444, 445.

CuUingworth on uterine fibroids, 470.

Culver (C. M.) on eyestrain and cata-
ract, 524.

Cuneiform shortening of broad liga-
ments for retrodisplacements of
uterus, 464.

Cuprocitrol in trachoma, 537.

Curettage of puerperal septic uterus,
415.

Curetting for nasal hemorrhage, 575.

Curie on radium in eye therapy, 568.

Current transformer, alternating, 12.

Currier (A. F.) on vaginal incision,
497.

Curtis (H. H.) on paraffin injection in
nose, 577.

Curtis (H. J.) on congenital periosteal
sarcoma in infant, 38.

Cushing on avoidance of shock in major
amputation, 14; on increased intra-
cranial tension, 269, 270; on nerve
anastomosis in facial paralysis. 278.

Cystalgia, causes, symptoms, and
treatment, 308.

Cysticercus, subretinal, 555.

Cystitis, chronic, etiology and treat-
ment, 308; tul^erculous, diagnosis
and treatment, 307.

Cystocele, 433; Hirsh's operation for,
433.

Cystopexy, suprapubic, 446.

Cystoscope, Cullen's, 444, 445.

Cystoscopic practice, aids to, 309.

Cystoscopy of female bladder, 443;
of nasopharynx, 606.

Cystotomy, suprapubic, suture of blad-
der after, 313.

Cysts, 21; dermoid, in labor, 367;
hemorrhagic, of spleen, 207; hydatid,
compression myelitis from, 286;
hydatid of liver, in pregnancy, 181;
of pancreas, 200; simple, of liver,
182.

Da Costa (J. C.) on carcinomatous
change in an area of chronic ulcera-
tion, 23; on endothelioma of mam-
mary gland, 37; on exophthalmic

658

INDEX.

goiter, 241 ; on Stellwagen's trephine
for osteoplastic resection of skull, 274.

Dacryoadenitis, acute, 535.

Daly and Harrison on rupture of blad-
der, 311.

Dalziel on gastroenterostomy for non-
malignant affections of stomach, 63.

Dandridge (N. P.) on hypertrophy of
prostate, 325.

Daniel on sarcoma of thyroid gland,
239.

Darling on subphrenic abscess after
removal of appendix, 163.

Darnall on suppuration of abdominal
incision, 499.

Das (K.) on double monstrosity, 356.

Davenport on pessary in retrodisplace-
ments of uterus, 463.

Davis (A. H) on prophylaxis in oph-
thalmology, 542.

Davis (A. M.) on chromatopsia follow-
ing labor, 528.

Davis (B. B.) on cholecystectomy, 193.

De Lee (J. B.) on Bossi dilator, 374;
on inducing labor in placenta prtcvia,
372.

Deafness, 624; catarrhal, treatment,
salient points in, 623; middle-ear,
ozone in, 620; throat, ozone in, 620;
tobacco, 630.

Deaver on disea.ses of pancreas, 204.

Deaver and Ross on appendicitis, 150.

Decapsulation, renal, for puerperal
eclampsia, 398.

Decentering lenses, 526.

Deciduoma malignum, 348; after
menopause, 350.

Deformities of upper jaw, teeth, and
palate, nasal obstruction and, re-
lationship between, 331; paraffin
in, 332.

Deformity at hip, correction, 511;
flexion-, at knee-joint, method of
correcting, 514.

Delatour on intestinal obstruction, 100.

Delavan (D. B.) on sinus diseases, 580.

Dench (E. B.) on ossiculectomy, 629.

Dennis (F. S.) on intracranial tension,
271.

Dental operations and pregnancy, re-
lation between, 370.

Depressed nose, treatment, 332.

Depressor, tongue-, Mosher's self-re-
taining, 604.

Derby on prophylaxis in ophthalmol-
ogy, 541.

Dermoid cyst in lalior, 367.

De Schweinitz (G. E.) on occlusion of
superior temporal artery of retina,
554 ; on ocular signs in chronic neph-
ritis, 553.

Dewar (M.) on forceps in obstetric
practice, 408.

Diabetes mellitus, myopia in, 566;
with movable kidney, 300.

Dilation of esophagus, idiopathic, 55;
of stomach, acute, 89; of stomach,
acute, after operation for ischiorectal
abscess, 89.

Dilator, Bossi, 373; Ramsay's uterine,
438.

Diphtheria and pregnancy, 361; bacilli
in atrophic rhinitis, 574.

Dislocation, compound, at calcaneoas-
tragaloid and scaphoastragaloid joints,
255; of hip, congenital, 510; poste-
rior, of head of tibia, 254; of hip,
congenital, treatment, 509.

Dislocations, 252.

Distoma cyst of orbit, 563.

Dobson on invagination of Meckel's
diverticulum, 96.

Donaghue (T. D.) on appendicitis, 64.

Donald and Walls on rupture of uterus,
402.

Donaldson (E.) on reflex movement of
ear, 619.

Donaldson (F.) on Johnson's modifica-
tion of Penrose's operation for nephro-
pexy, 298.

Donnellan's syringe for intratracheal
medication, 603.

Doran (A.) on uterine fibroids, 469.

Doriman (F. A.) on placenta pra-via, 371.

Dorland (W. A. N.) on cervical . car-
cinoma, 477; on congenital absence
of uterus, 439; on pelvic lymphatics
in uterine carcinoma, 479; on tarry
hematoma of ovary, 501.

Double extrauterine pregnancy, 378;
monstrosity, 356; Pott's disease, 507;
uterus, pregnancy in, 403.

Dowd on empyema, 217.

Downes's angiotriVje, 487; electrother-
mic angiotribe, 487; 'electrothermic
angiotribe in producing hemostasis,
11; method of electrothermic hemo-
stasis, 487, 497.

Drainage after abdominal section, 11;
after laparotomy, 496 ; tube for pleural
cavity, 12; tube, Wamsley's, 535.

Drew on vesicovaginal fistula, 441.

Duane on iodin-vasogen in ulcers of
cornea, 547.

Duchenne's palsy, surgical treatment,
281.

Duke's umbilical clamp, 390.

Dunbar's hay-fever antitoxin, 578.

Dunn (T. H.) on intestinal resection, 120.

Duodenal abscess, 79; ulcer, duodenal
abscess secondary to, 79; ulcer, per-
forating, 73, 76, 77; ulcer, ruptured,
79."

Duodenum, determination of, by glands
of Brunner, 641; rupture of, 114;
ulceration of, uremic, 79.

Dura mater cerebri, structure of, 643.

Dwight (E. W.) on head injuries, 269.

Dwight (T.) on branches of superior
mesenteric artery, 635.

INDEX.

659

Dysmenorrhea, 454 ; etiology, 454 ; nasal
treatment for, 456; spasmodic, 455;
thyroid extract in, 455; treatment,
455.

Dystocia, fetal, 403 ; maternal, 391.

Ear, auricle of, reflex movement of, 619;
diseases of, 616; diseases of, argyrol
in, 605 ; internal liquid of, 625 ; medi-
colegal relations, 630; middle (see
Middle ear).

Earache, chloroform in, 621.

Eastman's appendix forceps, 145.

Eccles on vermiform appendix, 142.

Eclampsia, puerperal, 391 ; cesarean
section for, 398 ; constipation as factor
in, 393; hemianopia after, 560; intra-
uterine kolpeurysis for, 398 ; patho-
genesis, 391; relation of thyroid to,
393 ; renal decapsulation for, 398 ; thy-
roid and parathyroid insufficiency in
pathogeny of, 396; treatment, 394;
treatment, operative, 398; venesec-
tion in, 396.

Ectromelus, 356.

Ectropion, cicatricial, operations for,
534.

Edebohls (G. M.) on renal decapsula-
tion, 295; on renal decapsulation
for chronic nephritis, 289; on renal
decapsulation for puerperal eclamp-
sia, 398.

Edema, hysteric, of larynx, 600.

Eisendrath on accidents of anesthesia,
44 ; on relation of gonorrhea to tuber-
culosis of genitourinary tract, 262;
on traumatic rupture of spleen, 210.

Elbow-joint, fractures of, treatment,
505; injuries of, treatment, 505.

Electrothcrmic hemostasis, Do^vnes
method, 487, 497; hysterectomy,
486.

Elephantiasis congenita cystica, 355.

Elliot (H. R.) on peritomy in trachoma,
537.

Emanuel (J. G.) on cancer of esophagus,
54.

Embolism of mesenteric artery, 233 ;
of retinal artery, 553.

Embryo, development of islands of
Langerhans in, 641; hibernating
gland in, 647.

Embryonic stomach, existence of un-
known blood-supply to, 635.

Employees, transportation, vision of,
542.

Empyema, antral, diagnosis, 582;
antral, treatment, 582; in children,
127; in children, surgical treatment,
217; of sphenoid sinus, 583; primary
sarcoma of lung simulating, 218.

Endometritis, treatment, 457.

Endoscopy, direct, of upper air-pas-
sages and esophagus, 594.

Endothelioma of mammary gland, 37;
of orbit, 563.

Endothelium of cornea, 546.

End-to-end anastomosis of popliteal
artery, for gunshot wound, 232.

Enterectomy, double, for matting of
intestines, 125; in gangrenous hernia,
174.

Enteroptosis, nature and anatomy,
129, 642.

Entropion, Ewing's modified operation
on, 535.

Enucleation, Mules's operation and,
563; suturing tendons after, 564.

Ependymitis, acute, in infant, 267.

Epilepsy, nasal vertigo simulating, 605;
surgical treatment, 273.

Epithelial structures, transitory, with
mammary apparatus, 649.

Epithelioma, ■ chorion-, 348 ; of eye-
lids, treatment, 533; of mouth,
diagnosis, differential, 27; primary,
of uvula and soft palate, Rontgen
rays in, 593; Rontgen rays in, 41.

Epithelium, corneal, detachment of,
546.

Erdmann on typhoid perforation of
gall-bladder, 199; on intussuscep-
tion, 95.

Ergot, eye and, 566.

Erving and Painter on lipoma arbores-
cens, 515.

Erythema, angioneurotic, 283.

Erythropsia, 528.

Esophagus, absence of, congenital, 52;
carcinoma of, 54; congenital absence
of, 52; idiopathic dilation of, 55;
perforation of, 52, 53; stricture of,
diagnosis and treatment, 53; up]ier
air-passages and, direct endoscopy
of, 594.

Estes on modern amputations, 13.

Etesse on gonorrhea in women, 426.

Etlunoiditis, chronic, 582.

Ethyl bromid as anesthetic, 48; chlorid
as anesthetic, 46; chlorid as anes-
thetic for mcmbrana tympani, 626;
chlorid in labor, 387.

Ewing (A. E.) on entropion, 535,

Excision of bladder with implantation
of ureters into rectum, for papillo-
matous growth, 314; of gasserian
ganglion, 275.

Exophthalmic goiter, 240; exophthal-
mos of, 566; in abnormal thyroid
gland, 242; operative treatment, 241.

Exophthalmos, 563; after injury, 562.

Extrauterine and intrauterine preg-
nancy, coexisting, 379; pregnancy,
378; pregnancy, double, 378; preg-
nancy, recurrent, 378.

Eye, bacteriology, 540; burn from
amyl nitrite, 563; cancer of, can-
croin for, 569; lead in, 564; con-
tagious diseases of, prophylaxis, 541 ;

660

INDEX.

effect of ergot on, 566; first aid in
injuries to from lime, 565; for-
eign bodies in, magnet and, 563; for-
eign bodies in, a;-rays in, 568; in
hysteria, 566; in nervous diseases,
566; in variola, 565; injuries, 563;
injuries of, from lime, 565; instru-
ments, 570; muscles of, extrinsic,
nerve terminals in, 648; new muscle
of, 634; penetrating wounds of, 564;
radium in therapy of, 568; rodent
ulcer of, .r-rays in, 568; silver fiuorid
in therapy of, 568 ; tachiolo in therapy
of, 568; therapeutic appliances, 520;
therapeutics of, 567; traclioma of,
x-rays in, 568; tuberculosis of, x-rays
in, 568 ; x-ray therapy, 567 ; yohimbin
as anesthetic, 569.

Eyeball, instrument for measuring
projection of, 570.

Eye-drops, keeping sterile, 572.

Eye-ground, photographing, 572.

Eyelids, diseases of. 532; epithelioma
of, treatment, 533; gangrene of,
532; operations on, 533; vicarious
menstruation from, 532.

Eyesight of school-children, testing,
528.

Eyestrain and cataract, 524; and
chronic ill health, 523; as cause of
chorea, 524.

Facial paralysis, surgical treatment,
278; treatment by nerve anasto-
mosis, 278.

Facultative sterility, 425.

Fallopian tube, carcinoma of, primary,
488.

Farlow's tonsil punch, Amberg's modi-
fication, 587.

Fascia, diseases of, 284.

Faulty attitude, round shoulders and,
508.

Fecal vomiting in operations for intes-
tinal obstruction and septic peri-
tonitis, 100.

Feces, incontinence of, Robson's opera-
tion for, 135.

Femoral hernia, Bassini operation in,
165; hernia, operation for, mortal-
ity, 166; hernia, radical cure, 164;
hernia, strangulated, 178; ring, right,
strangulation of vermiform appen-
dix in, 174; thrombophlebitis, post-
operative, 238.

Femur, neck of, fracture of, Maxwell
dressing in, 246; neck of, fracture
of, treatment, 246, 512; sarcoma-
tous growths in, 39; shaft of, frac-
ture of, Mummery's method, 247.

Ferguson on renal calculus, 292; opera-
tion of, for displacements of uterus,
467.

Ferguson (A. H.) on end-to-end an-

astomosis of popliteal artery for
gunshot injury, 232.

Fetal appendages, patholog}^ of, 348;
appendix, relation of meconium to,
346; dystocia, 403; monstrosities,
355; syphilis, recognition, 353.

Fetterolf (G.) on rhinologic terminol-
ogy, 604.

Fetus, pathology of, 348; rigor mortis
in, 354.

Fibroid tumors in pregnancy, 368;
tumor of uterus, 469 (see also
Uterine fibroids) ; uterus, pregnancy
in, 368.

Fibula, fracture of, 250.

Files (C. O.) on high-frequency appara-
tus, 337.

Findley on hydatidiform mole, 351.

Finney's method of pyloroplasty, 82.

Fisher (T.) on nystagmus, 530.

Fisher and Keen on cirrhosis of liver,
183.

Fissure, anal, 131.

Fistula, artificial valvular, in cecum,
for clironic colitis, 125; artificial
valvular, in jejunum, as adjunct to
operations on stomach, 125; between
gallbladder and stomach, 196; cor-
neal, 546; in women, 440; rectal,
complicating hemorrhoids, 131; sub-
conjunctival, in glaucoma, 661 ; urin-
ary, in women, apparatus for, 440;
vesicovaginal, 441.

Flat-foot supports, abuse of, 517.

Flegenheimer on pig-skin grafting, 334.

Fleming (R. A.) on retinal hemorrhage
in fracture of skull, 554.

Flexion-deformity at knee-joint,
method of correcting, 514.

Flint on framework of thyroid gland,
646.

Floating kidney, method of anchoring,
299.

Fiuorid of silver in eye therapy, 568.

Fluorine in bones and teetli, 633.

Follicular tonsillitis, acute, treatment,
596.

Foot, club-, 510 ; flat-, supports for, abuse
of, 517; orthopedic surgery of, 516;
painful affections of, among nurses,
516.

Forceps for removal of vermiform
appendix, 145; Lundholm's, for in-
testinal anastomosis, 123; Tarnier's
axis-traction, Friedman's modifica-
tion of, 409; use and abuse of, in
obstetrics, 408.

Foreign body in bronchus, 220; in
lung, 220; in rectum of infanta, 130;
in stomach, 91 ; in stomach, magnet
for removing, 91; in upper air-pas-
sages and esophagus, direct endos-
copy in, 594 ; in vermiform appendix,
155.

Formaldehyd in acute septicemia, 19, 20.

INDEX.

661

Formalin in endometritis, 457; in
puerperal septicemia, 413; solution
in inoperable cancer, 23.

Fortescue-Brickdale on intravascular
antisepsis, 20.

Fossa duodenojejunalis, hernia into,
171; middle cranial, surgical anat-
omy, 275.

Fowler (G. R.) on appendicular black
vomit, 157; on gtmshot wounds of
neck, 327; on toilet of peritoneum
in appendicitis, 155; on vicious
circle following gastroenterostomy, 63.

