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Full text of "Annals of surgery"

ANNALS 



SURGERY 



A MONTHLY REVIEW 
( n^^ SURGICAL SCIENCE AND PRACTICE 



EDITED BY 

LEWIS S. PILCHER, A. M, M. D., 

OF BROOKLYN, 
ROFFSSOR OF CLINICAL SURGERY IN THE NEW YORK POST GRADUATE MEDICAL SCHOOI 

AND 

CHARLES B. KEETLEY, F.R.C.S., 

OF LONDON, 
SENIOR SURGEON TO THE WEST LONDON HOSPITAL. 



VOLUME IV. 

JULY— DECEMBER, i885. 

ST. LOUIS: *^' 

J. H. CHAMBERS & C(;., 
1886. 



w 



0.^ 



CONTRIBUTORS TO VOL. IV 



R. ABBE, OF New York. 
P. S. ABRAHAM, of London. 
W. BROWNING, OF Brooklyn. 
W. T. BULL, OF New York. 
G. R. BUTLER, of Brooklyn. 
C. W. CATHCART, of London. 
W. B. CLARKE, of London. 
H, C. COE, OF New York. 
C. J. COLLES, OF New York. 

B. F. CURTIS, OF New York. 
H. P. DUNN, OF London. 

F. S. EDWARDS, of London. 

F. S. EVE OF London. 

G. R. FOWLER, of Brooklyn. 
F. H. GERRISH, of Portland. 
A. G. GERSTER, of New York. 
A. P. GOULD, of London, 

J. HUTCHINSON, Jr., of London. 
W. W. KEEN, of Philadelphia. 

C. B. KEETLEY. of London. 
R. LAKE, of London. 

F. LANGE, of New York. 
S. LLOYD, of New York. 
W. MACEWEN, OF Glasgow. 
L. MARK, OF London. 
T. M. MARKOE, of New York. 
C. McBURNEY, of New York. 
J. S. MILLER, OF Philadelphia 



.-'^ 



\ 



CONTRIBUTORS. 

R. T. MORRIS, OF New York. 

A. OGSTON, OF Aberdeen. 

J. E. PILCHER, U. S. Army. 

L. S. PILCHER, OF Brooklyn. 

P. J. POPOFF, OF Brooklyn. 

F. J. SHEPHERD, of Montreal. 

H. H. TAYLOR, of London. 

W. THOMPSON, OF Dublin. 

W. W. VAN ARSDALE, of New York. 

H. H. VINKE, OF St. Charles. 

W. W. WAGSTAFFE, of London. 



AUTHORS, OF WHOSE CONTRIBUTIONS TO RECENT SURGICAL 
LITERATURE. ABSTRACTS ARE PRESENTED. 



Agnew, D. H., Philadelphia, 165. 
Andrews, E., Chicago, 257, 546. 
Annandale, T., Edinburgh, 332. 
Baratoux, M., France, 397. 
Barwell, R., London, 190, 
Belfield, W. T., Chicago, 532. 
Belleli, v., Egypt, 352. 
Berger, M., Paris, 148. 
Bergmann, E. von, Berlin, 167, 256, 540. 
Berthod, P., Paris, 442. 
Boening, Dr., Nerdingen, 166. 
Bois, a., France, 329. 
BONI, A,, Pavia, 179. 
Braun, G., Vienna, 451. 
Bresson, H. Paris, 450. 
Briggs, W. T., Nashville, 165. 
Briddon, C. K., New York, 270. 
Brown, Dillon, New York, 73. 
Bruns, p., Tubingen, 261. 
Buchanan, G., Glasgow, 260. 
BuRCHARU, T. H., New York, 245. 
Casper, L , Berlin, 374. 
Castex, M., France, 388. 
Ceci, Anion, Genoa, 227. 
Chadwick, J. R., Boston, 459. 
Chassagne, M., France, 448. 
Chauval, M., Paris, 146. 
Clarke, H. E., Glasgow, 71. 
Clutton, H. H., London, 87. 
CzERNY, Prof., Heidelberg, 447. 
Daremberg, G.; Menton 235. 
Day, W. H., London, i8;-. 
Dennis, F. S., New York, 83* 
Despres, M., Paris, 147. 
Doerfler, H., Nurnberg, 262. 
DoLREis, Dr., France, 365. 
DoLLiNGER,]., Budapest, 66. 
Eales, G. Y., England, 192. 
Ebermann, Russia, 539. 
Fabre, Paul, Commentiy, 431. 
Fehleisen, Dr., Berlin, 77. 



Fischer, E., Strassburg, 8i. 
Fluhrer, W. F., New York, 519. 
toRTUNET, D. de, Lyon, 359. 
Eraser, T,R., Edinburgh, 169. 
Freyer, M., Darkehmen, 344, 
PUHR, H., uiesscn, 251, 
Gaston, J. McF., Atlanta, 529. 
Gerster, a. G. , N . Y . , 7cS, 82, 1 74, 270, 349. 
Gibney, V. P., New York, 271. 
Gillette, M , Paris, 373. 
Godlee, R. J., London, 72. 
GoLDENBURG, Dr., Germany, 370. ■ 
Gould, P., London, 170. 
GuNN, M., Chicago. 161, 521. 
Gussenbauer, Prague, 542. 
Habermas, O. Tubingen, 159. 
Hance, I. H.. New York, 523. 
Harris, R. P., Philadelphia, 556. 
Harrison, R., Liveipool, 161, 187, 
Hartmann, H„ Paris, 240. 
Hay, M., Aberdeen, 516. 
Heddens, J. W., St. Joseph, Mo., 528. 
Heidenreich, Th., Moscow, 230. 
Hirschfelder, J., San Fraicisco, 171. 
HoFMEiER, Dr., Berlin, 370. 
Romans, J., Boston, 242, 459. 
HoRSLEY, Victor, London, 499. 
HowLETi', E. H., London, 187. 
Hubbard, L. W., New York, 270. 
Hutchinson, J., London, 170, 356, 361. 
Hutchison, J. C, Brooklyn, 184. 
Imlach, Dr., England, 365. 
Israel, J., Berlin, 177, 542. 
Jacobson, W. H. a., London, 191,512. 
Jamieson, R. a., England, 365. 
Jardet, M., Paris, 444. 
Jersey, C. A., New York, 528. 
Johnson, C, Baltimore, 240. 
Johnston, G. W ., Washington, 368. 
JUDSON, A B , New York, 169. 
Kartulis, Dr., Alexandria, 341. 



AUTHORS. 



Katterfeld, F., Curland, 336. 

Kelley, H a., Philadelphia, 458. 

KiRMissON, E., Paris, 274. 

Knee, A. D., Moscow, 237. 

Koch, C, Nuremberg, 253. 

Koebel, F., Tubingen, 271. 

KOENIG, Prof., C.ottingen, 445, 535. 

Kramer, Gottingen, 543. 

Kroenlein, Prof., Zurich, 232. 

Kuemmell, H., Hamburg, 66, 238,551. 

Kuster, E., Berlin, 542. 

Landerer, a., Leipsic, 251, 266, 331. 

Lauenstein, C, Hamburg, 227. 

Le Fort, L., Paris, 149. 

Leloir, H., Paris, 514. 

Leopold, G., Dresden, 554. 

Lewers, a. H. N., London, 455. 

LiTTLEGOOD, J , Not ingham, 333. 

LONGHURST, Dr., London, 333. 

Lowe, J., London, 192. 

Lucas-Championniere, J., Paris, 147,530. 

Mabboux, M., Lille, 144. 

Mansell-Moulmn, C, London, 333. 

Mastin, C. H., Mobile, 533. 

May, C. H., New York, 172. 

Maydl, M., Germany, 515. 

McGraw, T. a., Detroit, 185. 

Mears, J. E., Philadelphia, 241. 

Michael, J. E., Baltimore, 240. 

Mikulicz, J., Cracow, 140, 335. 

Morgan, E. C, Washington, 521. 

Miles, A. B., New Orleans, 527. 

Moggi, G , Italy, 425. 

MORISANI, Dr., Italy, 372. 

Morton, T. G., Philadelphia, 531. 

Mueller, E., Tubingen, 174. 261. 

Mueller, W., Goettingen, 79. 

Muselier, p., Paris, 176. 

Negel, Dr., Roumania, 426. 

Neve, A., France, 517 

NiKOLAUS, K , Baden, 74. 

Notta, M., Paris, 430. 

Orth, K., Brussels, 336. 

Otis, E. O., Boston, 549. 

Park, R., Buffalo, 259. 

Parkes, C.T. , Chicago, 183, 241. 

Parkinson, J. H., Sacramento, 84. 

Pean, J., Paris, 367, 434. 

Penney, E. J., England, 456. 

Petersen, F., Kiel, 542. 



Phelps, A. M ., Chautaugay, 364. 
Plessing, E., Leipzig, 67. 
Podrez, a., Harkoff, 345. 
Polaillon, M., Paris, 148. 
Poncet, Dr , Paris, 372. 
PouLAiN, M., Paris, 68. 
PouLSEN, Kr., Kopenhagen, 229. 
PoussON, A., Paris, 417. 
Pozzi, S., Paris, 148. 
Prewitt, T. F., St. Louis, 164. 
QuENU, M., France, 526. 
Rabenau, Di. von, Germany, 369 
Ransohoff, J., Cincinnati, 163. 
Reclus, Paris, 73, 148. 
Renton, C., Glasgow, 334. 
Reulos, Dr., France, 362. 
Reyer, K. K , St. Petersburg, 439. 
Reynolds, A. S., Philadelphia, 545. 
Richardson, M. H , Boston, 517. 
Richelot, M., Paris, 148. 
Riedel, B., Aix-la Chapelle, 247. 
RiNNE, Dr., Griefswald, 351. 
Rivington, W., London. 190. 
Rosenbach, Dr. Gottingen, 422. 
RosER, W., Germany, 538. 
Ruault, a., Paris, 350. 
Salzar, F., \\ ien, 68. 
bANDS, H. B, Ne.v York., 243. 
ScHEDE, M., Hamburg, 541. 
Schlegtendal, B., Hanover, 76. 
SCHMITZ, A., St. Petersburg, 80, 539. 
Schmolck, G. Halle, 265. 
Schoenborn, Germany, 541. 
Schroeder, Carl, Berlin, 368. 
ScHULZ, Dr., Sonnenburg, 255. 
Schultze, Dr., Jena, 371. 
Skinner, \V., France, 429. 
Smith, Stephen, New York, 361. 
SOKOLOFF, N. A., St. Petersburg, 349. 
SoNNENBURG, Berlin, 541. 
Southam, F. a., London, 526. 
l^QUARE, J. E., England, 443. 
Steinthal, Dr., Heidelberg, 444. 
Suzar, R., Mauritus, 324. 
Terrier, F., Paiis, 452. 
Terrillon, M., Paris, 360. 
Thiriar, T., Fr nee, 339. 
Thiry, Prof., Belgum, 86. 
Thompson, J. F., Washington, 242. 
Trendelenburg, F., Bonn, 160, 540. 



AUTHORS. 



Vll 



Trelat, M., Paris, 149. 

Van Derveer, A., Albany, 165, 241. 

Vaseueff, M. a., Warsaw, 427. 

Veit, J., Berlin, 85. 

Verneuil, a.. Paris, 87, 247. 190, 235. 

Volkmann, R. von, Halle, 541. 

Wagner, W., Konigshiitte, 318. 

Wahl, M., Essen, 424. 

Watson, B. A., Jersey City, 547. 

Weir, R. F., New York, 259, 260,357. 

Wesener, F., Freiburg, 251. 



White, W. H., London, 510. 
Wiener, Dr., Germany, 371. 
Wising, P. J., Germany, 180. 
WoEi.FLER, A., Wien, 523. 
\\ OLFF, J., Berlin, 70. 
Woerner, a., Tiibingen, 173. 
Wyeth, J. A., New York, 269. 
Zahn, W., Geneva, 272. 
Zesas, D. G., Germany, 427. 
ZiELEWicz, J., Posen 457. 



INDEX. 



A BDOMEN (see also laparotomy); Myxo- 
"^ sarcomatous tumour of, 448 ; Sur- 
gery of, 42, 73. 74, 76, 85, 89, 180, 183, 
184, 237 238, 240, 242, 243, 245, 247, 
251. 253. 339, 341, 344, 345, 442, 445, 
448,452,455, 456, 458,459.468, 475, 526. 
Abdominal organs, Operation for echino- 
cocci of, 76, 

Abdominal wall. Fibromata of, 360. 

Abdominis. An improved trocar for para- 
centesis, 387. 
Abraham, P. S., Abstracts, 329, 350, 352, 
362, 426, 429, 430, 431, 434, 444, 450. 

, Excision of the larynx. 397. 

, On the contagiousness of leprosy, 

324. 

Abscess, Drainage of pelvic, 351 ; in the 
male. Pelvic, 245 ; Laparotomy for peri- 
typhliiic, 242, 243; of the liver, 341; 
simulating soft fibroid tumor of uterus, 
Pelvic, 455 ; subsequent to orbital peri- 
ostitis. Cerebral, 334; Treatment of 
lumbar, 546; with the thrombosis of cav- 
ernous sinus. Alveolar, 170. 

Accidents, Surgery of, 192. 

Acromial portion of clavicle. Excision of, 
255, 530- 

Actinomycosis, Bacteriology of, 217. 

Adenoma of thyroid body. Papillary cyl- 
indro-cellular, 274. 

Alexander's operation, 42, 365. 

Alcohol, Aneurism racemosum cured by 
subcutaneous injection of, 67. 

Alveolar abscess with thrombosis of cav- 
ernous .«inus, 170. 

Amputation at hip, 185 ; of entire arm and 
shoulder, 255, 530; of forearm. Inocula- 
tion-tuberculosis after, 424 ; of inverted 
portion of uterus by the ligature, 372. 

Anatomy of upper extremity. Review of 



Schiiller on surgical, 284, 291. 

Aneurism, Treatment of, by introduction 
of coagulants, 47, 163; caused by punc- 
tured wound of buttock, Traumatic, ^^y, 
cured by pressure. Popliteal, 333 ; of 
internal iliac artery. Ligature of com- 
mon iliac for, 5i9;of femoral,Traumatic, 
333 ; of internal carotid artery, Trau- 
matic, 164; racemosum cured by subcu- 
taneous injections of alcohol, 67. 

Angioma, Treatment of, 166. 

Anthrax, Bacteriology of, 217; Malignant, 
329- 

Antiseptic (see aseptic, bacteria, disin- 
infect) incision of hydrocele, 30 ; instru- 
ments and materials, 230 ; methods in 
the treatment of wounds, 480; solutions 
of carbolic acid. Device for distinguish- 
ing different, 516; surgery, 30,42, 47, 51, 
6f>; 71, 73, 82, 83, 89, 120, 139, 161, 171, 
177, 180, 183, 184, 193, 227, 230, 238, 
240, 253, 255, 293, 299, 304, 339, 344, 
345, 361, 395, 429, 442, 444, 447, 45o, 
451, 452, 455, 457, 458- 459, 480, 515. 

Antrum, Operative treatment of empyema 
of, 335- 

Anus, Artificial, 250, 253 ; Cure of fistula 
of the, 361 ; Syphilitic gummata at the 
11 argin of, 87. 

Aortic aneurism treated by insertion of 
wire, 47, 163. 

Aphasia followed by hemiplegia, Trephin- 
ing for traumatic, 169. 

Arm, Extirpation of whole, 255, 530. 

Artery (see also aneurism, meningeal, 
Scarpa), Compression of innominate, 
332 ; cured by pressure. Aneurism of 
popliteal, 333; Ligature of common 
iliac, 519; Ligature of subclavian, under 
clavicle, 427 ; producing uvular haemor- 



INDEX. 



rhage, Ascending pharyngeal, 521 ; Trau- 
matic aneurism of femoral. 333. 
Arteries in goitre, Ligature of afferent, 523; 
Surgery of 47, 67, 163. 164, 332, y^i, 

519- 

Arsenical treatment of malignant tumors, 

271. 
Atheroma, Extirpation of, 227. 
Autopsies, Review of Bourneville and 

Bricon's manual of the technique of, 

380. 



"DABER on the examination of the nose, 



Review of, 378. 



Bacterial science in its surgical relations, 
57,150,217, 

Baker on deformities, Review of, 280. 

Bardenheuer, hospital reports. Review 
of, 283, 285; on injuries of upper ex- 
tremities. Review of, 284. 290. 

Bergmann's Berlin clinic, Review of, 283, 
285. 

Biliary calculus, (see cholecystotomy, gall- 
stones). 

Bilharzia haematobia in the viscera. Le- 
sions caused by the presence of eggs and 
embryos of, 350, 352. 

Bismuth for ulcers, Subiodide of, 545. 

Bladder (see also suprapubic cystotomy, 
litholapaxy, lithotomy) and vagina, Sta- 
tistics of fistula of, 372 ; Choice of oper- 
ation for extraction of calculi from, 535, 
Digital exploration of, 532; Drainage of, 
187 ; Lesions caused by eggs and em- 
bryos of Bilharzia heematobia in, 350; 
Modern modifications of operations 
for stone in, 543; Tumors of, 208. 

Blood, Transfusion and infusion of, 331. 

Bones, Experimental production of typi- 
cal tuberculosis of, 79 ; Surgery of, 68, 
71, 77, 79, 81, 82, 83, 84, 123, 179, 185, 
227, 255, 261,262, 534, 335, 351, 562, 

364, 373> 417, 424» 430. 447. 450- 
Bourneville and Bricon's manual de 



technique des autopsies, Review ot, 380. 

Brain (see also cerebral trephining) Com- 
pression of, 167; Operative attacks upon 
the human, 499; Removal of tumor of, 
171,499. 

Briesky on diseases of the vagina. Review 
of, 283, 287. 

Bronchocele (see goitre). 

Bronchus, Removal of tracheotomy tube 
from, 72. 

Browning, W., Abstracts, 66, 67, 68, 70 
76, 77, 79, 80, 81, 160, 179, 180, 227, 
238, 331, 33S» 35i» 422, 424, 427, 444, 
445. 447.451, 515. 523. 535, 543- 

Bruns on fractures. Review of, 283, 288 ; 
Tubingen contributions, Review o , 283. 

Bull, W. T., Laparotomy for perforating 
gunshot wound of the abdomen, with 
recovery, 468, witli death, 475. 

, Radical cure of hydrocele, 30. 

Burn by electric lamp, 260. 

Bursata, Exostosis, 77. 

Butler, G. R., Review of Treves' Manual 
of Surgery, 375. 

Buttock, Traumatic aneurism caused by 
punctured wound of, 333. 



r^M£,KL Region, Surgical relations of 

^ ileo-, 529. 

Csesarean section in the United States, In- 
creasing mortality of, 556; An improved 
technique in, 554. 

Calcareous concretion of pleura. Resection 
of rib for, 179. 

Calculus (see bladder, cholecystotomy, 
gallstone, suprapubic) from bladder. 
Choice of operations for extraction of,535 
Modern transformations of operations 
for, 543; Surgical intervention in certain 
cases of biliary, 339. 

Cancer (see also carcinoma, tonsillar, tu- 
mors), Crateriform ulcer, a type of epi- 
thelial, 357; of cartilage, 350; of the fau- 
ces, 388; of lip, Results of operations for, 
i73;of lung. Primary, i76;of oesophagus, 



INDEX. 



GnstrosiDiiiy or, 237,01 uterus. 367, 370, 
371: of litems, Stalislics of, 370; from 
lunj^ to spine. Extension o(, 176. 

Carbolic acid, Device for distinguishing 
different solutions of, 516. 

Carcinoma corporis uteri, 85; of large in- 
testine. Operations for 247. 

Carotid artery, Tiaumatic aneurism of in- 
ternal, 164. 

Cartilage (see chondro-) Cancer 01 the, 

359- 
Castration in cavernous myofibroma of the 

uterus, 370. 
Catmcart, C. W., Abstracts, 339, 442, 

448. 452- 
Cavernous sinus. Alveolar abscess with 

thrombosis of, 170. 
Cerebral (see brain) abscess, subsequent to 

orbital periostitis, 334. Tumour, 100 

cases of. 510. 
Chancre of tongue, throat, etc., 86. 
Chest, Surgery of, 159, 174, 176, 177, 179. 
Cholycystectomy, 339. 
Cholecystolomy, 183, 184, 251. 
Chondro-osteoid sarcoma of thyroid body, 

272. 
Chondrosaic<.ma, 3^9. 
Cl.ARKE, \V. B., Abstract, 192. 
, Review of Morris on surgical dis- 
eases of the kidney, 282. 
Clavicle, Excision of acromial end of, with 

entire arm and scapula, 255,530; Ligature 

of subclavian vessels under, 427 ; Sub- 

perios-eal resecuon of a necrosed, 373. 
Cocaine in gynecology, 368. 
COF, 1 1. C, Abstracts, 365, 366, 367, 368, 

369.370,371,372. 
. Review ( f recent German surgical 

publications, 287. 
Coi.LES, C. J., Abstracts, 85, 166, 177, 247, 

33^341,344,457. 
Colotumia iliaca, 345. 
Compression f r haemorrhage, 332, 333. 
Coxitis, Diagnostic value of rectal exa.i<in- 

aiions in, 80. 
Cranium (see brain), 
lateriiorm ulcer, 357. 