Fractures, 243; compound, window-
ing plaster casts in, 244; diagnosis,
244 ; in or near joints, 505 ; of clavicle
in spontaneous labor, 418; of elbow-
joint, treatment, 505; of fibula, 250;
of hip in children, 245; of lower
extremity, mode of production, 251 ;
of neck of femur, Maxwell dressing
in, 246 ; of neck of femur, treatment,
246, 512; of patella, transverse,
Roberts's treatment, 248; of patella,
treatment, 248; of shaft of femur.
Mummery's method, 247; of skull,
268; of skull, cerebrospinal rhinor-
rhea after, 245; of skull, retinal
hemorrhage in, 554; of tibia, 250;
through greater process of calca-
neum, 249; through site of excision
of knee-joint, 248.

Francis's tonsilsector, 588.

Franklin (M.) on phototherapeutic ap-
paratus, 335.

Fraser on perforating gastric ulcer, 74.

Fraser (E. H.) on Monakow's bundle,
644.

Frazier and Spiller on tic doxiloureux,
276.

Freeman (L.) on tuberculous glands
of neck, 242.

Freeman (W. J.) on nasalsinusitis,581.

Freer on carcinoma of larynx, 213.

Freiberg (A. H.) on spondylitis, 509.

Freyer on prostatic hypertrophy, 322.

Freyer on tumors of bladder, 314.

Fridenberg (P.) on detection of central
color-perception, 545.

Friedenwald (H.) on tuberculosis, 548.

Friedman's modification of Tarnier's
axis-traction forceps, 409.

Fritsch's fundal incision in cesarean
section, 411.

Frost (H. P.) on head injury, 272.

Fuller (E.) on thyroid extract in hemo-
philia, 233.

Fundal incision, Fritsch's, in cesarean
section, 411.

Gage (H.) on appendicitis, 154.
Gallant (A. E.) on corset for movable

kidney, 297.
Gallbladder, anatomy, 639; and stom-

ach, fistula between, 196; diseases of,
178 ; diseases of, diagnosis, differential,
189; extirpation of, indications for,
194; extirpation of, through lumbar
incision, 196; malignant disease of,
197; position of , 640 ; rupture of , 200 ;
surgery of, 184; typhoid perforation
of, 199, 200.

Galloway on nitrous oxid as preliminary
to ether or chloroform, 45.

Galloway (D. J.) on otomycosis in Malay
archipelago, 623.

Galloway (H. P. H.) on fracture through
site of excision of knee-joint, 248.

Gall-passages, incision for operations on,
191.

Gallstones, diagnosis, 186; location of,
diagnosis, 190; transduodenal route
for, 192; transduodenal route for,
mortality of, 192.

Ganglion, gasserian, excision of, 275;
synovial, heredity as cause, 285.

Gangrene of eyelids, 532; of testicle,
305; traumatic, of extremities, 21.

Gangrenous appendicitis in hernial sac,
161 ; cholecystitis, 198 ; destruction
of pituitary body, 267; hernia, en-
terectomy in, 174; intestine, 123, 124.

Garceau on ureteritis in female, 447;
on tuberculosis of kidney, 293.

Gasserian ganglion, excision of, 275.

Gastrectomy, 87 ; partial, 87 ; total, 87,
88.

Gastric activity, influence of menstrua-
tion on, 452; tetany, 89.

Gastroenterostomy, 57; for nonmalig-
nant affections of stomach, 63 ; vicious
circle following, 63.

Gastrointestinal hemorrhage of new-
bom, 419; perforations, diagnosis, 75.

Gastrojejuno.stomy, McGraw elastic liga-
ture in, 63.

Gastroptosis, Beyea's operation for, 80;
Coffey's operation for, 81 ; gastro-
jejunostomy with McGraw elastic
ligature in, 63.

Gastrorrhagia, 83.

Gastrotomy for ulcer of stomach, 71.

Gelatin in aneurysm, 231.

Genital organs, thyroid gland and, 422.

Genitourinary tract, anatomy, 645;
tuberculosis of, relation of gonorrhea
to, 262.

Genu valgum, surgical pathology, 514;
varum, surgical pathology, 514.

Gerster (A. K.) on thrombosis of portal
vein in appendicitis, 158.

Gibbon on amputation of leg after
intraneural injection of cocain, 51;
on gangrenous cholecystitis, 198; on
penetrating woimd of heart, 224.

Gibbon and Cohen on tropical abscess of
liver, 179.

Gibney adhesive plaster dressing for
sprains, 255.

662

INDEX.

Gibney (H. P.) on correction of de-
formity at hip, 511.

Gibney (V. P.) on noisy shoulder, 509.

Gibson (C. L.) on artificial valvular
fistula in cecum and jejunum, 125.

Giles on fibroid tumor in labor, 369.

Gillette (A. J.) on fracture in or near
joints, 505.

Glasses, misuse of, 524.

Glaucoma, 560; adrenalin in, 562;
blood-pressure and, 560; dividing
anterior ciliary arteries for, 561 ; form-
ing subconjimctival fistula in, 561 ;
hemorrhagic, from potassium iodid,
561 ; iridectomy for, 561 ; resection of
cervical sympathetic nerve for, 561 ;
treatment, 560.

Gleitsmann (J. W.) on subglottic sar-
coma, 602.

Glioma, retinal, 555.

Gloves, rubber, in surgery, 10.

Glycosuria and cholelithiasis, pancreati-
tis with, 205.

Goelet (A. H.) on nephroptosis, 295.

Goiter, exophthalmic, 240. See also
Exophthalmic goiter.

Golding-Bird and White on right lumbar
colostomy in colitis, 126.

Goldthwaite (J. E.) on general treat-
ment of tuberculous bone and joint
diseases, 521 ; on round shoulders in
children, 508.

Gonococcus, mastoiditis from, 622.

Gonorrhea, albargin in, 260; argyrol in,
259; in women, 426 ; in women, incu-
bation period of, 258; in women,
yeast-treatment, 427 ; instructions for
patients with, 257; iridochoroiditis
from, 549; relation of, to sterility,
425; relation of, to tuberculosis of
genitourinary tract, 262.

Goodale (J. L.) on pathology of tonsil,
595.

Gould (A. H.) on duplication of ureters,
302.

Gould (G. M.) on eyestrain and chronic
ill health, 523.

Gout, acute, of pharynx, 592.

Gradle (H.) on eye symptoms in nervous
diseases, 566; on neuroretinitis, 553.

Grafting, bone-, Morton's method, 243;
pig-skin, 334.

Grant (W. W.) on rupture of gall-
bladder, 200.

Gray (A. A.) on catarrhal otorrhea, (i29.

Greene and Brooks on diseases of blad-
der, 310.

Greenough on cirrhosis of liver, 183.

Griffith (F.) on nevus of scalp and nose,
37; on poisoning after cocain-anes-

Griffith ' (T.' W.) on division of left

auricle of heart, 640.
Grooner (T. A.) on a;-rays in cancer,

40.

Grubbe on x-rays in malignant diseases,
41.

Guiteras (R.) on diagnosis of surgical
diseases accompanied by pyuria, 287 ;
on operation for fixation of kidney,
297.

Gunshot wounds, 325; of abdomen, 112,
327, 330; of cervical portion of
vertebral column, 325; of chest, 328,
330; of heart, 221; of intestines. 111;
of neck, 327 ; of popliteal artery, end-
to-end anastomosis for, 232; of skull
and brain, 326; of stomach, operation
for, 90; of stomach, pursestring suture
in repair of, 90; of thorax, 327.

Gynecology, 421 ; Rontgen rays in, 423.

Habitual luxation, 519.

Haden (H. C.) on retinal hemorrhage,
553.

Hair-ball complicating chronic ulcera-
tion of stomach, 71.

Hall on gastrojejunostomy, 63.

Hall (J. B.) on splenopexy for wander-
ing spleen, 211.

Hall (W. S.) on absence of flexors of
thumb, 634.

Halstead (A. E.) on inflammation and
perforation of Meckel's diverticulum
as cause of septic peritonitis, 97;
on prolap.se of rectum, 134 ; on tuber-
culous peritonitis, 91.

Hamill (S. M.) on neuroretinitis with
heart-disease, 567.

Hammond (F. C.) on carcinoma of
male breast, 38.

Hands, sterilization of, 9.

Harman (N. B.) on optic atrophy in
retrobulbar neuritis, 558; portable
refractometer, 570; on scotometer,
571.

Harris (G. R.) on gangrenous intestine,
123, 124.

Harris (H. F.) on hypertrophic tuber-
culosis of intestine, 92; on necrosis
of intestinal mucosa in pregnancy,
359.

Harrison on tubal gestation, 384.

Harrison (R.) on prostatic hypertrophy,
324.

Harrison and Daly on rupture of blad-
der, 311.

Hart (B.) on prolapsus uteri, 460.

Hart (D. B.) on hydatid mole, 352.

Hartmann (H.) on nonmalignant dis-
seases of stomach, 66.

Harvie (J. B.) on hernial complica-
tions, 169.

Hassall's corpuscles and gland tubules
in thymus, 648.

Hawthorne (C. O.) on eye lesions in
chlorosis, 567.

Hay-fever, antitoxin, 578; mixture,
578; suprarenal extract in, 577;

inde:^.

663

takamine in, 577; treatment, specific,
578.

Hays (G. L.) on perforation in typhoid
fever, 104.

Head, injuries of, 272; injuries of,
indications for operations, 268, 269;
injuries of, motor aphasia from, 269.

Hearing, functional tests of, 616; mas-
toiditis and, 627.; range of, 616.

Heart, auricle of, left, division of, by
fibrous bands, 640; gunshot wound
of, 221 ; stab-wounds of, suturing,
223; surgery of, 224; suture of, 222;
wound of, penetrating, 223; wound
of, penetrating, suturing, 224; wound
of, suture for, 222.

Heart-disease, congenital, neuroretinitis
with, 567; uterine fibroids and, 469.

Heath (C. J.) on otorrhea, 627.

Heaton (G.) on perforated gastric
ulcer, 74.

Hebotomy, 410.

Hellier (J. B.) on elephantiasis con-
genita cystica, 355.

Hematemesis, acute, operation for, 83;
in appendicitis, 158; postoperative,
83.

Hematoma, tarry, of ovary, 501.

Hematuria, 292; in pregnancy, 364.

Hemianopia after puerperal eclamp-
sia, 560.

Hemolysin,' subconjunctival injections
and, 569.

Hemophilia, thyroid extract in, 233.

Hemorrhage after tonsillectomy, 585;
control of, in removal of pelvic tumors
in female, 496; from stomach, 67;
gastrointestinal, of newborn, 419;
nasal, new treatment, 575; retinal,
in fracture of skull, 554; retinal, in
recognition of arterial degeneration,
553.

Hemorrhagic appendicitis, 157; cysts of
spleen, 207 ; pachymeningitis, surgical
treatment, 273.

Hemorrhoids, hot salt solution in, 133;
Metcalf's operation for, 132; Mit-
chell's operation for, 131; rectal
fistula complicating, 131; White-
head operation for, 131.

Hemostasis, electrothermic, Downes
method, 487, 497.

Henricksen on nerve-suture and nerve-
regeneration, 282.

Hepatic duct, carcinoma of, 197; in-
cision of, for calculi, 191.

Hepaticotomy, 191.

Hepburn (N. J.) on Mules's operation,
563.

Herbert on glaucoma, 561.

Heredity and twins, 405.

Herman on puerperal eclampsia, 395.

Hermaphroditism, genuine, 646.

Hernia, 164; and hydrocele, coexist-
ence, 174; congenital, of liver, into

umbiUcal cord, 179;- double con-
genital, 170; femoral, Bassini opera-
tion in, 165; femoral, operation for,
mortality, 166; femoral, radical cure,
164; gangrenous, enterectomy in,
174; inguinale irreducible, opera-
tion for, 178; inguinal, operation
for, mortality, 166; inguinal, radical
cure, 164; inguinal, radical cure,
local anesthesia in, 168; inguino-
superficial, 171; into fossa duodeno-
jejunahs, 171; lumbar, 173; of
cecum and appendix, 174; of linea
alba, 170; operation for, wounding
of bladder in, 169; preperitoneal,
172; radical cure, 167, 169; radical
cure, paraffin in, 168; retroperitoneal,
170; special varieties, 166; strangu-
lated, bilateral, 178; strangulated
femoral, 178; strangulated, operation
for, 177; strangulated, operation for,
results, 174; umbilical, operation for,
170.

Hernial apertures, large, implantation
of silver filigree for closure of, 167;
complications, 169; sac, bladder in,
169; sac, gangrenous appendicitis
in, 161.

Hewitt on bad and difficult subjects
for anesthetization, 43.

Hibbs (R. A.) on pelvic rest, 512; on
shortened tendo Achillis, 517.

Hibernating gland in embryo, 647.

Hiers (J. L.) on asthenopia and malaria,
525.

High-frequency ar-ray apparatus, 337.

Hill on stab-wounds of heart, 223.

Hinkcll (F. W.) on empyema of sphe-
noid sinus, 583.

Hip, deformity at, correction, 511;
dislocation of, congenital, 510; dis-
location of, congenital, treatment,
509; fracture of, in children, 245;
orthopedic surgery of, 509.

Hip-joint amputation under medullary
narcosis, 14; role of atmospheric pres-
sure in, 634.

Hirschberg on myopia in diabetes
mellitus, 566.

Hirst (B. C.) on examination and treat-
ment of women after childbirth, 387;
on new operation for cystocele, 433;
on treatment of idiopathic pruritus
vulvaj, 430.

Hogsett on aseptic cotton-holder, 606.

Holman on appendicitis, 145.

Holmes (C. R.) on glioma of retina,
556.

Holmes (R. W.) on third stage of labor,
387.

Holmgren test for color-blindness, 545.

Hoppe on eye injuries from lime, 565.

Horwitz (O.) on irrigation method of
treating urethritis, 260.

Hot- water mattress, 12.

664

IXDEX.

Hotz (F. C.) on cicatricial ectropion,
534; on misuse of glasses, 524.

Hourglass stomach, 69.

Houseman and Beaumont on rupture
of spleen, 209.

Howe (L.) on orbital connective tissue,
562.

Howlett on properitoneal hernia, 172.

Hugo on injury of bladder, 313.

Humor, aqueous, secretion of, 550;
vitreous, origin, 550.

Hutchings and Nancrede on steriliza-
tion of catheters, 10.

Hutchinson (J., Jr.) on epithelioma of
mouth, 27.

Hydatid cyst, compression myelitis
from, 286; of liver in pregnancy, 181.

Hydatidiform mole, 351.

Hydatids, pulmonary, treatment of,
219.

Hydrocele and hernia, coexistence, 174.

Hydrorrhcea gravidarum, 353.

Hydrosalpinx, nature of, 489.

Hyperemesis gravidariun, 357.

Hyperiodized oil in eye therapy, 569.

Hypernephroma, 293.

Hypertrophy of spleen, malarial, with
movability, splenectomy for, 212; of
synovial fringes of knee-joint, 252;
prostatic, chronic, treatment, 322;
prostatic, obstruction due to, cauteri-
zation of prostate through rectimi for,
319; prostatic, operation for, indica-
tions, 324; prostatic, pathogenesis
and pathologic anatomy, 316; pros-
tatic, symptoms, 325; prostatic,
transvesical cauterization as substi-
tute for Bottini operation in, 318;
prostatic, treatment, 321 ; pro.static,
treatment, present status of, 325.

Hypogastropagus, 357.

Hysterectomy, bladder after, 446; elec-
trothermic, 486; for puerperal sepsis,
416; for uterine fibroids, 475; or
myomectomy in uterine fibroids, 472;
superperitoneal, for uterine fibroids,
475.

Hysteria, eye in, 566.

Hysteric edema of larynx, 600.

Hysterokataphraxis, 462.

Idiot, microcephalic, cerebrum of, 644.

Ileum, branches of superior mesenteric
artery to, 635.

Iliopsoas bursa, surgical importance,
284.

Implantation of ureters into rectum,
excision of bladder with, for papillo-
matous growth, 314.

Impregnation, normal place of, 370.

Incarceration of retroflexed gravid
uterus, 365.

Incision, abdominal, suppurating, 499;
prerectal curvilinear, for prostatic

abscess, 317; suprasymphyseal, of
Pfaimenstiel, 493; vaginal, scope of,
497.

Incontinence of feces, Robson's opera-
tion for, 135.

Infection originating in lymphoid tissue
of upper air-tract, 594; tonsillar,
symptoms and treatment, 595.

Infectious fevers, ocular affections and,
565.

Ingals on acute follicular tonsillitis, 596 ;
on larjngectomy for carcinoma, 213.

Ingersoll (J. M.) on spasmodic torticollis
after adenoidectomy, 612.

Inguinal hernia, irreducible, operation
for, 178; operation for, mortality, 166;
radical cure, 164; radical cure, local
anesthesia in, 168.

Inguinosuperficial hernia, 171.