Cutaneous implnntation as an a Ijunct 10 
necrotomy, 82. 

Cutis, o teoma, 69. 

(. ysto-fibroid 01 labium majus, complicated 
by pregnancy, 457- 

Cystotomy (see calculus, lithotomy, supra- 
pubic\ with digital exploration of the 
bladder, 532. 

Cysts (see wens,echinococci). Intracapsular 
extirpation of thyroid, 174; of liver. Hy- 
datid, 73. 

"pvEFORMITIES, Review of Baker on, 

^ 280. 

Dislocation of fibula, Simple, 84; of fingers 
upon metacarpus, Backward, 549; of head 
of radius with fracture of upper third of 
ulna, 262. 

Dislocations, Review of Stetter on recent 
traumatic, 284, 292. 

Disinfect his hands, How shall the physi- 
cian, 66. 

Dist jmium haematobium. 350, 352. 

Dressing for ulcers, Subiodide of bismuth, 

545- 
Drills, after resection. Nails and, 269. 
Dunn, H I'., Abstracts, 71,72,161,334, 

425. 
, Review of Baber on examinations 

of the nose, 378. 
, Review of Bourneville and Bricon's 



manuel de technique' des autopsies, 380. 
Dura mater (see also meningeal) in brain 
tumors. Condition of, 510. 

"TARS, To remove foreign bodies from 

^-^ the, 170. 

Echinococcus of lungs. Operative treatment 
of, 177; of abdominal organs. Operation 
for, 76. 

Edwards, Y. S., Abstracts, 187, 188, 190. 

, Trea'mentof stiicture of urethra 

by electrolysis, 156. 

, Urethral fever, 20. 

Electric lamp. Stunning and burn by, 260 

Electrolysis, Treatment of urethral strict- 
ure b) , 1 56. 



INDEX. 



Embolism after fractures, Death from 

thrombosis and, 261. 
Empyema of antrum, Operative treatment 

of, 335- 

Enteroti my for ileus, 251. 

Epilepsy from old fracture of skull, 71. 

Esma'ch's niilitar\ surgery, Review of, 284, 
291. 

Eve, F. S., Abstract, 360. 

Excision for chronic disease of shoulder- 
joint, 270; of the larynx, 397, 434; of the 

bont-s of the tarsus, 293; of the hip-joint, 

51, 450; of the knee-joint, 364, 427. 

Extremities, Surgery o;, 185, 346, 359, 362, 
364, 424, 444, 530. 

Extremity, Review of Bardenheuer on in- 
juries of the upper, 284, 290; Review of 
■"chiiller's surgical anatomy of upper, 
2S4, 291. 

Exostoses, Congenital symmetrica! 362. 

Exostosis bursata, 77. 

Eyes, Enucleation with transplantation and 
reimplantation of, 172. 

T^ACE, Review of Trendelenburg on in- 
juries and surgical diseases of the, 

283. 288. 
Facial nerve, stretcliing of, I. 
Fallopian tube (see pyosalpinx). 
FasciiE of the n ck, 229. 
Fatty tumours of the knee-joint, 359. 
Fauces, ^^ureical treatment of malignant 

tumours of, 388. 
Femoral artery, Traumatic aneurism of 

ZZVi vessels and nerve in extirpation of 

tumours of Scarpa's triangle, 274. 
Fever, Stenosis oflarynx after typhoid; 336; 

Urethral, 20. 
Foot, Painful affection of, 53; Spontaneous 

phlebacieriektasia of, 346; Tubercular 

disease or the tarsus, 293. 
Foreign body (see also tracheotomy) from 

the ears. To remove, 170; in cesophagus, 

174. 193- 
Fowler, G. R., Shortening of round liga- 
ments, 42. 
Fibro-adenoma of the rectum p-.oduced by 

the eggs and embryos of distomum hae- 



matobium, 352. 

Fibroid of the labium majus complic.iU-a 
by pregnancy, Cysto-, 457; of the skin 
358; tumour of uterus. Pelvic abscess 
simulating soft, 455 

Fibromata of the abdominal walls, 360; of 
the uterus, Myo-, 305; of the uterus* 
Castration in myo-, 370. 

Fibrosarcoma of the abdominal wall, 360. 

Fibrosarcomatous tumours, 549. 

Fibula, Simple dislocation of, 84. 

Fingers upon metacarpus, Backward dis- 
locaiion of. 

Fistula, Case of gasto-vaginal, 459; Ital- 
ian statistics of vcsico-vaginal. 372; Ure- 
thro-perineal, 46; in-ano. Cure of 361. 

Foetation, Laparotomy for extra-uterine, 
458, 459. 

Fo-tus in one horn of a uterus bicornis. Re- 
moval of, 371. 

Foreum, Inoculation-tuberculosis after 
amputation of, 424. 

Fracture, Behavi.r of bodily tempeiature 
m subcutaneous, 261; Death from throm- 
bosis and embolism after, 261; of h.me- 
lus, 68; Paralysis of radial nerve follow- 
ing, 517; of patella by metallic suture, 
Treatment of, 83; of patella. New oper- 
ation for, 227; of ulna, in upper third, 
with dislocation of head of radius, 262; 
of skull, 430; of skull, Trephining in epi- 
lepsy from old, 71; of skull, treatment of 
compound, 318. 

Fracture.-, Review of Bruns on, 283, 288. 

Frontalis, Teratoma sinus, 68. 



G 



ANGRENE of hernia, 253. 



Gant's s rgerj', Review of, 376. 
Gallstone, ileus, 180, 251; Impaction of, 
183, 184, 251; -urgical intervention in, 

339- 
Gastrostomy for cancei of oesophagus, 

237- 
Gaatro-vaginal fistula. Case of, 459. 
Genito-urinary organs, Surgery of, 20, 30, 

187, 188, 190, 192, 256, 257, 259, 260, 

349,350,374, 44'^- '5^ -;':8, 459,461, 

532. 



Xll 



^DEX. 



Gerrish, F. H., Surgical neaaneni oi 
malignant tumours of the fauces, 387. 

Gerster, a. G., Advantages of supra- 
pubic lithotomy, 298. 

Gland. Lesions caused by eggs and em- 
bryos of Bilharzia haematobia in mesen- 
teric, 350; Tuberculosis of mammary, 
159- 

Glanders, Bacteriology of, 217; Review of 
Koch on splenic fever and, 283, 288. 

Glioma, 171. 

Glottis, CEdema of, 336. 

Goitre by ligature of afferent arteries, Op- 
erative treatment of, 523. 
.Gonorrhoea, Bacteriology of, 150; by means 
of grooved bougies, Treatment of chron- 
ic, 374. 

Gould, A. P., Ti eatment of aneurism, 47. 

Gummata at margin of anus. Syphilitic, 87. 

Gunshot wound of abdomen. Laparotomy 
for perforating, with recovery, 344, 468, 
528; with denth, 475, 528; wound of 
spine, Healed, 447. 

Gynecology, 42, 85, 365, 367, 368, 369, 370, 
371,372,451.452. 455. 456, 457. 458, 
459, 55 •• 



"LJ^MATOMATA of cranial cavity, 
232. 

Haemorrhage after uvulotomy, 521; into 
abdominal cavity during mensliuation, 
Fatal, 456; Middle meningeal 232, 512; 
Transfusii n and infusion for, 331. 

Hand, Tuberculous synovitis of tendinous 
sheaths of, 444. 

Head, Surgery of, 68, 70, 71, 167, 169, 170, 
171, 172, 173, 227, 232, 355, 388, 430. 

Head (see also brain). Tumours of, 68. 

Hernia, Gangrenous, 253; in a pregnant 
woman. Strangulated umliilical, 442; In- 
testinal obstruction relieved by liberat- 
ing the omentum from an omental, 526, 
into foramen of Winslow, Strangulated 
internal, 442; Laparotomy for internal 
strangulated, 526; of omentum by ab- 
dommal wounds, 240; Radical cure of 
oblique inguinal, 89; Spontaneous repo- 



sition of, 74; Testicular atif'ections and, 
190. 

Hernial sac. Hydrocele of, 259. 

Hip-joint, Amputation at, 185; diseases, 
Diagnostic value of rectal examination 
in, 80; Excision of, 51; in pulmonary tu- 
berculosis. Excision of, 450. 

Humerus, Excision of head of, 255; Paral- 
ysis of radial nerve following fracture of, 
68. 

Hutchinson, jr., J., Abstracts, 86, 87, 373, 
374. 

Hydatid cysts of liver, 73. 

Hydrocele of hernial sac, 259; of tunica 
vaginalis. Radical cure of, 30. 

Hydronephrosis, Traumatic, 192. 

Hyste'-ectomy for cancer. Vaginal, 367, 
371- 

TCTERUS accompanied by a general 

eruption of lichen. Emotional, 426. 
Ileo-caecal region, Surgical relations of, 

529- 

Ileus, Gallstone, 180, 251. 

Ilium 'or draining pelvic abscesses, Tre- 
phining the, 351. 

Iliac artery. Ligature of common for an- 
eunsm of external, 519. 

Incontinence of urine in children, 188. 

Infant, Fracture of skull in an, 430. 

Inguinal hernia, Radical cure of oblique, 
89. 

Injuries of upper extremities, Review of 
Bardenhauer on, 284, 290; Surgery of, 
260. 

Innominate artery, Compression of, 332. 

Instruments, Antiseptic surgical, 230. 

Intestine, Colotomia iliaca, 345; gunshot 
wound of, with recovery, 344, 468; 
with death, 475, 52S; obstruciion of (see 
also ileus) by internal strangulated her- 
nia. Laparotomy for, 526; obstruc- 
tion of, 527; obstruction of, from hernia 
into the foramen of Winslow, 442; ob- 
struction of, relieved by liberating the 
omentum from an omental hernia, 526; 
obstruction of. Signification of collapsed 
intestine in laparotomy for, 240, Opera- 



INDEX. 



tions for carcinoma of large, 247; Resec- 
lion of, 344; Surgical relations of ileo- 
csecal region of, 528. 
Intubation of larynx, 73; and tracheotomy, 
523- 



JOINT (see hip-, knee-, shoulder- tuber. 

culous). 
Joints, Surgery of, 51, 80, 185, 227, 255, 
262,265,269,270, 271, 359, 364, 427, 
45°. 549- 



TZ"EEN, W. W., Stretching of facial 
nerve, i. 

Keetley, C. B., Abstracts, 176, 260. 

, Osteoclasis, 417. 

, Review of Baker on deformities, 

280. 

, Review of Thompson on supra- 
pubic cystotomy, 277. 

Kidney (see also hydronephrosis), Extir- 
pation of,2 56, 259; Lesions caused by 
eggs and embryos of Bilharzia haemato- 
bia in, 350; Retro- and Intra-peritoneal 
incision for tumors of, 445. Review of 
Morris on the, 281; Rupture of, 192. 

Koch on splenic fever and glanders, Review 
of, 283, 288. 

Knee-joint, after resection, Nails and drills 
for fixation of, 269: Arborescent lipoma 
of, 265; Excision of the, 364; Extirpation 
of synovial membrane behind, 427; in 
hereditary syphilis. Synovitis of, 87; 
Treatment of white swelling of, 269; Tu- 
mours of, 359. 



T AHIUM majus complicated by preg. 
nancy, Cystro-fibroid of, 457. 

Lake, R., Servo-Bulgarian war from a sur- 
gical point of view, 381. 

Lange, F., Clinical observations on myo- 
fibromatous tumors of the uterus, 304. 

Larynx after typhoid fever, Stenosis of, 336; 
Excision of, 397, 434; Intubation of, 73, 
523- 



Laparotomy (see also Caesarean section, 
cholecystotomy, echinococci, gastrosto- 
my, hydatid, ovariotomy) and ligatuie of 
common iliac artery, 519; Diagnoslitial, 
240; Explonaive, 184, for affections of 
ileo-ccecal region, 529: for carcinoma of 
large intestine,247; for intestinal obstruc- 
tion, signification of collapsed intestine 
in, 240; for internal strangulated hernia, 
526; for obstruction of intestine, 527; for 
perforating gunshot wound of ab- 
domen,recovery, 344,468,528;with death, 
475' 528; for perityphlitic abscess, 242, 
243; for retained fcetus in uterus bicornis, 
371; in extra-uterine foetation. 458, 459; 
sublimate intoxication in case of, 551. 

Leprosy, Contagiousness of, 324; Nerve- 
s'.retching for anaesthetic, 517. 

Lichen, Emotional icterus accompanied by 
a general eruption of, 426. 

Ligaments, Shortening of round, 42, 365. 

Ligature, Amputation of an inverted uterus 
by the, 372; of afferent arteries in goitre, 
523; of common iliac artery, 519. 

Lip, Results of operations for cancer of, 
173- 

Lipoma of knee, 265, 359. 

Litholapaxy, Rapid evacuator for, 257. 

Lithotomy (:-ee bladder, calculus, cystoto- 
my, suprapubic) twice in fourteen 
months, 187. 

Lithotrity (see bladder). 

Liver, Absces^ of the, 341 ; Lesions caused 
by eggs and embiyo of Bilharzia 
hsematobia in, 350; Treatment of hydatid 
cysts of, 73; with recovery, Laparotomy 
for penetrating gunshot wound affecting 
the, 528. 

Lloyd, S., Operative attacks on the hu- 
man brain, 499. 

Lumbar abscesses, Treatment of, 546. 

Lungs (see tuberculous, tuberculosis) Op- 
erative treatment of echinococci of, 177' 
Primary cancer of, I/6. 

Lupus, Treatment of, 160; vulgaris and tu- 
berculosis, 514 

Lymphangitis and sublimate irrigations 
429. 



INDEX. 



1W| ACEWEN, ^\ .. Radical cure of her- 
nia, 89. 

Male, Pelvic abscess in the, 245. 

Malignant pustule, Three cases of, 425. 

Mammary glancls,Tuberculosis of, 159. 

Mark, L., Abstracts. 68, 73. 

Markoe, T. M., CEsophagolomy for for- 
eign bodies lodged in the tube, 193. 

Massage, Treatment of scoliosis by, 266. 

Maxillary sinus. Operative treatment of 
empyema of 335. 

McBuRNEY, C, Szymanowski's operation 
applied to the cure of urethro-perineal 
fistula, 461. 

Median nerve, Ulnar nerve grafted upon, 
161. 
Melanotic whitlow, 357, 360. 

Meningeal arterj', Haemorrhage from mid- 
dle, 232, 512, 

Meningitis, Traumatic, 430. 

Menstruation, Fatal haemorrhage into ab- 
dominal cavity during, 456. 

Mecenteric glands. Lesions caused by eggs 
and embryos of Bilharzia hsematobia in 
the, 350. 

Mesentery, Gunshot wound of, 468. 

Metacarpus, Backward dislocation of fin- 
ger upon, 549. 

Microbes (see bacteriology). 

Military surgery, Review of Esmarch's, 
284, 291. 

Miller, J. S., Trocar for Paracentesis ab- 
dominis, 387. 

Morris (Henry) on surgical diseases of kid- 
ney, Review of, 281. 

Morris, R.T., Results of antiseptic meth- 
ods in treatment of wounds, 480. 

Myotibromata of the uterus, 305; Castra- 
tion in, 370. 

Myxo-sarcomatous tumor of the abdomen* 
448. 



N 



AH."^, Melanotic whitlow along the 
357, 360. 



Nails and drills after resection, Use of, 269^ 

Neck, Aerial tumors of anterior part of, 235, 

431; Fasciae and interfascial spaces of* 

229, Surgery of, 73, 75, 139, 174, 229> 

235- r:>^^ 397,431. 434, 439, 521- 

Necrosis of clavicle. Subperiosteal resection 
for, 373; of tibia, 82. 

Necrotomy, 82. 

Nephrectomy, 256; on a patient 23 months 
Old, 259. 

Nephritis after laparotomy and ligature of 
common iliac, Fatal, 519. 

Nerve, Neuralgia of internal plantar, 517; 
following fracture. Paralysis of radial, 68; 
Value of enucleation of a neuroma which 
seemed to demand resection of a, 521. 

Nerves of different functions considered in 
in its physiological and surgical rela- 
tions. Union of, i6i;Operations on, 517; 
Secondary suture of median and ulnar, 
161; Surgery of, I, 66, 68, 161, 447, 
517- 

Nerve-stretching, i, for anaesthetic 
leprosy, 517. 

Nerve suture, 161, 

Neuralgia of external plantar nerves, 5/7. 

Neurectomy, 5 r 7. 

Neuroma, Enucleation of a, 521. 

Nose, Review of Baber on examination of, 
378. 



^OBSTRUCTION (see intestine). 

CEdema ol glottis, 336. 

CEsophagotomy, 193. 

CEsophagus, Gastrostomy for cancer of, 
237; Foreign body in, 174, 193. 

Ogston', a.. Operation for varicocele, 120. 

Omentum, Abdominal wounds witli hernia 
of, 240; from an omental hernia, Intes- 
tinal obstruction relieved by liberating, 
526. 

Oophoraphy, 365. 

Orbital periostitis. Cerebral abscess subse- 
quent to, 334. 



INDEX. 



Orthopedic surgery, 266, 269, 270, 271, 

427, 450. 
Osteoclasis, 417. 
Osteitis of knee. Treatment of articular, 

269. 
Osteoma cutis, 69. 
Ovariotomy, Conservative, 368; Remark 

on a series of cases of, 452. 
Ovary, Operation for prolapsed, 365. 



pAI.ATE, Cleft, 70. 

Patella by metallic suture, Treatment of 
fracture of, 83: New operation for frac- 
ture of, 227. 

Paracentesis abdominis. An improved tro- 
car for, 387. 

Paralysis of radial nerve following fract- 
ure, 68. 

Paraplegia from cancer of spine, 176. 

Parasites in the development of certain 
tumors. Role of, 352. 

Pathology of tumors, 272. 

Pelvic abscess. Drainage of, 351; abscess 
in the male, 245; abscess simulating soft 
fibroid tumor of the uterus, 455. 

Perineal fistula, Urethro-, 461. 

Perineum, Operation for complete lacera- 
tion of, 366. 

Periostitis, Cerebral abscess subsequent to 
orbital, 334. 

Peritoneal incision for tumors of the kid- 
ney, Retro- and intra-, 445. 

Perityphlitic abscess, Laparotomy for, 242. 

Perityphlitis, 243. 

Phalanx upon metacarpus. Backward dis- 
location of first, 540. 

Pharyngotomy for extirpation of malignant 
tumors of tonsillar region. Lateral, 139. 

Phlebacteriektasia of foot. Spontaneous, 
346. 

Pilch ER, J. E., 73, 78, 82, 83, 84, 161, 163, 
164, 171, I72,.i74,;i83,i84, 185, 235, 240, 
242, 243, 245, 257, 259, 260, 269, 270, 
271, 274, 346, 356, 359, 361, 364, 458o'7 
519,521, 523, 528, 529, 5:ji, 532, 533, 
545, 546, 547> 549- 



, Paris society of surgery and tuber- 
culous joint-disease, 144. 

PiLCHER, L. S., Lateral pharyngotomy for 
extirpation of malignant tumours of ton- 
sillar region, 139. 

Pleura, Resection of rib for calcareous con- 
cretion of, 179. 

Popliteal aneurism cured by pressure, 333. 

POPOFF, P. J., Abstracts, 230,237,345, 349, 
427, 439- 

Pregnancy, Cysto-fibroid of labium majus 
complicated by, 457; Laparotomy for 
extra uterine, 458, 459; Laparotomy for 
tubal, 458; of seven years' duration, 459. 

Pregnant woman, Strangulated umbilical 
hernia in, 442. 

Prostate, Lesions caused by eggs and em- 
bryos of Eilharzia hsematobia in, 350. 

Piostatotomy, 532. 

Pustule, Three cases of malignant, 425. 

ID ADIAL nerve, following fracture, Pa- 
ralysis of, 68. 

Radius in fracture of the upper third of ul- 
na. Dislocation ol, 262. 