Injuries, birth, suture of brachial plexus
for, 505; of bladder, 313; of elbow-
joint, treatment, 505; of head, 272;
of head, indications for operations,
268, 269; of head, motor aphasia
from, 269.

Innominate artery, aneurysm of, treat-
ment, 230; right subclavian, and
common carotid arteries, aneurysm
of, 229.

Insufflator, powder, Brown's, 631.

Internal ear, liquid of, 625.

Intestinal anastomosis, Lundholm's
method, 121, 122, 123; defects, trans-
plantation of omentum in, 124; injury
following abdominal contusion, diag-
nosis, 115; mucosa, necrosis of, in
pregnancy, 359; obstruction, 99; ob-
struction, acute, 100; obstruction due
to impaction with lumbricoids, 98;
obstruction due to Meckel's diverticu-
lum, 98 ; obstruction, fecal vomiting in
operation for, 100; perforation, 117;
resection, 120; sutures, through-and-
through, 120; tuberculosis, chronic,
treatment, radical, 108.

Intestines and stomach, carcinomatosis
of, 85; diseases of, 91; gangrenous,
123, 124; gunshot wound of, HI;
laceration of, 113; large, malignant
growths of, treatment, operative, 119;
matting of, double enterectomy for,
125; prolapse of, paraffin in, 134;
rupture of, 112, 116; strangulation of,
from adherent and elongated intes-
tine, 161; tuberculosis of, hypertro-
phic, 92.

Intraabdominal pressure in female, 459.

Intracranial tension, increased, 270; in-
dications for operation, 271.

Intratracheal medication, Donnellan's
syringe for, 603.

Intrauterine and extrauterine preg-
nancy, coexisting, 379.

Intubation-tubes, prolonged use of, rapid
dilation and, in stenosis of larynx, 599.

INDEX.

665

Intussusception, acute, 94; during con-
valescence from typhoid fever, 96; of
Meclcel's diverticulum, 96; of Meckel's
diverticulum, followed by intussuscep-
tion of ileum, 98; of Meckel's diver-
ticulum, with secondary ileocolic in-
tussusception, 98; recurrence of, 95;
transsacral removal of, complicated
by malignant growth, 95; treatment,
operative, 119.

lodin, substitutes for, in eye therapy , 569.

lodin-vasogen in ulcers of cornea, 547.

lodipin in eye therapy, 569; in uterine
fibroids. 472.

Iodoform in vitreous body in penetrating
wounds, 564.

lodoform-anilin treatment of catarrhal
otorrhea, 629.

Iridectomy, for glaucoma, 561.

Iridochoroiditis from gonorrheal infec-
tion, 549.

Iris and choroid, congenital defect of,
548; diseases of, 548; posterior layer
of, structure and development, 648;
sarcoma of, primary, 549; tuberculosis
of, 548.

Iritis after mumps, 565; in mumps, 548.

Irving on gunshot injuries of skull and
brain, 326.

Islands of Langerhans, development of,
in embryo, 641.

Itrol in trachoma, 537.

Jaboulay'.s treatment of inoperable

cancer of uterus, 483.
Jackson (C.) on chronic suppurative

otitis media, 631 ; on correctmg septal

deviations, 579.
Jackson (E.),on binocular magnifier, 570;

on protometer, 570; on tuberculosis

of conjunctiva, 539; on visual field

in head-conditions, 558.
Jacobson on hemorrhagic appendicitis,

157.
Jacobson (J. H.) on transplantation of

ureters, 309.
Jans.son's siderophone, 571.
Jardine on cardiac disease in pregnancy,

358.
Jay (M.) on pregnancy in double uterus,

403.
Jeffery on hernia of cecum and appendix,

174.
Jejunum, artificial valvular fistula in, as

adjunct to operations on stomach,

125; branches of superior mesenteric

artery to, 635; peptic ulcer of, 118,

119.
Jequiritol in trachoma, 569.
Jequirity beans, substitute for infusion

of. 569.
Jessett on peritoneal adhesions, 498.
Jessop (W. H. H.) on tuberculosis of

choroid, 549.

43 S

Jessup (D. S. D.) on primary carcinoma
of vermiform appendix, 150.

Johnson (G. B.) on ureteroureteral anas-
tomosis, 449.

Johnson's modification of Penrose's
operation for nephropexy, 298.

Johnston (R. H.) on papilloma of con-
junctiva, 537.

Johnston (S.) on treatment of tonsiUitis,
596.

Joints, anatomy, 633; diseases of, 252;
fractures in or near, 505; in children,
tuberculosis of, treatment after Lan-
nelongue method, 519; incision and
drainage of, in acute rheumatic fever,
252; tuberculosis of, malignancy of,
519; tuberculosis of, treatment, gen-
eral, 521.

Jonas on pes equino varus, 517.

Jones on surgery of paralyses of children,
285.

Jones (A. W.) on lumbar hernia, 173.

Jones (D. F.) on rupture of bladder, 310.

Jones (R.) on hydatid cyst of liver in
pregnancy, 181; on perforating gastric
ulcer, 72.

Joy (H. M.) on gastrorrhagia, 83.

Jubb and Livingstone on nail in liver,
182.

Keble on abscess of liver, 179.

Keefe (J. W.) on Downes's electrothermic
artgiotribe, 11.

Keen and Fisher on cirrhosis of liver,
183.

Keetley on transplantation by exchange,
333.1

Keiper (G. F.) on cataract, 552.

Keith (A.) on nature and anatomy of
enteroptosis, 129.

Kellock on strangulated hernia, 178; on
excision of chronic gastric ulcer, 70;
on foreign body in bronchus, 221.

Kelly (H. A.) on advisability of remov-
ing vermiform appendix, 146; on
functions and pathology of Skene's
glands, 442; on strictures of ureter,
302.

Kennedy on suture of brachial plexus,
505.

Kennedy (R.) on birth paralysis, 281.

Keratocx)nus following traumatism, 546.

Keratosis of pharynx, 590.

Kerr (J.) on testing eyesight of school-
children, 528.

Keyes on prostatic hypertrophy, 325.

Kidneys, carcinoma of, nephrectomy
for, 288 ; diseases of, 287 ; fixation of,
operation for, 297; fixation of, suture
in, 296, 297; floating, method of
anchoring, 299; moval)le, corset for,
297 ; movable, diabetes with, 300 ;
moval)le, statistics on, 300; movable,
treatment, 299; of pregnancy, 362;

666

INDEX.

polycystic, 293; tuberculosis of, opera-
tions for, 293, 294, 295; tumors of,
in female, 450.

Kilbum on exophthalmos, 562.

Killian on endoscopy of air-passages
and esophagus, 594.

Kilvington on cysts of liver, 182.

Kipp (C. J.) on ophthalmoplegia, 559.

Klebs-Loffler bacilli in atropine rhinitis,
574.

Kliseometer, 399.

Klotz (H. G.) on albargin in gonorrhea,
260.

Klotz's method of circumcision, 306.

Knapp (H.) on notation of ocular
meridians, 525.

Knee, orthopedic surgery of, 513; re-
section of, without opening joint, 254.

Knee-joint, drainage of, for acute
suppurative arthritis, 253; flexion-
deformity at, method of correcting,
514; hypertrophy of synovial fringes
of, 252; semilunar cartilage at, luxa-
tion of, 514.

Knife, new, for tonsillectomy, 586.

Knife-blade in lung, 220.

Knott on sarcoma of uterine parencliyma,
476; on traumatic gangrene, 21.

Kolisher on bladder after liystcrectomy,
446.

Kolpeurynter bag in placenta previa,
372.

Kolpeurysis, intrauterine, for puerperal
eclampsia, 398.

Kraurosis vulva? with rodent ulcer, 428.

Krause (L. J.) on circumcision, 306.

Kyle (D. B.) on infectious processes in
adenoid structures of children, 612.

Labor, 386 ; chloroform in, 386 ; chroma-
topsia following, 528 ; dermoid cy.st in,
367; ethyl chlorid in, 387; induction
of, in placenta pra;via, 372 ; laceration
of vagina during, 388; spontaneous,
fracture of clavicle in, 418; third
stage of, rational conduct, 387.

Laceration of cervix uteri, 438; of
intestines, 113; of spleen, 208, 209;
of vagina during labor, 388.

Lacrimal affections, 535; sac, extirpa-
tion of, 536; sac, syphilis of, 535;
sac, tumors of, 535.

Lagarde on gunshot wounds of chest
and abdomen, 328; on poisoned
w^ounds in warfare, 329.

Lambert (W. E.) on prophylaxis in
ophthalmology, 541.

Lambert and Coley on embolism of
mesenteric artery, 233.

Lamp, Cleaves's, for actinic rays, 336.

Lane (W. A.) on mode of production of
fractures of lower extremity, 251.

Langerhans, islands of, development of,
in embryo, 641.

Langwell (H. W.) on stammering, 607.

Laparotomy, drainage after, 496.

Larkin (F. C.) on cerebrospinal rhinor-
rhea, 245.

Laryngeal tuberculosis in pregnancy,
361.

Laryngectomy for carcinoma, 213.

Larynx and trachea, diseases of, 597
carcinoma of, diagnosis, 213; carci
noma of, pachydermia and, 597
carcinoma of, x-rays in, 600; hysteric
edema of, 600; myxoma of, 600
stenosis of, 598; stenosis of, rapid
dilation and prolonged use of intuba-
tion-tubes in, 599; syphilis of, 601.

Latham and Pendlebury on pericardial
effusion, 226.

Lead in eye, 564.

LeConte (R. G.) on diagnosis of intestinal
injury, 115; on perforation in typhoid
fever, 103.

Lederman (M. D.) on argyrol in diseases
of nose, throat, and ear, 605.

Lee (C. G.) on monocular optic neuritis,
557.

Leech (P.) on retroperitoneal hernia, 170.

Leg, amputation of, after intraneural
injection of cocain, 51.

Lehr and Christian on appendicitis, 162.

Lens, crystalline, ablation of, in high
myopia, 526; diseases of, 550.

Lenses, decentering, 526.

Leonard on 3:-rays in inoperable and re-
current carcinoma, 39.

Leukocytosis in pelvic suppuration^ 490.

Lewis (S.) on anal fissure, 131.

Ligature, McGraw elastic, in gastro-
jejunostomy, 63.

Lightning stroke, perforation of mem-
brana tympani from, 620.

Lime, eye injuries from, 565.

Linea alba, hernia of, 170.

Lipiodol in eye therapy, 569.

Lipoma arborescens, 515; of cecum, 39.

Lips, carcinoma of, 32.

Liquor amnii and blood of mother and
fetus, comparative investigations of,
344; origin, 343.

Lithemic nasopharyngitis, 589.

Littlewood on colectomy in malignant
disease of colon, 127.

Liver, abscess of, 179; abscess of, in
child, 178; abscess of, tropical, 179;
carcinoma of, 181 ; cells of, anatomy,
638 ; cells of, lymph-canaliculi of, 638 ;
cirrhosis of, 183; cirrhosis of, ascites
due to. Talma's operation for, 184;
cirrhosis of, surgical treatment, 183;
cysts of, simple, 182 ; diseases of, 178 ;
hernia of, congenital, into umbilical
cord, 178; hydatid cyst of, in preg-
nancy, 181 ; nail in, 182.

Livingstone and Jubb on nail in liver, 182.

Lloyd (J.) on prostatic hypertrophy, 323.

Lockwood (C. B.) on appendicitis, 149;

INDEX.

667

on idiopathic dilation of esophagus,
55.

Lofton on treatment of hemorrhoids,
133.

Long (S. F.) on circumcision, 305.

Longridge on blood examination in ap-
pendicitis, 144.

Lorenz (A.) on club-foot, 510; on con-
genital dislocation of hip, 510.

Lorenz's visit to United States, review
of, 512.

Lovett (R. W.) on affections of foot
among nurses, 516 ; on round shoulders
and faulty attitude, 508.

Lowe (M.) on corneal ulceration, 547.

Luckett on antitetanic serum in tetanus,
18.

Lumbar hernia, 173.

Lund (F. B.) on abnormalities of
phalanges, 333; on iliopsoas bursa,
284; on interscapulothoracic amputa-
tion for sarcoma of brachial plexus, 17.

Lvmd (H.) on excision of bladder with
implantation of ureters into rectum,
314.

Lundholm's method of intestinal anasto-
mosis, 121, 122, 123.

Lungs, foreign body in, 220; hydatids
of, treatment, 219; sarcoma of,
primary, simulating empyema, 218;
surgery of, 213; tuberculous cavities
of apex of, surgery of, 216.

Luxation, habitual, 519; of semilunar
cartilage at knee-joint, 514.

Lydston (G. F.) on cystalgia, 308; on
incubation period of gonorrhea, 258.

Lymphatic system, diseases of, 239.

Lymphatics and bloodvessels, anatomy,
635; and connective tissue, relations
between, 637; of peritoneal cavity,
relation of, in diaphragm and mechan-
ism of absorption of granular mate-
rials from peritoneum, 637 ; of ureters,
637; pelvic, condition of, in uterine
carcinoma, 479.

Lymph-canaliculi of cells of liver and
suprarenal body, 638.

Lymph-glands, bronchial and tracheal,
topographic anatomy, 636.

Lymplioid tissue of upper air-tract, in-
fections originating in, 594.

Lyons (A.) on tonsillar abscess, 586.

Macauley (J. B.) on dermoid cyst in

labor, 367.
MacCallan on adrenalin in glaucoma,

562.
MacCormick on pylorectomy for cancer

of stomach, 86.
MacDougall on appendicitis, 147.
Macewen (W.) on prostatic hypertrophy,

323.
Maekay on foreign bodies in rectum of

infants, 130.

Mackenzie (G. H.) on nasal hemorrhage,
575.

MacMunn (J.) on efficacy of remedies
in gonorrhea, 259.

MacMunn's instrument for retaining
solutions in urethra, 259, 260.

Macroglossia neurofibromatosa, 33.

Madison (J. D.) on brain tumor, 265.

Magnet for removing foreign bodies
from stomach, 91 ; in foreign bodies
in eye, 563.

Makuen (G. H.) on defective speech,
612; on development of faculty of
speech, 613; on speech-defects in
children, 613.

Malaria, asthenopia with, 525.

Malcolm on foreign body in appendix,
155.

Malignant disease of gall-bladder, 197;
disease of testicle, excision of lumbar
lymphatic glands in, 304; disease of
uterus, 476; uterine fibroids, 471.

Mallins on chronic ulceration of stomach
complicated by hair-ball, 71.

Mammals, cardiac glands of, 638.

Mammary apparatus, transitory epithe-
lial structures with, 649.

Manley (T. H.) on appendicitis, 144.

Manton (W. P.) on extirpation of gall-
bladder, 196.

Marion's method of resecting knee
without opening joint, 254.

Mar John's ulcer, carcinomatous change
in an area of, 23.

Marsh (J. P.) on congenital absence of
esophagus, 52.

Marta (M.) on tuberculosis of bones and
joints in children, 519.

Martin on traumatic aneurysm, 231.

Martin (E. D.) on spinal anesthesia, 50.

Martin (F.) on radical cure of hernia,
167.

Martindale (W.) on keeping eye-drops
sterile, 572.

Mastoid wound, skin-grafting for, 627.

Mastoiditis, acute, audition and, 627;
beer yeast for, 627 ; from gonococcus,
622; nonoperative measures. 621.

Matas (R.) on operation for cure of
aneurysm, 227.

Mattress, hot-water, 12.

Maxillary antrum, disease of, 582;
bone, superior, excision of, under
medullary narcosis, 50.

Maxwell dressing in fracture of neck
of femur, 246.

Mayer (E.) on Asch operation, 578;
on introducing finger into naso-
pharynx, 596; on nasal adenoma,
578.

Mayo (C. H.) on cancer of rectum, 139.

Mayo (W. J.) on malignant disease of
gallbladder, 197; on surgery of
gallbladder and bile-ducts, 184.

Mayou on magnet for removing foreign

668

INDEX.

bodies from stomach, 91 ; on x-rays
in eye therapy, 567.

McAuliffe (G. B.) on anesthesia of
membrana tympani, 625.

McCallum (W. G.) on lymphatics and
connective tissue, 637 ; on lymphatics
of peritoneal cavity, 637.

McCann on vesicovaginal fistula, 441.

McCann (F. J.) on deciduoma malig-
num, 350.

McCardie (W. J.) on ethyl chlorid
as anesthetic, 46; on management
and preparation of patient for anes-
thesia, 42.

McCaskey and Porter on brain abscess,
266.

McCaw (J. F.) on epithelioma of uvula
and soft palate, 593; on mastoiditis
and audition, 627.

McCosh (A.) on uterine fibroids, 472.

McCrae and Mitchell on tvphoid fever,
105.

McGibbon (J.) on ectromelus, 356.

McGraw ela-stic ligature in gastro-
jejunostomy, 63.

McGuire (E.) on hand sterilization, 9.

McGuire (S.) on drainage after abdom-
inal section, 11.

McKenion (J. F.) on cleft palate, 614;
on otorrhea of middle ear, 618.

McNamara (X. C.) on cerebrum of
microcephalic idiot, 644.

McNaughton-Jones (H.) on perforation
of membrana tympani, 620.

McReynolds (J. O.) on irterygium, 539.

McWilliams (C. A.) on movable kidney,
300.

Meckel's diverticulum, inflammation and
perforation of, as cause of septic
peritonitis, 97 ; intestinal olistruc-
tion due to, 98; intussusception of,
96; intussusception of, followed by
intussusception of ileum, 98; intus-
susception of, with secondary ileo-
colic intussusception, 98.

Meconium, relation of, to fetal appen-
dix, 346.

Medullary sheath, new method of
staining, 650.

Membrana tympani, anestliesia of, 625^
perforation of, from lightning stroke,
620.

Menopause, 457; cardiac disturbances
in, 457; deciduoma malignum after,
350.

Menstruation, disorders of, 450; influ-
ence of, on gastric activity, 452; tube
and uterus in, 453; vicarious, from
eyelids, 532; weight-wave of, 451.

Mental disease, retinal changes and,
567.

Mesenteric artery, embolism of, 233;
superior, branches of, to jejunum
and ileum, 635.

Metastatic carcinoma of choroid, 549.

Metcalf's operation for hemorrhoids
132.

Methyl atropin, bromid of, as mydri-
atic, 569.

Metritis, columnization of vagina for,
458.

Metrorrhagia, adrenalin in, 454; cal-
cium chlorid in, 454.

Meyer (W.) on general anesthesia, 46;
on implantation of silver filigree for
closure of large hernial apertures,
167; on irrigating colon, 125, 126.

Microcephalic idiot, cerebrum of, 644.

Middle ear, accessory cavities of, tuber-
culous disease of, 628; deafness,
ozone in, 620; suppuration of (see
Otorrhea) ; tuberculous disease of,
diagnosis, 628; tuberculous disease
of, treatment, 628.

Midwife act and teaching of obstetrics,
338.

Miles and Wilson on cataract, 552.

Milk, septic sore throat from, 597.

Milligan (W.) on tuberculous disease
of middle ear, 628.

Millikin on astigmatism, 525.

Mills (C. K.) on brain tumors, 264.

Milton on bilharziosis, 309.

Minie ball wound of stomach, 91.

Mitchell (A. B.) on inguinal hernia, 178.

Mitchell (J. F.) on tuberculous cer-
vical adenitis, 243.

Mitchell's operation for hemorrhoids,
131.

Mitchell and McCrae on tyi)hoid fever,
105.

Mix (C. L.) on hereditary optic atrophy,
558.

Mole, hydatidiform, 351.

Molluscum contagiosum of conjunc-
tiva, 538.

Monakow's bundle, 644.

Monks and Blake on vermiform appen-
dix, 641.

Monstrosities, fetal, 355.

Monstrosity, double, 356.

Moore (J. E.) on intestinal obstruc-
tion, 98.

Moran (J. F.) on gastrointestinal hemor-
rhage of newborn, 419.

Morley on parotiditis following ab-
dominal section, 500.

Morning drop, 261.

Morphin-scopolamin anesthesia, 48.

Morris (A. T.) on rubber gloves in
surgery, 10.

Morris (H.) on inoperable cancer, 21.

Morrison (R.) on incision for operations
upon gall-passages, 191.

Morton (A. W.) on bone-grafting, 243;
on hip-joint amputation under medul-
lary narcosis, 14; on spinal anes-
thesia, 50.

Mosher (H. P.) on cargile membrane
in nose, 574.

INDEX.

669

Mosher's self-retaining tongue-depres-
sor, 604.

Motor aphasia from head injury, 269.

MouHin on chronic ulceration of stom-
ach, 70; on liysterectomy for fibroids,
475.

Mouth, epithelioma of, diagnosis, dif-
ferential, 27.

Movable kidnev, corset for, 297; dia-
betes with, 300; statistics on, 300;
treatment, 299.

Moyer on traumatism of peripheral
nerves, 283.

Moynihan on cholecystectomy, 195;
on gastric tetany, 89; on pancreatic
calculus, 203; on surgery of simple
diseases of stomach, 66; on treat-
ment of malignant disease of stom-
ach, 87; on typhoid pancreatitis,
203.

Mucor mucedo cause of otomycosis,
623.

Mucosa, intestinal, necrosis of, in preg-
nancy, 359.

Mules's operation, 563; enucleation
and, 563; glass ball for, 564; par-
affin vitreous after, 564.

Mummery (J. P. L.) on method of
treating fracture of shaft of femur,
247.

Mumps following abdominal section,
500 ; iritis after, 565.

Munro (J. C.) on diagnosis of typhoid
perforation, 108; on hemorrhagic
pachymeningitis, 273.

Murpliy on diagnosis of gallstones,
186; on general sui)}ivirative peri-
tonitis ami typhoid perforation, 110.

Murphy and Neff on excision of gas-
serian ganglion, 275; on perforating
ulcers of duodenum, 76.

Murray on fracture of tibia and fibula,
250.'

Murray (CI. D.) on vision of railway
emjjloyees, 544.

Murray (H. L.) on vision of railway
employees, 543.

Muscles, anatomy, 633; disease of, 284;
ocular, 529; ocular, paralyses of, 531;
of eye, extrinsic, nerve terminals in,
648.

Musculus papillse optica?, 634.

Myasthenia gravis, ocular manifesta-
tions, 531.

Mycosis vagina?, 431.

Mydriatic, glaucoma after, 562.

Myelitis, compression, from hydatid
cysts, 286.

Myies (11. C.) on normal size of tonsil,
596.

Myoma of ovary, 503.

Myomectomy or hysterectomy in uterine
fibroids, 472.

Myopia, 526; high, ablation of crystal-
line lens in, 526; in diabetes mellitus.

566; spurious, 526; staphylomas in,

526.
Myrtle (G. Y.) on danger of cocain used

externally, 51.
Myxedema after removal of tumor of

pharynx, 596.
Myxofibroma of nose, 35.
Myxoma of larynx, 600.

Nanchede and Hutchings on steriliza-
tion of catheters, 10.

Nasal obstruction and deformities of
upper jaw, teeth, and palate, relation-
ship between, 331; surgery, paraffin
in, 331; treatment for dysmenorrhea,
456; truss, Walsham's, 603; vertigo
simulating epilepsy, 605.

Nash on pancreatitis with cholelithiasis
and glycosuria, 205; on septic sore
throat, 597.

Nasopharyngitis, lithemic, 589.

Nasopharynx, cystoscopy of, 606.

Neck, gunshot wound of, 327; tubercu-
lous glands of, treatment, 242.

Necrosis of intestinal mucosa in preg-
nancy, 359.

Neff and Murphy on excision of gasse-
rian ganglion, 275; on perforating
ulcers of duodenum, 76.

Neilson (T. R.) on Talma's operation
for ascites from cirrhosis of liver, 184.

Neoplasms, ovary, pedicle-torsion in, 502.

Nephrectomy for carcinoma, 288; preg-
nancy following, 364.

Nephritis, chronic, ocular signs in, 553;
chronic, renal decapsulation for, 289;
chronic, surgical treatment, 290;
surgical treatment, 291; unilateral
chronic, 292.

Nephropexy, 295; Penrose's operation
for, Johnson's modification, 298.

Nephroptosis, 295.

Nephro-ureterectomy, complete, in fe-
male, 449.

Nerve anastomosis in facial paralysis,
278; terminals in extrinsic muscles
of eye, 648.

Nerve-fibers, optic, uncrossed, 557.

Nerve-regeneration and nerve-suture,
282.

Nerve-suture and nerve-regeneration,
282; primary, 283.

Nerve-trunks, cocainization of, avoid-
ance of shock in amputations by, 14.

Nervous system, anatomy, 643; diseases
of, 262.

Neuritis, optic, 557; optic, from throm-
bosis, 567; optic, monocular, 557;
retrobulbar, optic atrophy in, path-
ology, 558.

Neurofibromatosis, generalized unilat-
eral, 34; of nerves of tongue, 33.

Neuroretinitis in congenital heart-dis-
ease, 567; of nephritic origin, 553.

670

INDEX.

Nevus of scalp and nose, 37.

Newborn, asphyxia in, 419; gastro-
intestinal hemorrhage of, 419; physi-
ology and pathology, 418.

Newman on motor aphasia from head
injury, 269.

Newman (D.) on acute nonsuppurative
perinephritis, 292.

Newman (H. P.) on plastic surgery of
female urethra, 442.

Nicholson on puerperal eclampsia, 397.

Nitrous oxid as preliminary to ether or
chloroform, 45.

Noble (C. P.) on renal tumors, 450; on
uterine fibroids, 470.

Noisy shoulder, 509.

Norris (R. C.) on saline solutions in
puerperal eclampsia, 395.

Nose, accessory cavities of, diseases of,
580; accessory cavities of, polyps in,
583; accessory sinuses of, transil-
lumination of, in coryza, 581; adeno-
carcinoma of, 574; adenoma of, with
sarcomatous metamorphosis, 578; ad-
hesions in, cargile membrane to pre-
vent, 574; and scalp, nevus of, 37;
and throat, operations upon, chloro-
form as anesthetic in, 45; catarrhal
diseases of, influence of, in producing
speech-defects in children, 613; com-
plications in scarlet fever, prevention,
606; crooked, treatment, 332; de-
formity of, from paraffin injection,
577; depressed, treatment, 332; dis-
eases of, 575; diseases of, argyrol in,
605; hemorrhage from, new treat-
ment, 575; influence of high altitudes
on, 607; myxofibroma of, 35; polyps
of, etiology, 575; polyps of, other con-
ditions and, 575; saddle-, paraffin in,
333; sinuses of, diseases of, prophy-
laxis, 580; sinuses of, inflammation of,
diagnosis, 581; septum of (see Sep-
tum, nasal).

Nucleus salivatorius of chorda tympani,
643.

Nurses, trained, painful affections of foot
among, 516.

Nuthall and Billington on neurofibroma-
tosis, 34.

Nystagmus, 530.

Oatman on cancer of choroid, 549.

Obstetric operations, 408.

Obstetrics, 338; forceps in, use and

abuse, 408; rectal approach in, 346;

teaching of, 338.
Ochsner on prostatic hypertrophy, 324;

on stomach surgery, 55.
O' Conor (J.) on incision and drainage of

joints in acute rheumatic fever, 252;

on lipoma of cecum, 39; on treatment

of appendicitis, 148; on treatment of

pulmonary hydatids, 219; on White-
head operation for hemorrhoids, 131.

Ocular fundus, photographing, 572;
manifestations of myasthenia gravis,
531; meridians, notation of, 525; mus-
cles, 529; muscles, paralysis of, 531;
signs in chronic nephritis, 553; symp-
toms in general diseases, 565.

Oculomotor palsy, total unilateral, 531.

Officier (D.) on fragility of bones, 243.

Oliver (J. C.) on foreign body in stom-
ach, 91.

Omental torsion, intraabdominal, 117.

Omentum, transplantation of, in intes-
tinal defects, 124.

Oophorectomv for inoperable cancer of
breast, 22, 37.

Opdyke on trachoma, 537.

Ophthalmia, metastatic, 567; phlycten-
ular, 536; sympathetic, 563.

Ophthalmology, 522; progress, 522;
prophylaxis in, 541.

Ophthalmoplegia, transient unilateral
external, 559.

Opie (E. L.) on anatomy of pancreas,
640.

Optic atrophy, hereditary, 558; atrophy
in retrobulbar neuritis, pathology,
558; disk, forward movement of, 529;
nerve, degenerations in, 557; nerve,
diseases of, 557; nerve-fibers, un-
crossed, 557; neuritis, 557; neuritis
from thrombosis, 567; neuritis, mon-
ocular, 557.

Orbit, 562; connective tissue of, 562;
distoma cyst of, 563 ; endothelioma of,
563.

Orr and Barrett on double optic neuritis,
558.

Orthopedic hospital pelvic rest, 512;
surgery, 505; surgery, recent advances
in, 519.

Os metopica, 633.

Osgood (R. B.) on lesions of tibial
tubercles in adolescence, 514; on
tibial tubercle of adolescent, 250.

Ossiculectomy, 629.

Osteoclast, new, 513.

Osteogenesis imperfectiva, 519.

Osteomyelitis, acute, of cervical spine,
245.

Osteoplastic resection of skull, Stell-
wagen's trephine for, 274.

Osteotomy, subtrochanteric, 511.

Otitis externa furunculosa, beer yeast
for, 627; media, beer yeast for, 627;
media, chronic suppurative, radical
operation for, 631.

Otoliths in liquid of internal ear, 625.

Otology, beer yeast in, 627.

Otomycosis in Malay archipelago, 623.

Otorrhea, catarrhal, new treatment, 629;
discharge of, examination, 628; of
middle ear, treatment, 618, 627.

Otoscope, Ball's, 631.

INDEX.-

671

Ovarian pregnancy, 383; pregnancy,
diagnosis and treatment, 384; tumors
in pregnancy, 367.

Ovaries, diseases of, 500; myoma of,
503; neoplasms of, pedicle-torsion
in, 502; tarry hematoma of, 501;
transplantation of, 501.

Owen (G.) on recurrence of intussuscep-
tion, 95.

Owen (I.) on perforation of aorta, 226.

Ozone in middle-ear deafness, 620.

Pachydermia and carcinoma of larynx,
597.

Pachymeningitis, hemorrhagic, surgical
treatment, 273.

Packard (T. R.) on nasal polyps, 575;
on removal of faucial tonsils, 585.

Paget on paraffin in nasal surgery, 331;
on prolapse of bowel, 134.

Painter (C. F.) on infantile paralysis,
519; on joint tuberculosis, 519.

Painter and Erving on lipoma arbores-
cens, 515.

Palate, cleft, congenital, operative tech-
nic, 614; soft, uvula and, primary
epithelioma of, Rontgen rays in, 593.

Panas's operation for ptosis, AUport's
modification of, 533.

Pancreas, anatomy, 640; cysts of, 200;
diseases of, 178, 204; neoplasms of,
200.

Pancreatic calculus, 203.

Pancreatitis, acute, 206; acute, relation
of cholehthiasis to, 206; typhoid, 203;
with cholelithiasis and glycosuria, 205.

Papillas in conjunctiva, 648.

Papilloma of conjunctiva, 537.

Papillomatous growth, excision of blad-
der with implantation of ureters into
rectum for, 314.

Paraffin in atrophic fetid rhinitis, 575; in
deformities, 332; in nasal surgery. 331
in prolapse of bowel, 134; in radical
cure of hernia, 168; in saddle-nose
333; injection, nasal deformity from
577; vitreous, 564.

Paralysis, birth, surgical treatment, 281
brachial, after anesthetic, 281; facial,
surgical treatment, 278; facial, treat-
ment by nerve anastomosis, 278; in-
fantile, 519; oculomotor, total uni-
lateral, 531; of children, surgery of,
285; of ocular muscles, 531; spondy-
litic, 508; treatment of, advances in,
518.

Paralytic talipes, tendon-transplanta-
tion in, 516.

Parametritis, chronic, treatment, opera-
tive, 492.

Parathyroid and thyroid insufficiency
in pathogeny of puerperal eclampsia,
396.

Parenchyma, uterine, sarcoma of, 476.

Parotiditis following abdominal section,
500; iritis after, 565.

Park (R.) on gangrenous intestine, 124;
on neoplasms of pancreas, 200; on
surgical treatment of epilepsy, 273.

Parker (R.) on gastric ulcer, 75.

Parsons (H. J.) on degenerations in
optic nerves and tracts, 557.

Patella, fracture of, transverse, Roberts's
method of treating, 248; fracture of,
treatment, 248.

Pearce (R. M.) on islands of Langerhans
in embryo, 641.

Pearse (H.) on control of hemorrhage in
removal of pelvic tumors, 496.

Pedicle-torsion in ovary neoplasms, 502.

Pelvic changes in symphyseotomy, 410;
floor, anatomy, 435; lymphatics, con-
dition of, in uterine carcinoma, 479;
operations on female, mortality, 494;
organs, affections of, 488; rest,
orthopedic hospital, 512; suppura-
tion, leukocytosis in, 490; tumors in
female, control of hemorrhage in
removal, 496.

Pelvigraph, 399.

Pelvis, contracted, 399; contracted,
treatment, 399; female, pus in, 490.

Pendlebury and Latham on pericardial
effusion, 226.

Penis, diseases of, 304.

Pennington (J. R.) on a;-rays in cancer
of rectum, 142.