Rectum in coxitis, Diagnostic value of ex- 
aminations by the, 80; Lesions caused 
by ej.igs and embryos of liilharziahaema- 
tobia in, 3:;2. 

Renal (.see kidney). 

Resection, Nails and drills for fixation 
after, 269; of a necrosed clavicle, sub- 
periosteal, 373; of rib, 179. 

Retroflexion of the uterus by a recent op- 
erative method, Treatment of, 369. 

Reviews of books, 277, 375, 

Rib, Resection of, 179. 

O ARCOMA, Chondro-, 359; Fibro- or 
spindle-celled, 547; of abdomen, 

Myo-, 448; of knee-joint, 359; of skin, 

Spindle-celled, 358; of thyroid body, 

Chondro-osteoid, 272. 
Scalp, Extirpation of wens in, 227. 
Scapula, Extirpation of entire, 255, 
Scarpa's triangle, Extirpation of tumors of, 

274 
Schiiller's surgical anatomy, Review of, 

2S4, 291. 
Scolioi-is by massage. Treatment of, 266. 



I.XDEX. 



Servo- Bulgarian war from a surgical point 

of view, 381. 
Sheaths of hand and wrist, Tuherculous 

synovitis of tendinous, 444. 
Shepherd, F. J., Excision of the bones of 

the tarsus for tubercular disease, 293. 
Shoulder-joint, Chronic disease oi, 270, 

271. 
Sinus, Alveolar abscess with thrombosis of 

cavernous, 170, Empyema of maxillary, 

335; frontalis, Teratoma, 68. 
Skin (see also cutaneous, cutis, lichen, 

lupus) Fibroid of the, 358; Transplanta- 
tion of, 78. 
Skull (see brain, meningeal, trephining) 

in brain tumors, 510; Fracture of, 430; 

Treatment of compound fracture of, 318. 
Spina bifida. Cure of, 66. 
Spine, Healed gunshot wound of, 447; in 

growth of animals. Torsion of, 81; by 

massage. Treatment of lateral curvature 

of, 225. 
Splenic fever and glanders, Review of 

Koch on, 283, 288. 
Staphylorrhaphy, 70. 
Stetier on recent traumatic dislocations. 

Review of, 284, 292. 
Stomach and vagina, Fistula connecting, 

459- 

Stridure of urethra by electrolysis. Treat- 
ment of, 156; Subcutaneous division of 
urethral, 533. 

Subclavian artery and vein. Ligature of, 
427. 

Sublimate in obstetrical irrigations. Use 
of, 451; intoxication in a case of laparot- 
omy, 551; lymphangitis and, 429. 

Suprapubic cystotomy, 349, 535, 543; Ad- 
vantages of, 298; Review of Thompson 
on, 277. 

Surgery, Review of Bruns' contributions 
to clinical, 283. 

Surgical clinic of univ. of Berlin, Contri- 
butions from, 283, 285. 

Synovial tuberculosis, 265, 427; membrane 
behind knee-joint, Extirpation of, 427. 

Synovitis of knee in hereditaiy syphilis, 
87; of tendinous sheaths of wrist and 
hand, Tuberculous, 444. 



SzYMAXOwsKi's Operation applied to cure 

ol urethro-perineal fistula, 461. 
Syphilis, 86, 87, 373, 



•"TARSUS, Excision of the bones of, 293 

Taylor, H. II., Abstiacts, 169, 170, 455, 

456. 
Telangiectasia, Treatment of, 166. 
Temperature in subcutaneous fractures, 
261. 

Tendons of wrist and hand, Tuberculous 
synovitis of sheaths of. 444. 

Teratoma sinus frontalis, 6S. 

Testicle and hernia, Affections of the, 190. 

Tetanus in man. Etiology of, 422. 

Thigh, Extirpation of tumors of Scarpa's 
triangle of, 274. 

Thompson, W., Abstracts, 332, 333. 

Thompson on suprapubic cystotomy. Re- 
view of 277. 

Throat, Chancre o*, 86. 

Thrombosis and embolism after fracture. 
Death from, 261 ; of cavernous sinus. 
Alveolar abscess with, 170. 

Thumb upon metacarpus. Backward dis- 
location of, 549. 

Thyroid body (see also goitre) Chondro- 
osteoid sarcoma of, 272 ; Intracapsular 
extirpation of cysts of, 174; Papillary 
cylindro-cellular adenoma of, 274, 

Tongue, Chancre of, 86, 

Tonsillary abscess, 336 ; region, Lateral 
phar}'ngotomy for extirpation of malig- 
nant tumors of, 139. 

Torsion in growth of animals, 81. 

Tracheocele, 235. 

Tracheotomy (see also intubation). Ex- 
ploratory, 175; Extraordinary cases of, 
439 ; for laryngeal stenosis from typhoid 
fever, 336 ; in a child, set. i year, 336 ; 
Intubation of larynx and, 523; tube in 
the right bronchus. Removal of, 72. 

Transfusion and infusion, 331. 

Transplantation of eyes, 172. 

Trendelenberg on injuries and surgical 
diseases of face, Review of, 283, 288. 

Trephining for middle meningeal haemov- 



II^DEX. 



rhage, 232, 512; for traumatic aphasia 
followed by hemiplegia, 169; in epilepsy 
from old fractures of the skull, 71 ; the 
ilium for draining pelvic abscesses, 351. 

Treves' manual of surgery, Review of, 375. 

Trigger-finger, Mechanism of, 444- 

Tuberculosis after amputation of forearm. 
Inoculation, 424 ; Bacteriology of, 57 ; 
Cases of surgical, 159; improved by ex- 
cision of hip, Pulmonary, 450; Lupus 
vulgaris and, 514; of mammary glan 1, 
etc., 159; of bones. Experimental pro- 
duction of typical, 79; Synovial, 265, 
427. 

Tuberculous disease, Excision of bones of 
tarsus for, 293 ; joint disease, 144 ; knee- 
joint disease, 427; synovitis of tendinous 
sheaths of wrist and hand, 444. 

Tumor (see also adenoma, angioma, ather- 
oma, cancer, carcinoma, chondro- cer- 
ebral compression, cyst,exostoses, fibro-, 
goitre, gumma, lipoma, neuroma, ovary, 
osteoma, sarcoma, tracheocele) of abdo- 
men, rapid growth of myxo-sarcoma- 
tous, 448 ; of brain. Removal of, 17 1,499; 
of uterus. Pelvic abscess simulating soft 
fibroid, 455. 

Tumors, Abdominal, 458, 459 ; Arsenical 
treatment of malignant, 271; Clinical 
groups of, 356 ; Fibro- or spindle-celled 
sarcomato is, ^47; of anterior part of 
neck, Aerial. 431; of brain, 499; of 
fauces, Malignant, 388 ; of head, 68; of 
kidney, Retro-and intra-peritoneal in- 
cision for. 445 ; of knee-joint, Fatty and 
sarcomatous, 359 ; of Scarpa's triangle. 
Extirpation of, 274 ; of tonsillar region. 
Lateral pharyngotomy for extirpation of 
malignant, 139 ; of urinary bladder, 208; 
of uterus, Myo-fibromatous, 305 ; Pa- 
thology of, 272 ; Role of parasites in 
the development of certain, 352. 

Typhoid fever, Stenosis of larynx after, 
336. 

T TLCER, Crateriform, 357; Flap trans- 
plantation for, 78. 
Ulcers, Subiodide of bismuth for, 545. 
Ulna in upper third, Fracture of, 262. 



Ulnar nerve grafted upon median, 161 ; 
Secondary suture of median nervous, 161. 

Umbilical hernia in a pregnant woman. 
Strangulated, 442. 

Urethra (see gonorrhoea) by electrolysis. 
Treatment of stricture of, 156; Subcu- 
taneous division of stricture of, 533. 

Urethral fever, 20. 

Urethro-perineal fistula, 461. 

Urine in children. Incontinence of, 188. 

Uterus bicomis. Extirpation of pregnant 
horn of a, 371 ; by a recent operative 
method, Treatment of retroflexion of, 
369; by means of a ligature, Gradual 
amputation of an inverted, 372 ; Cas- 
tration in myo- fibromata of the, 37; Car- 
cinoma of body of, 85; Myo-fibromatous 
tumors of, 305 ; displacement, Shorten- 
ing round ligament for, 42, 365 ; Ex- 
cision of diseased portion of cancerous, 
367 ; Pelvic abscess simulating soft 
fibroid tumor of, 455 ; Statistics of can- 
cer of, 370. 

Uvulotomy, Haemorrhage after, 521. 

'^ rAGINA a minute canal. Case of, 459 ; 
Review of Briesky on diseases of, 
283, 287. 

Vaginal fistula, Gastro-, 459 , fistula, Sta- 
tistics of vesico-, 372. 

Van Arspale, W. W., Abstracts, 159, 167, 
173, 174, 227, 229, 232, 251, 253, 255, 
256, 261, 262, 265, 266, 271, 272, 



, On the present state of knowledge 

in bacterial science in its surgical rela- 
tions, 57, 150, 217. 

, Reviews of recent German sur- 



gical publications, 284, 291. 
, Treatment of compound fractures 



ofthe skull, 318. 
Varicocele, Operation for, 120; Treatment 

of, 260. 
Vein (see cavernous, Scaroa) Ligature of 

subclavian under clavicle, 427. 
Veins, Surgery of, 120, 166, 260, 261. 
Vertebral column (see spine). 
Vesical (see bladder). 
Vesico-vaginal fistula. Statistics of, 372. 



INDEX. 



ViNKE, H. H., Excision of the hip-joint, 
51- 

'^A^'AGSTAFFE, W. W., Review of 

Gant's surgery, 376. 
Wens in scalp, Extirpation of, 227. 
Whitlows, Melanotic, 357, 360. 
Winslow, Strangulated internal hernia into 



the foramen of, 442. 
Wire for aneurism, Introduction of 47, 163. 
Wound of abdomen, 240, 344, 468, 475, 

528; of liver, 478, 528; of sipne. Healed 

gunshot, 447. 
Wrist, Tuberculous synovitis oftendinois 

sheaths of hand and, 444. 



ANNALS OF SURGERY. 



ON NEPHROLITHOTOMY, WITH REPORT OF A 
CASE. 

By KENDAL FRANKS, F. R. C. S. I., 

OF DUBLIN, 
SURGEON TO THE ADELAIDE HOSPITAL. 