Penrose operation for nephropexy, John-
son's modification of, 298.

Peptic ulcer of jejunum, 118, 119.

Percy (J. F.) on hypernephroma, 293.

Perforation of esophagus, 52, 53.

Pericardial effusion, 226.

Perineorrhaphy, 435.

Perinephritis, acute nonsuppurative, 292.

Periosteal sarcoma, congenital, in in-
fant, 38.

Peripheral nerves, traumatism of, surgi-
cal relations, 283.

Peritomy in trachoma, 537.

Peritoneal adhesions in female, 498;
cavity, relation of lymphatics of,
in diaphragm and mechanism of ab-
sorption of granular materials from
peritoneum, 637.

Peritoneum, diseases of, 91; toilet of, in
appendicitis, 155.

Peritonitis, acute, simulation of, by
pleuropneumonic diseases, 93; diag-
nosis, early, 94; general, appendicitis
with, 162; septic, fecal vomiting in
operation for, 100; septic, inflamma-
tion and perforation of Meckel's di-
verticulum as cause of, 97; suppura-
tive, general, 110; tuberculous, 91;
tuberculous, treatment, 93.

Perivascular rosets, 555.

Perkins (W. M.) on spinal analgesia,
49.

672

INDEX.

Pes equino varus, operative treatment,
517.

Pessary in retrodisplacements of uterus,
462.

Peterson (P.) on nephrectomy for car-
cinoma, 288.

Pettus on gunshot wound of intestines,
111.

Pfannenstiel, suprasymphyscal incision
of, 493.

Plialanges, congenital abnormahties of,
333.

Pharynx, carcinoma of, 590 ; diseases of,
589; gout of, acute, 592; keratosis of,
590; tumor of, myxedema after re-
moval of, 596.

Phillips (W. C.) on skin-grafting in
mastoid wound, 627.

Phlyctenular ophthahnia, 536.

Phototherapeutic ai)paratus, 335.

Pig-skin grafting, 334.

Pituitary body, gangrenous destruction
of, 267.

Placenta previa, 370; cesarean section
in, 375; inducing labor in, 372; kol-
peurynter bag in, 372; treatment, 371.

Plastic surgery, 325; of female urethra,
442.

Pleural cavity, drainage-tube for, 12.

Pleuritic adhesions, method of produc-
ing, 219.

Plexus, brachial, suture of, for birth in-
jury, 505.

Plexuses, choroid, structure of, 643.

Pneumonectomy, 215.

Pneumonopexy, 215. <

Pneumonorrhapiiy, 215.

Pneurnonotomy, 214.

Poisoned wounds in warfare, 329.

Poisoning following use of cocain as
local anestlietic, 51.

Polk (W. M.) on sterility, 426.

Pollard on drainage-tube for pleural
cavity, 12; on matting of intestines,
125.

Polyarthritis in children, 520.

Polyps in nasal accessory cavities, 583;
nasal, etiology, 575; nasal, other
conditions and, 575.

Pond (C. J.) on hysterectomy for
fibroids, 475.

Pooley on cataract, 552.

Popliteal artery, gunshot wound of, end-
to-end anastomosis for, 232.

Portal circulation, diverting of, 184;
vein and ascending vena cava, anasto-
mosis between, topographical anat-
omy, 635; vein, thrombosis of, in
appendicitis, 158.

Porter on tuberculous peritonitis, 93.

Porter and McCaskey on brain abscess,
266.

Posey (W. C.) on congenital defect of
iris and choroid, 548 ; on neuroretinitis
in heart-disease, 567.

Position, Trendelenburg, 495; posterior-
occipital, management of, 404.

Potassium iodid, hemorrhagic glau-
coma from, 561 ; substitutes for, in
eye therapy, 569.

Potts (W. A.) on autointoxications of
pregnancy, 363.

Pott's disease, double, 507.

Powder insufflator. Brown's, 631.

Powell (A. F. M.) on formalin solution
in inoperable cancer, 23.

Power on acute perforation of duodenal
ulcer, 77; on oophorectomy in in-
operable cancer of breast, 37.

Precipitin, subconjunctival injections
and, 569.

Precocious sexual development, 450.

Pregnancy, abdominal, 380; abdom-
inal, secondary, 382; and tubercu-
losis, 360; appendicitis in, 164;
autointoxications of, 363; bleeding
polyp of nasal septum in, 579; cancer
of rectum in, 366; celiotomy during,
369; dental operations and, relation
between, 370; dermoid cyst in, 367;
diagnosis, 346; diphtheria and, 361;
extrauterine, 378 (see also Extra-
uterine pregnancy); fever of, 365;
fibroid tumors in, 368; following
nephrectomy, 364; hematuria in,
364; hydatid cyst of liver in, 181;
in double uterus, 403; in fibroid
uterus, 368; intrauterine, coexisting
with extrauterine, 379; kidney of,
362; laryngeal tuberculosis in, 361;
multiple, 407; necrosis of intestinal
mucosa in, 359; ovarian, 383; ova-
rian, diagnosis and treatment, 384;
ovarian tumors in, 367; pathology,
357; physiology, 340; tumors in,
366; twin tubal, in same tube, 380;
uterus in, retroflexed, incarceration
of, 365; valvular cardiac disease in,
358.

Prepyramidal tract, anatomy, 644.

Presentation, posterior, mechanism of,
403.

Price-Brown on laryngeal stenosis, 598;
on septal curvature, 576.

Prince (A. E.) on squint, 530.

Prolapse of intestine, paraffin in, 134;
of rectum, treatment, 134; of uterus,
treatment, operative, 460.

Prostate, abscess of, prerectal cur-
vilinear incision for, 317; cauteriza-
tion of, through rectum, for obstruc-
tion due to hypertrophy, 319; dis-
eases of, 307; hypertrophy of,
chronic, treatment, 322; hypertrophy
of, obstruction due to, cauterization
of prostate through rectum for, 319;
hypertrophy of, operation for, in-
dications, 324; hypertrophy of, patho-
genesis and pathologic anatomy, 316;
hypertrophy of, symptoms, 325; hy-

INDEX.

673

pertrophy of, transvesical cauteriza-
tion as substitute for Bottini opera-
tion in, 318; hypertrophy of, treat-
ment, 321; hypertrophy of, treat-
ment, present status, 325.

Prostatectomy, 320; infrapubic sec-
tion in, 319; suprapubic, 320.

Protometer, Jackson's, 570.

Pruritus vulvtip and allied conditions,
429; idiopathic, treatment, 430.

Pryor (W. R.) on puerperal fever, 415.

Pterygium, 539.

Ptosis, Allport's modification of Panas's
operation for, 533.

Pubiotomy in obstetrics, 409.

Puerperal aphasia, 417; eclampsia, 391 ;
eclampsia, cesarean section for, 39S;
eclampsia, constipation as factor in,
393; eclampsia, hemianopia after,
560; eclampsia, intrauterine kol-
peurysis for, 398; eclampsia, patho-
genesis, 391; eclampsia, relation of
thyroid to, 393; eclampsia, renal
decapsulation for, 398; eclampsia,
thyroid and parathyroid insufficiency
in pathogeny of, 396; eclampsia,
treatment, 394; eclampsia, treat-
ment, operative, 398; eclampsia,
venesection in, 396; pyemia, treat-
ment, operative, 416; sepsis, col-
largolum in, 412; sepsis, fluid in
rectum for, 413; sepsis, hysterec-
tomy for, 416; septic uterus, curet-
tage of, 415; septicemia, formalin
in, 413.

Puerperium, 386; baths during, 390;
pathology, 412.

Pupils in accommodation, paradoxic
reaction of, 566; inequality of, in
diagnosis, 566.

Pursestring suture in repair of wounds
of stomach, 90.

Pus in female pelvis, 490.

Pusey (B.) on glioma of retina, 555.

Pu.sey and Wood on sarcoma of iris,
549.

Putnam, Krauss, and Park on sarcoma
of third cervical segment, 286.

Pyemia, puerperal, treatment, opera-
tive, 416.

Pyle (W. L.) on glaucoma after mydri-
atic, 526; on spontaneous disappear-
ance of cataract, 551.

Pylorectomy for cancer of stomach, 86.

Pyloroplasty, Finney's method, 82.

Pylorus, carcinoma of, 85; stenosis of,
congenital liypertrophir, 72.

Pyopericarditis, pyopneumopericarditis,
and pneumococcuH pyemia, 225.

Pyuria, surgical diseases accompanied
by, diagnosis of, 287.

Radium, emanations from, 335; in eye
therapy, 568.

Radkey and Smith on mycosis vagina;,
431.

Railroad transportation, relation of
color-blindness to, 542.

Rake on strangulation of vermiform ap-
pendix in right femoral ring, 174.

Ramsay on paraffin vitreous, 564.

Ramsay's uterine dilator, 438.

Randolph (R. L.) on bacteria in ocular
conditions, 540.

Rankin on gelatin in aneurysm, 231.

Ransohoff on prostatic abscess, 317.

Rectal approach in obstetrics, 346; fis-
tula comi:)licating hemorrhoids, 131 ;
stricture, treatment, 136.

Recti muscles, inferior, congenital ab-
sence of, 634.

Rectum, adenocarcinoma of, 137; ade-
noma of, 137; affections of, 428; and
anus, surgery of, 130; carcinoma of,
in pregnancy, 366; carcinoma of, sig-
moidoproctectomy for, 141 ; carci-
noma of, treatment, 139 ; carcinoma of,
-T-rays in, tubes, sliields and speculunis
for, 142; cauterization of prostate
through, for obstruction due to hyper-
trophy, 319; fluid in, for puerperal
sepsis, 413; implantation of ureters
into, excision of bladder with, for
papillomatous growth, 314; of in-
fants, foreign bodies in, 130; prolapse
of, treatment, 134; transplantation of
ureters into, for exstrophy of bladder,
309.

Refraction, changes in, 525.

Refractometer, portable, Harman's, 570.

Reik (H. ().) on cataract, 552.

Renal calculus, 292; calculus, method
for diagnosing, 292; decapsulation,
295; decapsulation for chronic neph-
ritis, 289 ; decapsulation for puerperal
eclam]>sia, 398.

Resection, intestinal, 120; of knee with-
out opening joint, 2.54; of skull,
osteoplastic, Stellwagen's trephine for,
274.

Resjnratory organs, diseases of, 213.

Retina, changes of, mental disease and,
567; disf;ases of, 553; glioma of, 555;
temjioral artery of, superior, occlu-
sion of, 554.

Retinal artery, embolism of, 553; de-
tachment, 555; hemorrhage in frac-
ture of skull, 554; hemorrhage in
recognition of arterial degeneration,
553; hemorrhage, recognition of arte-
rial degeneration, 553.

Retinitis, unusual cases of, 553.

Rheumatic fever, acute, incision and
drainage of joints in, 252.

Rheumatoid arthritis, 520.

Rhinitis, atrophic, diphtheria bacilli in,
574; atrophic fetid, paraffin injections
in, 575.

Rhinologic terminology, 604.

674

INDEX.

Rhinorrhea, cerebrospinal, after frac-
ture of skull, 245.

Rice (C. C.) on astringent applications
to tonsil, 596.

Richards on gunshot wounds of chest,
330.

Richards (C. L.) on aural bougies, 630.

Richardson (C. W.) on keratosis of
pharynx, 590.

Richardson (H. M.) on extirpation of
gallbladder, 194.

Rickets, surgery of, 513.

Ricketts on cardiotomy and cardior-
rhaphy, 26; on heart surgery, 224;
on lung surgery, 213.

Ricketts (E.) on puerperal appendicitis,
164.

Ries (E.) on rectal stricture, 136.

Rigby on acute intussusception, 94.

Rigor mortis in fetus, 354.

Rinn6 test of hearing, 617.

Risley (S. D.) on changes in refraction,
525.

Riviere on perforation of esophagus, 53.

Robb (H.) on pelvic operations on
female, 494.

Roberts (C.) on abdominal wounds in
war, 329.

Roberts (G. W.) on sigmoidoproctectomy
for cancer of rectum, 141.

Roberts (J. B.) on malignant disease of
testicle, 304; on transverse fracture
of patella, 248.

Robertson (C. M.) on new instrument
for tonsillectomy, 586; on syphilis of
larynx, 601.

Robertson's knife, 587; scissors, 587.

Robinson (B.) on landmarks in ureter,
300.

Robinson (W.) on cataract, 552.

Robson (A. W. M.) on carcinoma of
stomach, 83; on complete removal of
bladder, 314; on gastroenterostomy,
57; on intestinal tuberculosis, 108; on
operation for incontinence of feces,
135; on sterilizing catgut, 9; on
total gastrectomy, 87.

Rodent ulcer, kraurosis vulvae with,
428.

Rodman (W. L.) on gunshot wounds of
thorax and abdomen, 327.

Rodman and Pfahler on x-rays in car-
cinoma and tuberculosis, 41.

RoUeston and Trevor on sarcoma of
lung, 218.

RoUet (E.) on extirpation of lacrimal
sac, 536.

Rolhns (W.) on x-light, 334.

Rontgen rays, 334; apparatus, high fre-
quency, 337 ; in cancer of larynx, 600 ;
in cancer of rectum, tube-shields and
speculum for, 142; in carcinoma, 39,
40, 41; in carcinoma of uterus, 488;
in epithelioma, 41 ; in eye therapy,
567; in gynecology, 423; in inopera-

ble and recurrent carcinoma, 40;
in primary epithelioma of uvula and
soft palate, 593; in tuberculosis, 41,
334; picture of calcified aorta mis-
taken for foreign body, 337.

Rose (A.) on rectal fistula complicating
hemorrhoids, 131.

Rose (J. S.) on placenta prsevia, 371.

Rosets, perivascular, 555.

Ross (J. F. W.) on gall-stones, 195.

Ross and Deaver on appendicitis, 150.

Roughton on cerebellar abscess, 265, 266.

Round shoulders and faulty attitude,
508; in children, 508.

Rubber gloves in surgery, 10; splints
in septal curvature, 576.

Rucker's instrument for packing urethra,
259; method of treating inflammatory
diseases of urethra, 258.

Rupture of bladder, intraperitoneal, 310,
311, 312; of duodenum, 114; of gall-
bladder, 200; of intestines, 112; of
intestines, 116; of spleen, 209; trau-
matic, of spleen, 209, 210; uterine,
treatment, 400.

Russell (A. W.) on cancer of rectum in
pregnancy, 367.

Ruth on Maxwell dressing in fracture of
neck of femur, 246.

Rutherford on thorium emanations, 337.

Saddlk-nose, paraffin in, 333.

Salt solution, hot, in hemorrhoids, 133.

Sampson's operation for cancer of
uterus, 485.

Sandstein on pelvic changes in sym-
physeotomy, 410.

Saphenous vein, internal, anatomy of,
238.

Sarcoma, medullary giant-cell, of tibia,
244; of brachial plexus, interscapulo-
thoracic amputation for, 17 ; of cervi-
cal portion of spinal cord, 287; of
lung, primary, simulating empyema,
218; of stomach, 86; of third cervical
segment of spine, 286; of thyroid
gland, 239; of uterine parenchyma,
476; of uterus, 476; periosteal, con-
genital, in infant, 38 ; primary, of iris,
549; subglottic, endolaryngeally re-
moved with galvanocautery snare, 602.

Sarcomatous growths in femur, 39.

Savage (G. C.) on decentering lenses, 526.

Sayre (R. H.) on noisy shoulder, 509.

Scalp and nose, nevus of, 37.

Scaphoastragaloid and calcaneoastra-
galoid joints, dislocation at, 255.

Scarlet fever, nose and throat complica-
tions in, prevention, 606; orbital
cellulitis from, 565.

Schaefer on instrument to protect brain
in craniotomy, 273.

Schaffer (N. M.) on Lorenz's visit to
United States, 512.

INDEX.

675

Schauta on cesarean section in placenta
prsevia, 375.

Scheppegrell on cancer of larynx, 600;
on ear medicolegally, 630.

Schmitt (J. A.) on Bright's disease, 288.

School-children, testing eyesight of, 528.

Schwaback test of hearing, 617.

Scissors, new, for tonsillectomy, 586.

Sclera, scars of, perrneability of, 561.

Sclerotomy, permeability of scars after,
561.

Scotometer, Harman's, 571.

Scott (K.) on new color test, 545.

Scully (S.) on x-rays in uterine cancer,
488.

Semilunar cartilage at knee-joint, luxa-
tion of, 514.

Semon on hay-fever, 578.

Senn (E. J.) on transplantation of
omentum in intestinal defects, 124.

Senn (N.) on preparation of catgut by
Claudius method, 9; on purse-string
suture in repair of gunshot wounds
of stomach, 90.

Sepsis, puerperal, collargolum in, 412;
fluid in rectum for, 413; hysterectomy
for, 416.

Septic infections in obstetrics, collar-
golum in, 412; uterus, puerperal
curettage of, 415.

Septicemia, acute, formaldehyd in, 19,
20; of buccal or dental origin, 21;
puerperal, formalin in, 413.

Septum, curvature of, treatment, 576;
nasal, bleeding polyp of, in pregnancy,
579; nasal, curvature of, rubber
splints for, 576; nasal, deviations of,
Asch operation, 578; nasal, devia-
tions of, failures to correct, 579.

Serum, antitetanic, in tetanus, 18; of
maternal and fetal blood, 345; jeq-
uiritol, in trachoma, 569.

Sex, determination of, 340; influence of
parental age upon, 343.

Sexual development, precocious, 450.

Seymour (W. W.) on gallstone surgery,
196.

Shattock and Abbott on macroglossia
neurofibromatosa, 33.

Shaw-Mackenzie on iodipin in uterine
fibroids, 472.

Sheild (M.) on splenectomy for rupture
of spleen, 209.

Sheild and Shaw on fracture of skull, 268.

Sheldon (J. G.) on posterior dislocation
of head of tibia, 254.

Sheplicrd (R. K.) on form of spleen, 639.

Shock, avoidance of, in amputations, by
cocainization of nerve-trunks, 14.

Shoulders, noisy, 509; round, and
faulty attitude, 508; round, in chil-
dren, 508.

Shucking on asphyxia neonatorum, 420.

Shumway (E. A.) on eye bum from
amyl nitrite, 563.

Shurley (E. L.) on physiologic function
of tonsils, 596; on tumor of pharynx,
596.

Siderophone, Jansson's, 571.

Silver fluorid in eye therapy, 568;
filigree for closure of large hernial
apertures, 167.

Simon (W.) on hermaphroditism, 646.

Sinclair (W. J.) on carcinoma in women,
480; on midwife act, 338; on puer-
peral aphasia, 417.

Sinus diseases, prophylaxis, 580 ; lateral,
thrombosis of, 266.

Sinusitis, nasal, diagnosis, 581.

Sippel on puerperal pyemia, 416.

Siren formation, 649.

Skene's glands, pathology, 442.

Skin-grafting from pig, 334; in mastoid
wound, 627.

Skull and brain, gunshot injuries of, 326;
fracture of, 268; fracture of, cerebro-
spinal rhinorrhea after, 245; fracture
of, retinal hemorrhage in, 554; osteo-
plastic resection of, Stellwagen's tre-
phine for, 274.

Slocum's operation for cystocele and
vesical prolapse, 446; for retroversion
of uterus, 464.

Small (A. R.) on spina bifida, 286.

Smallpox, ocular complications, 565.

Smith (F. W.) on hygiene of pregnancy,
347.

Smith and Radkey on mycosis vaginae,
431.

Snares, aural, Wilson's wire loop for,
631.

Snell's method of suturing after enuclea-
tion, 564.

Snively on fistula between gall-bladder
and stomach, 196.

Snow (F.) on catarrhal deafness, 623.

Sodium sozoiodolate in conjunctivitis,
568.

Solenberger on ethyl bromid as anes-
thetic, 48; on polyps in nasal acces-
sory cavities, 583.

Solly (S. E.) on influence of high~ alti-
tudes on nose and throat, 607.

Sore throat, septic, from milk, 597.

Sozoiodolate of sodium in conjunctivitis,
568; of zinc in conjunctivitis, 568;
salts in conjunctivitis, 568.

Speech, defective, from spinal cord dis-
ease, 612; development of faculty
of, 613.

Speech-defects in children, influence
of catarrhal diseases of nose and
throat in producing, 613.

Sphenoid sinus, empyema of, 583.

Spiller (W. G.) on entire absence of
visual system, 557; on pupils in
accommodation, 566.

Spiller and Frazier on tic douloureux,
276.

Spina bifida without sac, 286.

676

INDEX.

Spinal anesthesia, 49; anesthesia, exci-
sion of superior maxillary bone under,
50; anesthesia with cocain, ampu-
tation of leg after, 51; cord, cervical
portion, sarcoma of, 287; cord dis-
ease, defective speech due to, 612;
cord, tumor of, 287.

Spine, cervical, acute osteomyelitis of,
245; diseases of, 236; orthopedic
surgery of, 507; third cervical seg-
ment of, sarcoma of, 286.

Spitzka (E. A.) on brain-weights, 644.

Spleen, diseases of, 178; enlarged, with
tunsted pedicle, 212; form of, 639;
hemorrhagic cysts of, 207; lacera-
tions of, 208, 209; malarial hyper-
trophy of, with movability, splenec-
tomy for, 212; rupture of, 209; rup-
ture of, traumatic, 209, 210; tropical
abscess of, 207; wandering, splenopexy
for, 211.

Splenectomy for lacerations of spleen,
208; for malarial hypertrophy and
movability of spleen, 212; for rup-
ture of spleen, 209; for traumatic
rupture of spleen, 209.

Splenopexy for wandering spleen, 211.

Splints, rubber, in septal curvature, 576.

Spondylitic paralysis, 508.

Spondylitis with unusual lateral devia-
tion, 509.

Sprains, Gibney adhesive plaster dress-
ing for, 255.

Squint, degree of deviation in, deter-
mination, 530; section and resection
of recti muscles for, 530.

Stab-wounds of heart, suturing, 223.

Stain, carmine, for axis-cylinder, 650.

Staining medullary sheath, new method,
650.

Stammering, treatment of, by general
practitioner, 607; Wyllie's method of
treating, 607.

Standish (M.) on prophylaxis in oph-
thalmology, 541.

Staphylomas in myopic eyes, 526.

Stark (S.) on posterior presentation, 404.

Starr's test letter, 527.

Steam in surgery and gynecology, 458.

Stellwagen's trephine for osteoplastic
resection of skull, 274.

Stenosis of larynx, 598; of larynx, rapid
dilation and prolonged use of intuba-
tion-tubes in, 599; of pylorus, con-
genital hypertrophic, 72.

Stephenson (S.) on x-ray therapy, 568.

Stephenson and Ashby on acute amau-
rosis, 559.

Sterility, facultative, 425; operations
upon appendages for, 426; relation of
gonorrhea to, 425.

Sterilization of catheters, 10; hand, 9.

Sterilizing catgut, 9.

Stevens and Vachell "on carcinoma of
liver, 181.

Stewart (F. W.) on acute dilation of
stomach, 89.

Stewart and Ballance on facial paraly-
sis, 278.

Stirling on laceration of spleen, 209.

Stoker (G.) on ozone in middle-ear
deafness, 620.

Stoker (T.) on cancer of lips, 32.

Stokes on chronic cystitis, 308.

Stomach and gallbladder, fistula be-
tween, 196; and intestines, carcino-
matosis of, 85; carcinoma of, diag-
nosis, early, importance of, 83; car-
cinoma of, pylorectomy for, 86; car-
cinoma of, treatment, 87; carcinoma
of, treatment, surgical, 84; dilation
of, acute, 89; dilation of, acute, after
operation for ischiorectal abscess, 89;
embryonic, existence of unknown
blood-supply to, 635; foreign body
in, magnet for removing, 91; gunshot
wound of, operation for, 90; gunshot
wound of, pursestring suture in re-
pair of, 90; hemorrhage from, 67;
hourglass, 69; minie ball wound of,
91; nonmalignant diseases of, gastro-
enterostomy for, 63; nonmalignant
disease of, operation for, 65; non-
malignant diseases of, surgical treat-
ment, 66; operations on, artificial
valvular fistula in jejunum as adjunct
to, 125; sarcoma of, 86; surgery,
clinical observations, 55; surgery,
history and present status, 57; sur-
gery of simple diseases of, 66 ; syphilis
of, 85; syphilitic tumor of, 86; ulcer
of, chronic, 68; ulcer of, chronic, ex-
cision, 70; ulcer of, gastrotomy for,
71; ulcer of, multiple, 75; ulcer of,
perforating, 73; ulcer of, perforating,
operation, 72, 74; ulceration of,
chronic, complicated by hair-ball, 71;
ulceration of, operative treatment,
70.

Stonham on aneurysm of subclavian
artery, 231.

Strabismus, degree of deviation in, de-
termination, 530; section and resec-
tion of recti muscles for, 530.

Strangulated hernia, bilateral, 178; her-
nia, femoral, 178; hernia, operations
for, 177; hernia, operation for, results,
174.

Strangulation of testicle, 305; of vermi-
form appendix in right femoral ring,
174.

Stricture of esophagus, diagnosis and
treatment, 53; of ureter, 302; rectal,
treatment, 136.

Stuart-Low's anatomic tonsillotome,
588.

Stucky (J. A.) on lithemic nasopharyngi-
tis, 589.

Subclavian artery, aneurysm of, 231;
right, innominate, and common caro-

INDEX.

677

tid arteries, aneurysm of, 229; tri-
angle, anatomy, 649.

Subconjunctival injections, 569.

Subglottic sarcoma endolaryngeally re-
moved with galvanocautery snare,
602.

Sublamin in eye therapy, 568.

Submaxillary gland, anatomy, 647

Subretinal cysticercus, 555.

Subtrochanteric osteotomy, 511.

Suprapubic cystopexy, 446.

Suprarenal body and growth of body,
relations between, 639; body, cells
of, lymph-canaliculi of, 638; extract
in hay-fever, 577.

Suprasymphyseal incision of Pfannen-
stiel, 493.

Surgical diseases accompanied by pyu-
ria, diagnosis of, 287.

Suture in fixation of kidney, 296, 297
intestinal, through-and-through, 120
nerve-, and nerve-regeneration, 282
nerve-, primary, 283; of bladder after
suprapubic cystotomy, 313; of bra-
chial plexus for birth injury, 505; of
heart, 222; pursestring, in repair of
wounds of stomach, 90.

Suturing penetrating wound of heart,
224; stab-wounds of heart, 223.

Swain (H. L.) on tonsillar infection, 595.

Swain (J.) on movable kidney, 299.

Syme on carcinoma of stomach, 84; on
total gastrectomy, 88.

Symes (J. O.) on diphtheria bacilli in
rhinitis, 574.

Symonds on stricture of esophagus, 53.

Symphyseotomy, pelvic changes in, 410.

Syms (P.) on appendicitis, 153; on
prostatic hypertrophy, 323.

Synovial ganglions, heredity as cause,
285.

Synovitis, septic, treatment, 252.

Syphilis, fetal, recognition, 353; in-
structions for patients with, 258;
nasal, in child, 573; of lacrimal sac,
535; of larynx, 600; of stomach, 85;
prophylaxis of, 255.

Syphilitic tumor of stomach, 86.

Syphiloma, nasal, 573.

Syringe, Donnellan's, for intratracheal
medication, 603.

Tachiolo in eye therapy, 568.

Takamine in hay-fever, 577.

Talipes equino varus, operative treat-
ment, 517; paralytic, tendon-trans-
plantation in, 516.

Talma's operation for ascites from
cirrhosis of liver, 184.

Tarnier's axis-traction forceps, Fried-
man's modification, 409.

Tarry hematoma of ovary, 501.

Taylor (F. L.) on prophylactic injections
of tetanus antitoxin, 19.

Taylor (H. L.) on congenital hip-dis-
location, 509; on recent advances in
orthopedic surgery, 519; on surgery
of rickets, 513.

Taylor (J. W ) on recurrent abortion,
377.

Taylor (R. T.) on double Pott's disease,
507; on new osteoclast, 513; on
rachitic deformities of lower extremi-
ties, 573.

Taylor and Waterman on subdural
cervical carcinoma secondary to car-
cinoma of breast, 37.

Teacher (J. H.) on deciduoma malignum,
348.

Teeth, amount of flourine in, 633.

Tendo Achillis, shortening of, for restora-
tion of function of calf, 517.

Tendon-transplantation in paralytic
taUpes, 516.

Tendon-tucking, Todd's instrument for,
531.

Tenotomy, subconjunctival, in a.stigma-
tism, 525.

Tension, intracranial increased, 270;
intracranial, indications for operation,
271.

Teratopagus, 357.

Terminology, rhinologic, 604.

Terry on intus.susception of Meckel's
diverticulum, 98.

Test for color-blindness, 545; for vision,
527; Holmgren, for color-blindness,
545.

Testicle, diseases of, 304; gangrene of,
304, 305; imperfect descent of, 305;
malignant disease of, excision of lum-
bar lymphatic glands in, 304; strangu-
lation of, 305; tuberculosis of, 304.

Testing eyesight of school-children, 528.

Tetanus, 18; antitetanic serum in, 18;
antitoxin, prophylactic injections of,
in wounds from toy pistols, 19;
Fourth of July, 18.

Tetany, gastric, 89.

Theisen (C. F.) on nasal syphihs, 573.

Theobald (S.) on niastoidi'tis, 621.

Thiol in endometritis, 457.

Thomas (J. L.) on nephropexy, 295.

Thompson on fetal monstrosities, 355.

Thompson (C. E.) on fracture of neck
of femur, 246, 512.

Thompson (J. F.) on ovarian preg-
nancy, 383.

Thompson (W.) on suprapubic prosta-
tectomy, 320.

Thorax, gunshot wounds of, 327.

Thorburn (W.) on strangulated hernia,
177.

Thorium emanations, 337.

Thorndike (P.) on prostatectomy, 320.

Thorndike and Bailey on tuberculosis
of testicle 304.

Throat and nose, operations upon,
chloroform as anesthetic in, 45;

678

INDEX.

catarrhal diseases of, influence of,
in producing speech-defects in chil-
dren, 613; complications in scarlet
fever, 606; deafness, ozone in, 620;
diseases of, argyrol in, 605; influence
of high altitudes on, 607; septic
sore, from milk, 597.

Thrombophlebitis, femoral, postopera-
tive, 238.

Thrombosis of lateral sinus, 266; of
portal vein in appendicitis, 158; optic
neuritis from, 367.

Through-and-through intestinal sutures,
120.

Thumb, superficial flexors of, absence
of, 634.

Thymus, gland tubules and Hassall's
corpuscles in, 648.

Thyroid, abnormal, goiter in, 242;
accessory, 596; and genital organs,
422; and parathyroid insufficiency
in pathogeny of puerperal eclamp-
sia, 396; diseases of, 239; extract in
dysmenorrhea, 455; extract in hemo-
philia, 233 ; note on framework of, 646 ;
relation of, to puerperal eclampsia,
393; sarcoma of, 239.

Thyroidectomy, partial, 241.

Tibia, fracture of, 250; head of, pos-
terior dislocation of, 254; medullary
giant-cell sarcoma of, 244.

Tibial tubercles, lesions of, in adoles-
cence, 250, 514.

Tic douloureux, treatment, 275, 276.

Tinker (M. B.) on cryoscopic examina-
tions, 303.

Tirard on perforation of esophagus, 52.

Tissue, connective, lymphatics and,
relations between, 637.

Tobacco deafness, 630.

Todd's instrument for tendon-tuck-
ing, 531.

Tongue, carcinoma of, 25; carcinoma
of, diagnosis, early, 31 ; carcinoma
of, excision for, 29; nerves of, neuro-
fibromatosis of, 33.

Tongue-depressor for exposing tonsil,
588; Mosher's self-retaining, 604.

Tonsillar abscess, death from bursting
of, 586; infection, symptoms and
treatment, 595.

Tonsillectomy, 585; hemorrhage after,
585; new instruments for, 586.

Tonsillitis, follicular, acute, treatment,
596; in children, treatment, 596;
treatment, 596.

Tonsillotome, anatomic, of Stuart-Low,
588.

Tonsils, astringent applications to, 596;
Baber's tongue-depressor for exposing,
588; carcinoma of, 590; diseases of,
585; faucial, removal, 585; faucial,
removal of, indications, 585; faucial
removal of, new instruments for, 586;
normal size, 596; pathology, 595;

punch, Amberg's modification of
Farlow's, 587.

Tonsilsector, Francis's, 588.

Torsion, intraabdominal omental, 117;
pedicle-, in ovary neoplasms, 502.

Torticollis, spasmodic, after adenoidec-
tomy, 612.

Townsend insufflator in treatment of
urethritis, 261.

Towaisend (W. R.) on flat-foot, 517.

Trachea and larynx, diseases of, 597.

Tracheal Ivmph-glands, topographic an-
atomy, 636.

Trachoma, 537; cuprocitrol in, 537;
itrol in, 537; jequiritol in, 569;
peritomy in, 537; .r-rays in, 568.

Tracy (E. A.) on actinic rays for
anesthetic purposes, 334.

Transplantation, anterior, of round liga-
ments of uterus, 467; by exchange,
333; of omentum in intestinal de-
fects, 124; of ovaries, 501; of ureters
into rectum, for exstrophy of bladder,
309; tendon-, in paralytic talipes, 516.