IN reporting the following case and in shortly discussing 
some of the chief points in connection with the opera- 
tion, I do so because the history of nephrolithotomy is of 
such recent date that every case ought to be published in 
which the operation is resorted to, and also because the pres- 
ent case is the first in Ireland in which a stone has been en- 
cised from the kidney in the living subject. The term "ne- 
phrolithotomy " was proposed by Schurigius as far back as the 
earlier half of the eighteenth century, but the operation itself 
was performed for the first time by Mr. Henry Morris in 1880, 
and the details reported by him to the Clinical Society of Lon- 
don in the same year. Mr. Morris defines nephrolithotomy to 
be " an incision into the secreting substance or pelvis of the 
kidney, with the express purpose of removing a calculus there- 
from ; and that too at a date in the progress of the disease 
prior to the disorganization of the renal substance, or the 
conversion of the renal pelvis into a large abscess cavity. " 
Although of so recent an origin, the operation has already 
been performed a sufficient number of times, in England, in 
America, and on the continent, to show that it is not only a 
justifiable proceeding, but one fruitful of the best results, 
and free from risk to an extent hardly to be anticipated. 

It is reported that the late Mr. Lawrence used to begin one 
of his lectures thus : " The kidney, gentlemen, is fortunately 
beyond the reach of the surgeon."^ 

That day is past, and the kidney has ceased to occupy such 

^Ashhurst's International Encyclopaedia, Vol. V., p. 1090. 



2 KENDAL FRANKS. 

a distinguished position. There are four well recognized 
methods of operative interference with the kidney. (i.) 
Nephrotomy , or simple incision into the kidney, whether for 
diagnostic purposes, for the opening of an abscess, or for 
hydronephrosis. (2). Nephrorraphy, designed for the pur- 
pose of fixing a movable kidney. (3). Nephrolithotomy, and 
(4). Nephrectomy or excision of the kidney. I do not purpose 
in the compass of this paper to discuss the several proced- 
ures, but I shall confine myself to that one only which is illus- 
trated by the case which I now desire to report. 

J. H., a man, set. 28, by occupation a silk weaver, was admitted to 
the Adelaide Hospital in the autumn of 1885, and first came under 
my care on the 5th of October of the same year, suffering from loss 
of flesh, increasing debility and pain in the left side. His history was 
as follows : He had always been healthy till five or six years ago, 
when his troubles began. He had been in the habit of indulging 
largely in stimulants, with occasional intermissions, sometimes extend- 
ing to a period of three months. His drink was invariably ale. In 
the winter of 1879-80, during one of his drinking bouts, he caught a 
heavy cold which confined him to bed for a fortnight, with shiverings, 
fever and pains all over the body. At the end of the fortnight sup- 
pression of urine came on and lasted for three days. At the end of 
this time it was again secreted, and when passed was bloody. For 
the first day the blood was passed in clots, subsequently it came mixed 
with the urine, and did not entirely disappear for three months. Dur- 
ing this time micturition was not unusually frequent, nor was the act 
accompanied by pain. There was no vomiting, but the bowels be- 
came constipated and sometimes would not act for three days. Con- 
currently with the hematuria, severe and paroxysmal pain came on. It 
began in the left groin and hip, and sometimes shot down into the left 
testicle. When sufficiently well to move about, he noticed that the 
pain frequently shifted from the testicle to the crest of the ilium and 
up into the left side near the spine. This pain has continued more or 
less ever since, but sometimes it is absent for a few days. 

Two and a half years later he contracted a gonorrhoea, of which he 
has not been cured. The passage of a bougie revealed a stricture 
six inches from the meatus which just allowed a No. 7 Enghsh gauge 
to pass. 

For some time previous to his admission to hospital he had been 



NEPHROLITHOTOMY. • 3 

gradually getting weaker. During the previous week he had been 
lying up at home unable to eat or drink, and vomiting whatever he 
took. Previous to this he had had no vomiting. The day after com- 
ing into the Adelaide Hospital he was seized with retention of urine, 
and a catheter had to be passed every day for about a week. At this 
time he complained of symptoms which suggested vesical calculus, 
and accordingly he was sounded on two occasions, but nothing ab- 
normal could be detected in the bladder. 

His family history was good. 

When first he came under my care he was very anaemic. His large 
dark eyes, with clear bluish conjunctiva, his white lips, and colourless, 
pasty face was highly suggestive of phthisis. His lungs, however, 
were sound, and he had no cough. His appetite was fairly good, and 
when not in pain, he slept well. Whenever he stood or walked the 
pain in the side came on. It sometimes seized him in the loin, some- 
times in the groin or over the iUac crest, but it never shot into the tes- 
ticle during the whole period that he was under observation. His 
pulse was io6, and the temperature normal. 

The urine he passed contained pus, the amount of this constantly 
varying. Sometimes it formed but a thin layer at the bottom of the 
urine glass, and again after twelve hours standing it would occupy 
nearly a third of the column of fluid. The specific gravity was 1017. 
The urine was always acid, though sometimes extremely foetid. The 
microscope revealed pus cells and crystals of uric acid, but there were 
no pyriform cells and no tube casts. I was first inclined to look upon 
the case as one of tubercular pyelitis, as on account of the constant 
acidity of the urine and the absence of all vesical symptoms, it was 
evident the pus could not come from the bladder ; whilst the cachec- 
tic appearance of the man was suggestive of tubercular disease. At 
my request Dr. Wallace Beatty, on two occasions carefully examined 
the urinary deposits for bacilU, but none could be detected. 

He never passed any calculi or gravel. 

I kept him under observation till the 27th of October, when he left 
hospital, but attended occasionally as an out-patient. He was treated 
at first with benzoate of soda, which materially diminished the foetor of 
the urine, but did Uttle good otherwise. This was subsequently 
changed for saUcylic acid and salicylate of soda with the same result, 
Astringents of various kinds, including pyrogallic acid, seemed to have 
no eff'ect. 

He was re-admitted to hospital on the loth of April last, as he was 
decidedly losing ground, was obviously weaker, and the pain seemed 



4 KEND.'.L FRANKS. 

to be getting worse. The urine had not improved, and pus continued 
to be passed in large quantities. I now came to the conclusion that 
the case was one either of purulent pyelitis of the left side or of renal 
calculus, and that it was a case in which an exploratory operation 
should be performed. Before, however, resorting to this expedient, I 
asked my colleague. Dr. Wallace Beatty, to examine the case and to 
give me his opinion, and I am glad of this opportunity of acknowl- 
edging the material assistance and support which he afforded me. 

An examination of the abdomen and back revealed nothing abnor- 
mal, there was no fulness or tumour or anything. The only thing 
elicited by this examination was tenderness behind on pressing over 
the last rib and below the last rib, immediately external to the erector 
spinae. There was tenderness nowhere else. The pain was referred 
to the same region, extending over the lower half of the left side of 
the thorax, and in the left side of the abdomen below the left costal 
arch. It was occasionally absent. The pain was described as burn- 
ing or aching. He could lie with greatest comfort on his back, and 
better on his left side than on his back. Lying on the right side in- 
creased the pain. The character of the urine was the same as when 
in hospital in October. 

From the character and localization of the pain, from the condition 
of the urine, and from the history of the onset of the disease five or 
six years previously. Dr. Beatty considered that the weight of evidence 
was in favour of a renal calculus. Under these circumstances and 
with the concurrence of my colleagues, I operated on the 6th day of 
March last, as follows : 

The patient was placed under the influence of ether, lying on his 
right side in a semi-prone position. Pillows were placed beneath the 
right loin and abdomen, in order to throw the left loin well out and to 
support the kidney, so that it should not slip forward when reached. 
An incision was then made parallel to the twelfth rib, three-quarters of 
an inch below it, and beginning over the external border of the erector 
spinae muscle. This incision was five inches long and extended for- 
wards to a point a Uttle superior and posterior to the anterior superior 
spine of the ilium. The muscles were divided to the full length of 
the incision and then the lumbar aponeurosis appeared. It bulged 
out into the incision, and looked so Hke the colon that for a few mo- 
ments I was undecided as to its nature. By tracing it backwards, 
however, I found that it passed behind the kidney, and the doubt 
being thus removed I divided it freely. The perirenal fat at once came 
into view, and was carefully torn through by means of fingers and for- 



NEPHROLITHOTOMY. 5 

ceps, thus exposing the kidney which looked quite healthy. Passing 
my finger behind it, I broke down some adhesions, and was then en- 
abled to explore its posterior surface thoroughly. At its inner border 
my finger impinged upon a hard mass, which at first felt like the spine, 
but passing the finger downwards its lower limit could be felt. It 
appeared to be about two and a half to three inches long. An ex- 
ploring needle was then passed through the substance of the kidney, 
and as it reached the inside of the pelvis it grated against a calculus. 
An incision about two inches long was made on the outer border of 
the kidney down to the pelvis. The haemorrhage at first was very 
brisk, but a finger passed through the wound served as a plug, and it 
quickly became checked. The stone was friable and chalky, but was 
so firmly imbedded in the pelvis that it had to be crushed with a for- 
ceps and removed piecemeal. A large piece occuying the upper por- 
tion of the pelvis I succeeded in hooking out with the finger, but most 
of it was removed with the aid of a Hthotomy scoop. The calices 
of the kidney seemed to contain processes from the stone, and I ex- 
perienced great difficulty in enucleating them. When I was satisfied 
that all was clear I irrigated the wound in the kidney with a weak 
solution of corrosive sublimate to wash out the debris. By this time 
the bleeding from the substance of the kidney had nearly quite ceased. 
Accordingly, I plugged the wound lightly with some sal-alembroth 
gauze wrung out in weak carbolic lotion. A drainage-tube was placed 
from the deep parts of the wound external to the kidney and brought 
out at the external angle of the skin wound. All divided tissues were 
sutured in successive layers with catgut. The wound was dressed 
with sal-alembroth gauze and a large, thick pad of turf mould was 
placed over all and the parts firmly bandaged with a flannel roller. 
During the whole operation, which occupied just an hour, the patient's 
pulse remained remarkably good. The subsequent progress of the 
case was most satisfactory. 