Transportation employees, vision of,
542; railroad, relation of color-
blindness to, 542.

Traumatic aneurysm, 231; gangrene of
extremities, 21; rupture of spleen,
209, 210.

Traumatism, amputations for, 15; kera-
toconus following, 546; of peripheral
nerves, surgical relations, 283.

Travers on intussusception of Meckel's
diverticulum with secondary ileocolic
intussusception, 98.

Trendelenburg position, 495.

Trephine, Stellwagen's, for osteoplastic
resection of skull, 274.

Trephining for brain tumors, 262.

Trevor and Rolleston on sarcoma of
lung, 218.

Triangle, subclavian, anatomy, 649.

Trimethylamin in vaginal secretion, 427.

Trow (C.) on mastoiditis from gono-
coccus, 622.

Truesdale (P. E.) on cesarean section in
placenta prajvia, 376.

Truss, Walsham's nasal, 603.

Tubal pregnancy, twin, in same tube,
380.

Tubby on spastic paralysis, 518.

Tubercles, tibial, lesions of, in ado-
lescence, 250, 514.

Tuberculosis, intestinal, chronic, treat-
ment, radical, 108; laryngeal, in
pregnancy, 361; of bones, in children,
treatment after Lannelongue method,
519; of bones, treatment, general,
521; of choroid, 549; of conjunctiva,
538; of conjunctiva, x-rays in, 568;
of genitourinary tract, relation of
gonorrhea to, 262; of intestine,
hypertrophic, 92; of iris, 548; of
joints in children, treatment after

INDEX.

679

Lannelongue method, 519; of joints,
malignancy of, 519; of joints, treat-
ment, general, 521; of kidney, opera-
tions for, 293, 294, 295; of testicle,
304; pregnancy and, 360; x-rays in,
41, 334.

Tuberculous cavities of apex of lung,
surgery of, 216; cervical adenitis,
treatment, 243; cystitis, diagnosis
and treatment, 307; glands of neck,
treatment, 242; lesions, pulmonary,
surgery of, 217; peritonitis, 91;
peritonitis, treatment, 93.

Tubules, gland, and Hassall's corpuscles
in thymus, 648.

Tucker (A. B.) on perineorrhaphy, 436.

Tumor, fibroid, in pregnancy, 368;
fibroid, of uterus, 469 (see also
Uterine fibroids); in pregnancy, 366;
malignant, a;-rays in, 40; of bladder,
314; of brain, from neurologic stand-
point, 264; of brain, trephining for,
262; of cecal wall after removal of
appendix, 161; of cornea, 547; of
kidney in female, 450; of lacrimal
sac, 535; of pharynx, myxedema
after removal of, 596; of spinal cord,
287; ovarian, in pregnancy, 367;
pelvic, in female, control of hemor-
rhage in removal, 496; syphilitic, of
stomach, 86; vascular, injection of
hot water into, 35.

Tumors, 210.

Typhoid fever, intussusception during
convalescence, 96; perforation in, 100,
103, 104, 110; perforation in, diag-
nosis, 108; perforation in, diagnosis,
blood-pressure in, 109; perforation
in, operation for, 109, 111; surgical
features, 105.

Typhoid pancreatitis, 203.

Typhoid perforation of gall-bladder,
199, 200.

Tytler and Williamson on compres-
sion myelitis from hydatid cysts, 286.

Twin tubal pregnancy in same tube,
380.

Twins, heredity and, 405.

Ulceu, 325; duodenal, duodenal ab-
scess secondary to, 79; duodenal,
perforating, 73, 76, 77; duodenal,
ruptured, 79; Marjolin's, carcino-
matous change in an area of, 23;
of cornea, 547; of cornea, iodin-
vasogen in, 547 ; of stomach, chronic,
70; of stomach, chronic, excision,
70; of stomach, gastrotomy for, 71;
of stomach, multiple, 75; of stom-
ach, perforating, 73; of stomach,
perforating, operation, 72, 74; peptic,
of jejunum, 118, 119; rodent, krauro-
sis vulvae with, 428.

Ulceration, chronic, carcinomatous

change in an area of, 23; of duode-
num, uremic, 79; of stomach, chronic,
complicated by hair-ball, 71; of
stomach, chronic, operative treat-
ment, 70.

Ulcers, 325.

Ultra-violet ray anesthesia, 336.

Umbilical cord, clamp for, 390; cord,
congenital hernia of liver into, 178;
cord, ligation of, 389; hernia, opera-
tion for, 170.

Unwin and Boyd on cancer of tongue,
25.

Uremic ulceration of duodenum, 79.

Ureter, calculus in, 293; diseases of,
287; duplication of, bilateral, 302;
implantation of, into rectum, exci-
sion of bladder with, for papillo-
matous growth, 314; landmarks in,
300; lymphatics of, 637; strictures
of, 302; transplantation of, into
rectum, for exstrophy of bladder,
309.

Ureteral anastomosis, 301.

Ureteritis in female, 447.

Ureteroureteral anastomosis in female,
449.

Urethra, curve of fixed portion of, 645;
diseases of, 304; female, carcinoma
of, primary, 443; female, plastic
surgery of, 442; inflammatory dis-
eases of, Rucker's method of treat-
ing, 258; MacMunn's instrument
for retaining solutions in, 259.

Urethritis, chronic anterior, insufflator
for treatment of, 261 ; irrigation
method of treating, 260.

Urinary fistula in women, apparatus
for, 440; organs, female, 442.

Urine, segregation of, instrument for,
302.

Uterine appendages, inflammation of,
492; displacements, 459; fibroids,
469; fibroids and heart-disease,
469; fibroids, degenerations and
complications, 470; fibroids, hyster-
ectomy for, 475; fibroids, hysterec-
tomy or myomectomy in, 472;
fibroids, iodipin in, 472; fibroids,
malignant, 471; fibroids, myomec-
tomy or hysterectomy in, 472; fi-
broids, superperitoneal hysterectomy
for, 475; inflammation, 457; paren-
chyma, sarcoma of, 476; rupture,
treatment, 400.

Uterosacral ligaments, vaginal shorten-
ing of, 469.

Uterus, absence of, congenital, 439;
adenomyoma of, 476; anomalies of
development of, 439; anteflexion of,
congenital, treatment, 459; carcinoma
of, age-limit in, 478; carcinoma of,
clinical aspects, 480; carcinoma of,
condition of pelvic lymphatics in, 479;
carcinoma of, hemostasis in treatment.

680

l.VDEX.

487, 497; carcinoma of, inoperable,
Jaboulay's treatment, 483; carcinoma
of, inoperable, ligation of hypogastric
and ovarian arteries in, 483; car-
cinoma of, inoperable, treatment, 482;
carcinoma of, mortality, 482; car-
cinoma of, Rontgen rays in, 488;
carcinoma of, Sampson's operation
for, 485; carcinoma of, statistics on,
477; carcinoma of, treatment, opera-
tive, 483; displacements of, Fergu-
son's operation for, 467; double,
pregnancy in, 403; fibroid, pregnancy
in, 368; fibroid tumor of, 469 (see
also Uterine fibroids); in pregnancy,
retroflexed, incarceration of, 365;
living, isolation of, 345; malignant
disease of, 476; prolapse of, treat-
ment, operative, 460; puerperal sep-
tic, curettage of, 415; retrodisplace-
ments of, 462 ; retrodisplacements of,
cuneiform shortening of broad liga-
ments for, 464; retrodisplacements
of, pessary in, 462; retrodisplace-
ments of, treatment, operative, 464;
retroflexed gravid, incarceration of,
365; retroversion of, Slocum's opera-
tion for, 464; round ligaments of,
anterior transplantation of, 467; sar-
coma of, 476.
Uvula and soft palate, primary epithe-
lioma of, Rontgen rays in, 593.

Vachell and Stevens on carcinoma of
liver, 181.

Vagina, absence of, congenital, 432;
affections of, 428; columnization of,
for metritis, 458; laceration of, during
labor, 388.

Vaginal incision, scope of, 497; secre-
tion, trimethylamin in, 427; section,
cesarean, 412; section, complications
during and after, 498; shortening of
uterosacral ligaments, 469.

Vai on sympathetic ophthalmia, 563.

Valentine (F. C.) on aids to cystoscopic
practice, 309; on educational limita-
tion of venereal diseases, 257; on
morning drop, 261.

Valvular cardiac disease in pregnancy,
358.

Vander Veer on gastrectomy, 87.

Varicose veins of lower limbs, 235;
operative treatment, 237.

Variola, ocular complications, 565.

Vascular system, diseases of, 221;
tumors, injection of hot water into,
35.

Veasey (C.) on endothelioma of orbit,
563.

Vena cava, ascending, and portal vein,
anastomosis between, topographical
anatomy, 635.

Venereal diseases, 255; diseases, educa-

I tion limitation of, 257; diseases, in-
structions for patients with, 257;
j diseases, prophylaxis, 255, 256.
I Venesection in puerperal eclampsia, 396.

Vertebral column, cervical portion, gun-
shot wound of, 325.

Vertigo, nasal, simulating epilepsy, 605.

Vesicovaginal fistula, 441.

Vicious circle following gastroenteros-
tomy, 63.

Villi, chorionic, transmission of, 350.

Vineberg on cancer of female urethra,
443.

Viscera, anatomy, 638.

Vision, colored, 528; of transportation
employees, 542; tests for, 527.

Visual system, entire absence of, 557.

Vitreous body, iodoform in penetrating
wounds of, 564; humor, origin, 550.

Vomit, appendicular black, 157.

Vomiting, fecal, in operations for intes-
tinal obstruction and septic peritoni-
tis, 100.

Von Arlt on cuprocitrol in trachoma, 537.

Von Mikulicz on surgery of intestinal
tract, lis.

Vulva, affections of, 428.

Walker (H. O.) on gastrojejunostomy,

63.
Wallace and Box on appendicitis, 164.
Wallis (F. ('.) on septic synovitis, 252. .
Walls and Donald on rupture of uterus,

402.
Walsham on crooked and depressed

noses, 332.
Walsham's nasal truss, 603.
Wamsley's drainage-tube, 535.
Wandering spleen, splenopexy for, 211.
War, abdominal wounds in, treatment,

329; poisoned wounds in, 329.
Warren (H. S.) on acute osteomyelitis

of cervical spine, 245.
Wasdin (E.) on gangrenous destruction

of pituitary body, 267.
Water, hot, injection of, into vascular

tumors, 35.
Watkins-Pitchford on intussusception,

96.
Weber test of hearing, 617.
Webster (.1. C.) on enlarged spleen with

twisted pedicle, 212; on examination

of female bladder, 444.
Weigel (A.) on family physician, special-
ist, and patient, 519.
Weights, brain-, of professional men, 644.
Weight-wave of menstruation, 451.
Weir (R. F.) on appendicitis, 161; on

artificial anus in colitis, 125.
Weiss (L.) on venereal prophylaxis, 256.
Wells (G.) on tetanus, 18.
Wendel (W.) on habitual luxation, 519.
Wessely (K.) on subconjunctival injec-
tion, 569.

INDEX.

681

Whitacre on surgery of pulmonary
tuberculous lesions, 217; on suppres-
sion of urine, 292.

White (C.) on hydrosalpinx, 489.

White and Golding-Bird on right lumbar
colostomy in colitis, 126.

Whitehead on excision of tongue for
cancer, 29; on operation for hemor-
rhoids, 131.

Whitman (R.) on correcting flexion-
deformity at knee-joint, 514; on
polyarthritis in children and rheuma-
toid arthritis, 520; on treatment of
paralytic talipes, 516.

Wiener (J.) on relation of cholelithiasis to
acute pancreatitis, 206.

Willard (De Forest) on surgery of tuber-
culous cavities of apex of lung, 216.

Williams (H.) on gunshot wounds of
stomach, 90.

Williams (R.) on evil effects of corset,
421 ; on precocious sexual develop-
ment, 450.

Williams (W. W.) on gangrene of
testicle, 305.

Wilson (T.) on cancer of uterus, 483.

Wilson's wire loop for aural snares, 631.

Wilson and Miles on cataract, 552.

Windmark on myopia, 526.

Wingrave (W.) on discharge in otorrhea,
628; on tobacco deafness, 630.

Woakes (E.) on nasal vertigo simulating
epilepsy, 605.

Wood and Pusey on sarcoma of iris, 549.

Woods (H.) on hemianopia after puer-
peral eclampsia, 560.

Woolsey (G.) on acute pancreatitis, 206.

Wound, abdominal, in war, treatment,
329; gunshot, 325 (see also Gunshot
wounds) ; minie ball, of stomach, 91 ;
of heart, penetrating, 223; of heart,
penetrating, suturing, 224; of heart,
suture for, 222 ; poisoned, "in warfare,
329; stab-, of heart, suturing, 223.

Wright (J.) on bleeding polyp of nasal
septum, 579.

Wyeth (J. A.) on hot water in vascular
tiimors, 35.

Wyllie's method of treating stammering,
607.

Wynter on tetanus, 18.

X-HAYS, 334. See also ROntgen rays.

Yeast, beer, in otology, 627.
Yeast-treatment of gonorrhea in women,

427.
Yohimbin as ocular anesthetic, 569.
Young (H. H.) on calculus in ureter, 293.

Zimmerman (C.) on metastatic ophthal-
mia, 567.
Zinc sozoiodolate in conjunctivitis, 568

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Written, as it is, for the laity, the subject is discussed in language readily grasped
even by those most unfamiliar with medical subjects.

Binnin^ham Medical Review, England

" We do not as a rule care for medical books written for the instruction of the public. But
we must admit that the advice in Dr. Galbraith's work is in the main wise and wholesome."

Pyle*s Personal Hygiene

A Manual of Personal Hygiene : Proper Living upon a Physiologic
Basis. By Eminent Specialists. Edited by Walter L. Pyle, A. M.,
M. D., Assistant Surgeon to Wills Eye Hospital, Philadelphia. Octavo
volume of 344 pages, fully illustrated. Cloth, ^1.50 net.

PROPER LIVING UPON A PHYSIOLOGIC BASIS

The object of this manual is to set forth plainly the best means of developing
and maintaining physical and mental vigor. It represents a thorough exposition
of living upon a physiologic basis. There are chapters upon Hygiene of the
Digestive Apparatus, Skin and its Appendages, Vocal and Respiratory Apparatus,
Eye, Ear, Brain, and Nervous .System, and a chapter upon Exercise.

Boston Medical and Surjfical Journal

" The work has been excellently done, there is no undue repetition, and the writers have
succeeded unusually well in presenting facts of practical significance based on sound knowl-
edge."

SAUNDERS' BOOKS ON

Draper's Leg^al Medicine

A Text=Book of Legal Medicine. By Frank Winthrop Draper,
A. M., M. D., Professor of Legal Medicine in Harvard University, Bos-
ton ; Medical Examiner of the County of Suffolk, Massachusetts, etc.
Handsome octavo volume of nearly 600 pages, fully illustrated.

A NEW WORK— PREPARING

The subject of Legal Medicine is one of great importance, especially to the
general practitioner, for it is to him that calls to attend cases which may prove to
be medicolegal in character most frequently come. The medicolegal field includes
not only deaths of a homicidal nature, but also suits at law — the fatal railway acci-
dent, machinery casualties, and the like, to which the neighboring physician may
be called, and later, perhaps, summoned to court. It is evident, therefore, that
every practitioner should be thoroughly versed in all branches of medicolegal
science. This volume, although prepared as a help to medical students, will be
found no less valuable and instructive to practitioners. The author has not only
cited illustrative cases from the standard treatises on forensic medicine, but these
he has supplemented with details from his own exceptionally full experience — an
experience gained during his service as Medical Examiner for the city of Boston
for the past twenty-six years. During this time his investigations have comprised
nearly seventy-seven thousand deaths under a suspicion of violence. It will be
seen, therefore, that the work is authoritative, and, written by an experienced
teacher, the* language is clear and concise.

Jakob and FisherV

Nervous System and its Diseases

Atlas and Epitome of the Nervous System and Its Diseases.

By Professor Dr. Chr. Jakob, of Erlangen. Fyom the Second Revised
German Edition. Edited, with additions, by Edward D. Fisher, M. D.,
Professor of Diseases of the Nervous System, University and Bellevue
Hospital Medical College, New York. With 83 plates and copious text.
Cloth, ;$3.50 net. In Saunders' Hand- Atlas Series.

The matter is divided into Anatomy, Pathology, and Description of Diseases
of the Nervous System. The plates illustrate these divisions most completely ;
especially is this so in regard to pathology. The exact site and character of the
lesion are portrayed in such a way that they cannot fail to impress themselves on
the memory of the reader.