The external wound healed by first intention, with the exception of 
the track of the drainage-tube which was not finally closed till between 
the lourth and fifth week. For the first few days the dressings had to 
be changed two or three times a day owing to their rapidly becoming 
saturated with blood-stained urine, but by degrees the dressings be- 
came less frequent, and by the fifth week were abandoned altogether. 
The day after operation I found him lying on his right side, his favor- 
ite position since the operation, though previously he could not do so 
owing to the aggravation of pain which it induced. Mr. Piel, the as- 
sistant to the Professor of Chemistry in the College of Surgeons very 



O KENDAL FRANKS. 

kindly analyzed the urine passed day by day /^r 7'/(7w tiaturalem. The 
evening after operation it contained a large quantity of blood, but this 
rapidly diminished and ceased to appear on the fourth day. On the 
tenth day the pus was scarcely noticeable in the urine, but since then 
it has reappeared though in much less quantity. As soon as the 
external wound had healed he passed a normal quantity of urine 
daily, and the amount of urea excreted varied from one to two and a 
half per cent. 

The patient has now been back at his work for several months. He 
has begun to fill out and looks healthy, though still somewhat 
anaemic. The other day I met him running hastily down some steps 
very different in appearance to what he was in May last. The pain in 
the side has completely disappeared. A good deal of the stone was 
lost in the process of washing away the debris from the pelvis of the 
kidney, but all that was collected was carefully washed and dried by 
Mr. Piel, who found that it weighed then 17 1.3 grains. It is com- 
posed of carbonate of lime, phosphate of lime and ammonium mag- 
nesium phosphate. 

The operation of nephrolithotomy has already obtained a 
v^^ell-established position in surgery. The statistics hitherto 
have been exceptionally good. Up to the beginning of the 
present year twenty-two cases were recorded by English and 
American surgeons. Of these none died as a direct result of 
the operation. Two died shortly afterwards, one from mor- 
phinismus (Pepper) and the other from a calculus becoming 
imparted in the ureter on the opposite side (Culhngworth). 
The other twenty cases made good recoveries. In German 
Hterature I can only find two cases reported. The first was 
operated upon by Bardenheuer,^ but the patient died of anuria, 
and the autopsy showed that a calculus was impacted in the 
opposite ureter. The second case was operated upon by Lau- 
enstein in January last and a large calculus removed, the 
patient making a most satisfactory recovery. It would thus 
appear that the danger of nephrolithotomy consists more in 
our uncertainty as to the presence of calculus in the second 
kidney than to any inherent risks in the operation itself. To 
obviate this Mr. Knowsley Thornton operated for the removal 

1 Centralblatt f. Chirurgie, 1882, No. 12. 



NEPHROLITHOTOMY. 7 

of renal calculus by combined abdominal and lumbar sections 
in March, 1885, with complete success, but in this I scarcely 
think, he will find many to follow his example, as from the ex- 
perience afforded by nephrectomy, the abdominal operation is 
much more risky than the lumbar, and the additional risk in- 
curred by opening the abdomen in addition to the opening in 
the loin more than compensates for the additional knowledge 
which may or may not be gained by so doing. 

The great difficulty, however, in nephrolithotomy will al- 
ways consist in the diagnosis. We may fail to recognize the 
symptoms as renal, as in a case reported elsewhere, where a 
woman is said to have had both ovaries removed before her 
troubles were finally dissipated by the extraction of a stone 
from her kidney. Or we may feel perfectly certain of the ex- 
istence of a renal calculus, and yet an exploratory incision 
may fail to reveal it. This has happened already several 
times, and in one case reported in the Transactions of the 
Medico-Chirurgical Society for 1S85, Mr. Henry Morris, having 
failed by manipulation and by the help of an exploring 
needle to detect any stone, excised the kidney and subse- 
quently found a calculus hidden away in one of the calices. 
He recommends that in future instead of excising an otherwise 
healthy kidney, a free incision should be made into it, opening 
up the calices one after an another until the stone is found. 

The case which I have now reported illustrates the fact that 
we cannot rely altogether on the classical symptoms of stone 
in the kidney. The only symptoms which an examination of 
the various cases hitherto published shows to be present in all 
these cases are pain radiating from the position of the kidney 
in the loin, and tenderness on pressure over the kidney. The 
diagnosis in each case has been helped out by other symp- 
toms ; in mine, for instance, by the acidity of the urine and the 
pus it contained, but none of these are constant except the 
pain and the tenderness on pressure. 



THE TREATMENT OF THE WOUND AFTER CAS- 
TRATION. 

By WILLIAM L. AXFORD, M.D., 

OF CHICAGO. 

IN cutting operations on the scrotum, such as castration or 
ablation of the lower portion for varicocele, there is 
always an unpleasant possibility of a recurrent haemorrhage, 
into the causation of which two important factors enter : in the 
first place the dartos, very vascular and readily contracting 
under the stimulus of the knife, again relaxes when the patient 
becomes warm in bed ; secondly, the position and relations of 
the scrotum are such that there is no satisfactory way of com- 
pressing and supporting the wound by bandaging. 

A rather unpleasant experience with a recurrent haemor- 
rhage after castration has led to the adoption of a method of 
wound treatment, for which is claimed security from after 
haemorrhage and an increased probability of primary union. 

Inasmuch as the case is one of considerable interest a brief 
report may be acceptable. 

R. P., colored, set. 26. Had both testicles bruised in July, 1882. 
Pain caused insensibility. Swelling subsided in a few days, and he 
again resumed his work as a coal-heaver. About six months after he 
noticed that the left testicle was enlarged and hardened. Tried all 
sorts of medical treatment. Came under my care at the South Side 
Dispensary in January, 1884, No history of syphilis. Testicle en- 
larged and hard. Some fluid in the tunica vaginalis, cord much hy- 
pertrophied but not roughened or indurated. Epididymis free from 
disease. The other testicle was apparently normal. I beHeved the 
testicle to be the seat of maUgnant disease and advised castraiion. Op- 
eration was performed in the usual manner, skin approximated with silk 
suture, a drainage'tube placed in the wound, and an antiseptic dressing 
applied. I had ligated the cord with silk, en masse. A severe recur- 



TREATMENT OF WOUND AFTER CASTRATION. 9 

rent hEemorrhage occurred within an hour and required styptics to con- 
trol. Even then it was stopped \vith difficulty. Convalescence, though 
much retarded by the accident, was uninterrupted. The testicle was 
the seat of a growth beginning at the centre and involving nearly the 
entire gland. Microscopical examination proved it a sarcoma. 

In October, 1886, he again presented himself with exactly the same 
condition of affairs in the right testicle, and asked me to operate, say 
ing that he had had no comfort for a year. The testicle had com- 
menced to enlarge two months after the first operation. There was 
no return of disease in the left groin. Seeing no other way of reliev- 
ing my patient, on October 18 I again operated, in a small room and 
under the worst hygienic surroundings imaginable. After shaving and 
scrubbing the field of operation the usual incision was made, the tes- 
ticle rapidly enucleated, and the cord transfixed and tied in halves 
with fine carbolized catgut. After the testicle was cut away one or two 
bleeding points were secured with the catgut and all oozing controlled 
by hot water. Beginning at the lower end of the wound, with a small 
glover's needle armed with No, 9 iron-dyed silk, at intervals of three- 
fourths of an inch, sutures were passed at right angles to the line ot 
incision so as to traverse the tissues underlying the wound surface 
and extend completely around and beneath this surface, much the 
same as in laceration of the perineum. The sutures were visible only 
at the points of entrance and exit. The wound was closed in this man- 
ner up to where the cord lies by the side of the penis where it was 
found impracticable. A few interrupted sutures from this point up- 
wards and a few superficial sutures between the long sutures com- 
pletely closed the wound. At the side of the penis a small drainage 
tube was introduced ; gauze, cotton, and a triangle bandage completed 
the operation. At the end of twenty-four hours the drainage tube was 
removed and a fresh dressing applied. At the end of six days it was 
found that primary union had occurred along the entire wound except 
at a point where two sutures that had been too t ghtly tied had cut 
into the wound, causing a small amount of suppuration. There was 
also some pus along the track of the deep sutures. The patient, con- 
trary to my wishes, had spent a considerable portion of h:s timeout of 
bed. All sutures were removed and a rest of a week enjoined, though 
practically the man was well. In again operating I should use aseptic 
sutures, and had perhaps better state that m an operation in the inter- 
val between these two I employed siiver wire after this method, but do 
not hke it, as it cuts more than silk and caused great pain on removal. 
The testicle presented much the same appearance as did the first, the 
microscope agam proving it a sarcoma. 



lO WILLIAM L. AXFORD. 

From a pathological standpoint the case is of much interest 
showing the relation between traumatism and neoplasm, and 
may be cited in support of the theory that single injuries are 
much more liable to produce sarcoma, while continued irrita- 
tion usually results in carcinoma. Exactly why the disease 
developed so much later in one gland than in the other is 
problematical. Possibly the disease had started in the second 
testicle, though at the time of the first operation it could not be 
detected, the irritation of the styptic serving to incite it to 
new activity. 

In conclusion : to obtain primary union and avoid recurrent 
hjemorrhage after the operation of castration. 

I. Observe strict surgical cleanliness. 

II. Ligate the cord with catgut. 

III. Put in aseptic sutures as above described, because : 

a. In the lower and dangerous portion of the wound all 
oozing will be controlled and drainage will be necessary. 

b. The wound surfaces will be approximated and supported, 
primary union favored and recurrent haemorrhage avoided. 

IV. Drainage on the side of the penis alone is necessary. 



CASE OF WOUND OF LARGE IRREGULAR VEIN- 
TRUNK IN GROIN DURING ABLATION 
OF GLANDULAR TUMOR, WITH 
CONSECUTIVE GREAT CEDE- 
MA AND DISABILITY 
OF LIMB. 

By HERMAN G. KLOTZ, M.D., 

OF NEW YORK. 

SURGEON TO THE GERMAN HOSPITAL AND DISPENSARY. 

THE following case is the one briefly referred to by Dr. L. 
S. Pilcher, in his ^memoir on Prophylactic Arterial Li- 
gation, (Annals of Surgery, February, 1886, p. 114) as case 
III, it having been communicated to him by Dr. W. Brown- 
ing. The full description of the case, as subjoined, will show 
it to have possessed special features of interest that make it 
worthy of record, in addition to the ligation of the internal 
saphenous vein, which, as will appear, was not the most im- 
portant of the trunks ligated. The case is as follows : 

Schoenemann, lVvi.\ set. 29, born in Germany, lithographer by 
trade and suffering from gonorrhoea, applied for treatment at the Ger- 
man Dispensary, of New York, February, 1881. 

He presented himself again March 23, 1881, with an indurated 
chancre on the inner surface of the prepuce, and by June 18, distinct 
secondary lesions of syphilis had developed ; angina, roseola, stoam- 
titis. July 6, angina still noticeable ; considerable enlargement of 
lymphatic glands in the groin on both sides and acneiform eruption of 
the face. August 9, inguinal glands much larger ; general eruption of 
small pustular syphilide. 