Pluladelphia Medical Journal

" We know of no one work of anything like equal size which covers this important and
complicated field with the clearness and scientific fidelity of this hand-atlas."

DISEASES OF CHILDREN.

American Text-Book of
Diseases of Children

American Text-Book of Diseases of Children. Edited by Louis
Starr, M. D., Consulting Pediatrist to the Maternity Hospital, etc. ;
assisted by Thompson S. Westcott, M. D., Attending Physician to the
Dispensary for Diseases of Children, Hospital of the University of Penn-
sylvania. Handsome octavo, 1244 pages, profusely illustrated. Cloth,
$7.00 net ; Sheep or Half Morocco, ^8.00 net.

SECOND REVISED EDITION

To keep up with the rapid advances in the field of pediatrics, the whole sub-
ject-matter embraced in the first edition has been carefully revised, new articles
added, some original papers amended, and a number entirely rewritten and
brought up to date. The volume has thus been increased in size by a very
considerable amount of fresh material.

British Medical Journal

" May be recommended as a thoroughly trustworthy and satisfactory guide to the subject
of the diseases of children."

Gould and Pyle's
Curiosities of Medicine

Anomalies and Curiosities of Medicine. By George M. Gould,
M. D., and Walter L. Pyle, M. D. An encyclopedic collection of rare
and extraordinary cases and of the most .striking instances of abnormal-
ity in all branches of Medicine and Surgery, derived from an exhaustive
research of medical literature from its origin to the present day,
abstracted, classified, annotated, and indexed. Handsome octavo
volume of 968 pages, 295 engravings, and 12 full-page plates. Pop-
ular Edition : Cloth, $3.00 net ; Sheep or Half Morocco, ;^4.oo net.

As a complete and authoritative Book of Reference, this work will be of value
not only to members of the medical profession, but to all persons interested in
general scientific, sociologic, and medicolegal topics ; in fact, the absence of any
complete work upon the subject makes this volume one of the most important
literary innovations of the day.

New York Medical Journal

" We would gladly exchange a multitude of the relatively useless works which but encumber
all branches of medicine, for one so comprehensive, so exhaustive, so able, and so remarkable
in its field as this."

SAUNDERS' BOOKS ON

Hofmann and Peterson's
Leg(al Medicine

Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna,
Edited by Frederick Petersojsi, M. D., Chief of Clinic, Nervous De-
partment, College of Physicians and Surgeons, New York.. With 120
colored figures on 56 plates and 193 half-tone illustrations. Cloth,
;^3.50 net. In Saunders' Hand-Atlas Series.

By reason of the wealth of illustrations and the fidelity of the colored plates,
the book supplements all the text-books on the subject. Moreover, it furnishes to
every physician, student, and lawyer a veritable treasure-house of information.

The Practitioner. London

" The illustrations appear to be the best that have ever been published in connection with
this department of medicine, and they cannot fail to be useful alike to the medical jurist and to
the student of forensic medicine."

Chapman's
Medical Jurisprudence

Medical Jurisprudence, Insanity, and Toxicology. By Henry C.
Chapman, M. D., Professor of Institutes of Medicine and Medical
Jurisprudence in Jefferson Medical College, Philadelphia. Handsome
l2mo of 329 pages, fully illustrated. Cloth, ^1.75 net.

RECENTLY ISSUED— THIRD REVISED EDITION, ENLARGED

This work is based on the author's practical experience as coroner's physician
of the city of Philadelphia for a period of six years. Dr. Chapman's book,
therefore, is of unusual value.

This third edition has been thoroughly revised and greatly enlarged, so as to
bring it absolutely in accord with the very latest advances in this important branch
of medical science. There is no doubt it will meet with as great favor as the
previous editions.

Journal of the American Medical Association — In Reviewing the Second Edition

" It is an excellent manual in which an accurate epitome is given of the existing knowledge
on the subject."

NURSINtJ.

DeL/ee's Obstetrics for Nurses

Obstetrics for Nurses. By Joseph B. DeLee, M.D., Professor
of Obstetrics in the Northwestern University Medical School; Lecturer
in the Nurses' Training Schools of Mercy, Wesley, Provident, Cook
County, and Chicago Lying-in Hospitals. i2mo volume of 460 pages,
fully illustrated.

JUST ISSUED

While Dr. De Lee has written his work especially for nurses, yet the prac-
titioner will find it useful and instructive, since the duties of a nurse often devolve
upon him in the early years of his practice. The illustrations are nearly all
original, having been made especially for this work. The photographs were
taken from actual scenes, and are true to life in every respect. The text is the
result of the author's eight years' experience in lecturing to the nurses of five
different training schools.

Davis* Obstetric and
Gynecologic Nursing

Obstetric and Gynecologic Nursing. By Edward P. Davis, A.M.,
M.D., Professor of Ob.stetrics in the Jefferson Medical College and
Philadelphia Polyclinic ; Obstetrician and Gynecologist, Philadelphia
Hospital. i2mo of 400 pages, illustrated. Buckram, $\.7S "^t.

The Lancet, London

" Not only nurses, ])ut even newly qualified medical men, would learn a great deal by a
perusal of this book. It is written in a clear and pleasant style, and is a work we can recom-
mend."

Watson's Nursing

A Handbook for Nurses. By J. K. Watson, M.D. P^din., Assistant
House-Surgeon, Sheffield Royal Hospital. American Edition under
the supervision of A. A. Stevens, A.M., M.D., Professor of Pathology,
Women's Medical College, Philadelphia. i2mo, 413 pages, 73 illustra-
tions. Cloth, ;^i.50 net.

Journal of the American Medical Association

"Tlie intelligent nurse will find this a most convenient manual, and there are many things
in it that the physician might find of use. In recommending text-books to nurses it could be
put in the first rank."

SAUNDERS' BOOKS ON

Golebiewski and Bailey*s
Accident Diseases

Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed.

Golebiewski, of Berlin. Edited, with additions, by Pearce Bailey,
M.D., Consulting Neurologist to St. Luke's Hospital, New York.
With yi colored illustrations on 40 plates, 143 text-illustrations, and
549 pages of text. Cloth, $4.00 net. In Saunders' Hajid-Atlas
Series.

This work contains a full and scientific treatment of the subject of accident
injury ; the functional disability caused thereby ; the medicolegal questions in-
volved, and the amount of indemnity justified in given cases. The work is
indispensable to every physician who sees cases of injury due to accidents, to
advanced students, to surgeons, and, on account of its illustrations and statistical
data, it is none the less useful to accident-insurance organizations.

The Medical Record, New York

" This volume is upon an important and only recently systematized subject, which is grow-
ing in extent all the time. The pictorial part of the book is very satisfactory."

Stoney*s
Materia Medica for Nurses

Practical Materia Medica for Nurses, with an Appendix containing
Poisons and their Antidotes, with Poison-Emergencies ; Mineral Waters ;
Weights and Measures ; Dose-List, and a Glossary of the Terms used
in Materia Medica and Therapeutics. By Emily A. M. Stoney, Super-
intendent of the Training School for Nurses at the Carney Hospital,
South Boston, Mass. Handsome octavo volume of 306 pages. Cloth,
;^i.50 net.

The present book differs from other similar works in several features, all of
which are intended to render it more practical and generally useful. The consid-
eration of the drugs includes their names, their sources and composition, their
various preparations, physiologic actions, directions for handling and administer-
ing, and the symptoms and treatment of poisoning.

Journal of the American Medical Association

" So far as we can see, it contains everything that a nurse ought to know in regard to drugs.
As a reference-book for nurses it will without question be very useful."

CHILDREN AND HYGIENE. 13

Griffith's Care of the Baby

The Care of the Baby. By J. P. Crozer Griffith, M. D., Clinical
Professor of Diseases of Children, University of Penn. ; Physician to the
Children's Hospital, Phila. i2mo, 436 pp. Illustrated. Cloth, ^1.50 net.

RECENTLY ISSUED— THIRD EDITION, THOROUGHLY REVISED

The author has endeavored to furnish a reliable guide for mothers. He has
made his statements plain and easily understood, in the hope that the volume
may be of service not only to mothers and nurses, but also to students and practi-
tioners whose opportunities for observing children have been limited.

New York Medical Journal

" We are confident if this little work could find its way into the hands of every trained
nurse and of every mother, infant mortaUty would be lessened by at least fifty per cent."

Crothers* Morphinism

Morphinism and Narcomania from Opium, Cocain, Ether, Chloral,
Chloroform, and other Narcotic Drugs ; also the Etiology, Treatment,
and Medicolegal Relations. By T. D. Crothers, M. D., Superintendent
of Walnut Lodge Hospital, Hartford, Conn, tiandsome i2mo of 351
pages. Cloth, ;^2.oo net.

The Lancet, London

"An excellent account of the various causes, symptoms, and stages of morphinism, the
discussion being throughout illuminated by an abundance of facts of clinical, psychological, and
social interest."

Abbott's Transmissible Diseases

The Hygiene of Transmissible Diseases : Their Causation, Modes
of Dissemination, and Methods of Prevention. By A. C. Abbott, M. D.,
Professor of Hygiene and Bacteriology, University of Pennsylvania.
Octavo, 351 pages, with numerous illustrations. Cloth, ^2.50 net.

SECOND REVISED EDITION

During the interval that has elapsed since the appearance of the first edition
investigations upon the modes of dissemination of certain of the specific infections
have been very active. The sections on Malaria, Yellow Fever, Plague, Filariasis,
Dysentery, and Tuberculosis have been both revised and enlarged.

The Lancet, London

" We heartily commend the book as a concise and trustworthy guide in the subject with
which it deals, and we sincerely congratulate Professor Abbott."

14 SAUNDERS' BOOKS ON

Stoney*s Nursing

Practical Points in Nursing: for Nurses in Private Practice. By
Emily A. M. Stoney, Superintendent of the Training School for Nurses
at the Carney Hospital, South Boston, Mass. 466 pages, fully illus-
trated. Cloth, $\.7S net.

THIRD EDITION. THOROUGHLY REVISED— RECENTLY ISSUED

In this volume the author explains the entire range of private nursing as dis-
tinguished from hospital nursing, and the nurse is instructed how best to meet the
various emergencies of medical and surgical cases when distant from medical or
surgical aid or when thrown on her own resources. An especially valuable feature
will be found in the directions how to improvise everything ordinarily needed in the
sick-room.

The Lancet, London

"A very complete exposition of practical nursing in its various branches, including obstetric
and gynecologic nursing. Thie instructions given are full of useful detail."

Stoney*s Bacteriology and
Surgical Technic for Nurses

Bacteriology and Surgical Technic for Nurses. By Emily A. M.
Stoney, Superintendent of the Training School for Nurses at the
Carney Hospital, South Boston, Mass. i2mo, 200 pages, profusely
illustrated. Cloth, ;!gi.25 net.

The work is intended as a modern text-book on Surgical Nursing in both hos-
pital and private practice. The first part of the book is devoted to Bacteriology
and Antiseptics ; the second part to Surgical Technic, Signs of Death, and
Autopsies. The matter in the book is presented in a practical form, and will
prove of value to all nurses who are called upon to attend surgical cases.

Tndned Nurse and HospitaJ Review

" These subjects are treated most accurately and up to date, without the superfluous reading
which is so often employed. . . . Nurses will find this book of the greatest value both during
their hospital course and in private practice."

NERVOUS AND MENTAL DISEASES. 15

A • rk ixr\*x* Fourth Edition, Revued

American Pocket Dictionary just issued,

American Pocket Medical Dictionary. Edited by W. A. New-
man Borland, M. D., Assistant Obstetrician to the Hospital of the
University of Pennsylvania. Containing the pronunciation and defini-
tion of the principal words used in medicine and kindred sciences, with
64 extensive tables. Handsomely bound in flexible leather, with gold
edges, $1.00 net; with patent thumb index, $1.25 net.

" I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., Dean
of the Jefferson Medical College, Philadelphia.

Warwick and Tunstall's First Aid

First Aid to the Injured and Sick. By F. J. Warwick, B. A.,
M. B. Cantab., Associate of King's College, London; and A. C. Tun-
stall, M. D., F. R. C. S. Edin., Surgeon-Captain Commanding the East
London Volunteer Brigade Bearer Company. i6mo of 232 pages and
nearly 200 illustrations. Cloth, ^i.oo net.

" Contains a great deal of valuable information well and tersely expressed. It will
prove especially useful to the volunteer first aid and hospital corps men of the National
Guard." — Journal American Medical Association.

Saunders' American Year-Book

American Year-Book of Medicine and Surgery. A Yearly Digest
of Scientific Progress and Authoritative Opinion on all Branches of
Medicine and Surgery, drawn from journals, monographs, and text-books
of the leading American and foreign authors and investigators. Arranged,
with critical editorial comments, by eminent American specialists, under
the editorial charge of George M. Gould, A. M., M. D. In two
volumes: Vol. I. — General Medicine, octavo, 715 pages, illustrated;
Vol. II. — General Surgery, octavo, 684 pages, illustrated. Per volume:
Cloth, $3.00 net; Sheep or Half Morocco, $3.75 net. Sold by Sub-
scription.

" It is much more than a mere compilation of abstracts, for, as each section is entrusted
to experienced and able contributors, the reader has the advantage of certain critical
commentaries and expositions . . . proceeding from writers fully qualified to perform
these tasks." — T/te Lancet, London.

r^%_ mv v>* « V 'j Third Edition*

Shaw on Nervous Diseases and Insanity Revued

Essentials of Nervous Diseases and Insanity : their Symptoms
and Treatment. A Manual for Students and Practitioners. By the late
John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and
Nervous System, Long Island College Hospital, New York. i2mo of
204 pages, illustrated. Cloth, $1.00 net. In Saunders' Question- Com-
pend Series.

"Clearly and intelligently written ; we have noted few inaccuracies and several sug-
gestive points. Some affections unmentioned in many of the large text-books are noted."
— Boston Medical and Surgical Journal.

Chapin's Insanity

A Compendium of Insanity. By John B. Chapin, M. D., LL.D.,
Physician-in-Chief, Pennsylvania Hospital for the Insane ; Honorary
Member of the Medico-Psychological Society of Great Britain, of the
Society of Mental Medicine of Belgium, etc. i2mo, 234 pages, illus-
trated. Cloth, $1.25 net.

" It is not a made book, but a genuine condensed thesis, which has all the value of ripe
opinion and all the charm of a vigorous and natural style." — Philadelphia Medical Journal.

SAUNDERS' BOOKS ON CHILDREN.

Griffith's Vieiihi Chart

Infants' Weight Chart. Designed by J. P. Crozer Griffith,
M. D., Clinical Professor of Diseases of Children in the University of
Pennsylvania; Physician to the Children's Hospital, to the Methodist
Episcopal Hospital, and to St. Agnes' Hospital, Philadelphia. 25 charts
in each pad. Price per pad, 50 cents net.

Printed on each chart is a curve representing the average weight of a healthy infant,
so that any deviation from the normal can readily be detected.

POWeirS Diseases of Children Third Edition. RevUed

Essentials of the Diseases of Children. By William M. Pov^^ell,
M. D., author of "Saunders' Pocket Medical Formulary," etc. Revised
by Alfred Hand, Jr., A. B., M. D., Dispensary Physician and Pathol-
ogist to the Children's Hospital, Philadelphia. i2mo volume of 259
pages. Cloth, $1.00 net. In Saunders^ Question- Compend Series.

" One of the best books of this excellent Question Series, and one which will prove
very popular." — The Medical World, Philadelphia.

Starr's Diets for Infants and Children

Diets for Infants and Children in Health and in Disease. By
Louis Starr, M. D,, Consulting Pediatrist to the Maternity Hospital,
Philadelphia; editor of "American Text-Book of the Diseases of Chil-
dren." 230 blanks (pocket-book size), perforated and neatly bound
in flexible Morocco, $1.2^ net.

" The diets are various and well selected, and are adapted to children of all ages. At
the end of the book are a few simple recipes which can be detached and given to the
nurse." — British Medical Journal.

Grafstrom's Mechano-Therapy

A Text-Book of Mechano-therapy (Massage and Medical Gymnas-
tics). By Axel V. Grafstrom, B. Sc, M. D., late House Physician,
City Hospital, Blackwell's Island, New York. i2mo, 139 pages, illus-
trated. Cloth, $1.00 net.

" Certainly fulfills its mission in rendering comprehensible the subjects of massage and
medical gymnastics." — New York Medical Journal.

Mei^s' Feeding in Infancy

Feeding in Early Infancy. By Arthur V. Meigs, M. D., Physician
to the Pennsylvania Hospital, Philadelphia. Bound in limp Cloth, flush
edges, 25 cents net.

^c^\^

P American year-book of medicine

Med and surgery

190^

pt.2

GislRSTS

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