August 10, the patient was admitted to the German Hospital with a 
papulo-pustular syphilide, general indolent lymphadenitis, an acute, 
painful sweUing of the lymphatic glands in the right groin. After a 
vigorous course of anti-syphilitic treatment all direct symptoms of 
syphilis had disappeared by September 20 ; the buboes on both sides, 

(11) 



12 



HERMAN G. KLOTZ. 



however, had not been favorably influenced, but had increased in size 
with a tendency to acute suppuration; it was, therefore, decided to re- 
move the affected glands by operation. 

September 22, the glands of the right side were first removed in the 
usual manner and without any difficulty. On the left side the tumefied 
glands formed a swelling fully as large as a hen's egg, approaching the 
spermatic cord very closely at the upper and inner aspect of the 
wound. The glands were firmly adherent to the surrounding parts, so 
that they could not be separated easily with the finger or a blunt in- 
strument ; right below the spermatic cord the adhesions were found to 
be particularly firm, so that it became necessary to detach the glandu- 
lar mass by means of traction and short clips with a pair of curved 
scissors, during which manipulation the presence of a large blood-ves- 
sel was discovered in close proximity to the thickened capsule of the 




Fig. 



Irregular Large Superficial Inguinal Vein. 



a. Large vein formed by: — b, Internal saphenous vein; c. Irregular muscular 
branch from outside of thigh, and d\ circumflex iliac vein. 
* Place of rupture of vein. 

Dotted line indicating extent of tumor. 

Ligatur'^s. 



gland. While attempting to get clear of this vessel, and probably in 
consequence of undue traction or manipulation with the closed and 
blunt scissors, the coat of the blood-vessel gave way and through a 
rent about 3 millimetres wide an immense quantity of venous blood 
gushed forth and deluged the field of operation. An attempt to check 
the flow of blood by means of an artery-forceps failed, owing to the de- 
generated condition of the walls of the blood-vessel. Direct pressure 
by means of sponges was then applied, and finally a large rubber 



WOUND OF THE IRREGULAR INGUINAL VEIN. 13 

tube adjusted around the thigh about two inches below Poupart's lig- 
ament stopped circulation and haemorrhage effectually. Now the re- 
maining attachments of the glandular mass were quickly severed and 
the arrangement of the veins was recognized to be as indicated in the 
accompanying diagram. The inguinal vessel proved to be a large 
vein formed by the junction of the internal saphenous vein and an ir- 
regular vein of large size, The former, instead of piercing the femoral 
fascia and descending into the femoral vein, continued a superficial 
course, while the latter emerged from between the fascial layers di- 
rectly over the femoral artery, the pulsation of which could be plainly 
seen and felt. From the posterior aspect of the common trunk 
another vein of medium size could be traced, which was probably the 
circumflex iliac vein. The common trunk, covered only by the lym- 
phatic glands and the superficial fascia took an upward course, and was 
lost to view beneath the spermatic cord. It was thought best to ap- 
ply ligatures not only to the trunk itself but also to the branches near 
their origin (as indicated in the diagram by the lines across the vessels) 
and after removal of the rubber tube the arrest of hemorrhage was 
found perfect. The wound was now dressed with antiseptic precau- 
tion, the extremity showing a shghtly bluish color, but no perceptible 
lowering of temperature, and to avoid any disturbance of the wound 
the patient was kept in the operating room for several days. 

The first change took place September 26 on account of a slight rise 
of temperature and slight oedema of the limb. The wounds were 
found to be in good condition ; no hsemorrhage, no discoloration. The 
oedema was less by September 28 and had entirely disappeared by 
October 16, when the wounds on both sides were found to be healing 
nicely. October 21, owing to inversion of the edges of the skin, cica- 
trization was somewhat retarded, otherwise the wounds showed a 
healthy appearance ; the same was observed October 29. On Novem- 
ber 4 the wounds were healed so far that they required but a strip of 
adhesive plaster as a protection. About this time a marked polyury 
was observed iu the patient withoutincrease of thirst or the presence 
of sugar in the urine. This symptom had disappeared by November 
II, when the patient was allowed to leave the bed. Soon after, how- 
ever, oedema of the whole extremity developed, distending the limb up 
to the hip, whenever the patient remained in the upright position any 
length of time. During the night the swelling would decrease consid- 
erably ; massage and the rubber bandage had no permanent good 
effect: At the expiration of about six months the tendency to oedema 
was still so great that the patient was unfit for any regular work, and 



14 HERMAN G. KLOTZ. 

he thought he would be better off without the limb. I had occasion 
to see the patient once in that condition, but have not met him since. 
I distinctly remember, however, that after several months I was in- 
formed by one of the resident physicians of the hospital that Sch. had 
been employed there as an assistant porter, and that he had been 
able to use his leg fairly well This was confirmed on recent inquiry 
by the superintendent of the hospital and several other parties em- 
ployed there. As Sch., however, was at no time upon the list of reg- 
ular employes of the hospital, I was not able to ascertain the exact 
time when it happened. 

It becomes evident from a glance at the diagram that in the 
case presented we have an irregular distribution of the veins 
of the inguinal region, and while there is no question as to 
the identity of the vena saphena magna, it must remain uncer- 
tain whether the severed vessel emerging from the depth, was 
the femoral vein or only an irregular branch of it, although I 
am inclined to think that the latter view is the most plausible, 
and that a femoral vein of reduced size accompanied the fem- 
oral artery in its normal situation. As the case stands, es- 
pecially if we take into consideration the effect on the circula- 
tion of the lower extremity, it has to be ranged between liga- 
tion of the internal saphenous and ligation of the femoral vein. 
While the oedema, that was observed during the first week 
was undoubtedly due directly and solely to the occlusion of 
the vein, I believe that later on cicatricial contraction and 
pressure upon the newly established circulation had their 
share in causing the more permanent and severe swelling. I 
have observed more or less extended oedema of the limb after 
extirpation of tumefied lymphatic glands and in cases in which 
no larger blood-vessels had been injured, the oedema appearing 
after cicatrization. 



TWO CASES OF OPERATION FOR R/VDlCAL CURE 
OF HERNIA, WITH UNUSUAL FEATURES. 
CASE OF CIRRHOSIS OF PE- 
NIS. REMARKS.^ 

By GEORGE A. PETERS, M. D., 

OF NEW YORK, 
SURGEON TO THE NEW YORK, ST. MARY'S AND ST. LUKE's HOSPITALS. 

MICHAEL M'GOWAN, Ireland, was admitted into St. Luke's 
hospital. May 4, 1885, with double inguinal hernia, that upon 
the left side being much the larger of the two. Twelve years ago, 
while lifting a child at arm's length, he felt something "give way." 
There was but little pain, although a small lump was observed in the 
left groin. A physician whom he consulted pronounced it to be her- 
nia, and directed him to wear a truss, which he did for about two 
years, after which time, as he experienced no pain or inconvenience 
and the tumor was very small, he discontinued its use. Three years 
ago, while Hfting a heavy weight, the tumor immediately became much 
larger, and was attended with sharp pain in the lumbar region, for 
which he remained in bed for a week or two ; since this time he has 
never been able to hold up the hernial swelling \vith any truss which he 
could procure. 

Eight years ago he came violently in contact with a " sharp corner," 
and a small bubonocele appeared in the right groin. This gave him 
no trouble until he lifted the heavy weight three years ago, after which 
time both his herniae became larger and painful. For the year or two 
past he has grown very fleshy. Summing up, this is his condition on 
admission to hospital, viz: On the left side is a large, indirect inguinal 
hernia easily reduced, except a small knuckle of intestine apparently 
adherent to the sac. The pillars of the ring are readily defined and 
very much spread, easily admitting four fingers. On coughing or 
straining, a large mass of intestine comes down, measuring three to 
SIX inches. 

1 Read before the New York Surgical Society, November 6, 18S6. 
(15) 






1 6 GEORGE A. PETERS. 

The inguinal ring upon the right side easily admits two fingers, and 
the edges are sharply defined. On coughing, only a small bubonocele 
comes down. 

Family history and general condition good, except that he had been 
drinking ft-eely of spirits for some time. 

As he suffered so much from the size of the tumor, and the fact that 
he could not wear a truss, I determined, after consultation with my 
colleagues, to perform Banks's operation for the radical cure of the her- 
nia in the left groin. 

On May yth the patient was put upon the table for operation, and 
with much delay brought under the influence of ether. During almost 
the entire time of the inhalation he vomited, coughed, and struggled, 
so that it made the operation one of great difficulty. 

A free incision was made through the skin, commencing just above 
the level of the external abdominal ring, and the dissection carried 
carefully down, layer by layer, until the sac was exposed and the pillars 
of the ring were brought distinctly into view. The ring was very large 
and patulous, easily admitting four fingers. The hernia was now re- 
duced by gentle taxis, leaving the collapsed sac in the wound. The 
cord was found behind and well out of the way. The sac was now 
opened and a knuckle of gut was found closely adherent to its wall 
just at a level with the ring. It was not deemed prudent to attempt 
its separation, and it was left as found. The opening in the sac was 
now carefully and with much difficulty stitched to the pillars through 
and through with stout catgut, and the ring closed. 

Owing to the restlessness of the patient under ether and frequent 
attacks of vomiting, the bowels were forced down in a large mass and 
spread out upon the outside of the belly. 

The protruding bowel was carefully guarded with towels and sponges 
wet with hot water. This stage of the operation was exceedingly diffi- 
cult and prolonged. It was, however, finally accomplished. A great 
portion of the sac was now dissected out, two bone drainage-tubes 
were introduced, and the wound was closed with carbolized catgut and 
an antiseptic dressing placed over all. During the escape of the bowel 
the pulse sank very low, and he suffered very much from shock, but was 
finally restored by brandy, ether, and digitalis hypodermically adminis- 
tered. 

The patient suffered very much from nausea, pain, and tympanites 
for a few days after the operation ; but these symptoms gradually sub- 
sided. The wound did not heal throughout its whole extent by first 
intention, but remained open at the two angles, gradually filling up 
with granulations until June 17, 1885, when he was dischared cured. 



OPERATION FOR RADICAL CURE OF HERNIA. 1/ 

Alice Surminski, Ireland, aet. 50, married, was admitted into St. 
Luke's Hospital, January 22, 1886. Six years ago, after lifting a heavy 
weight, she noticed a small lump in the right groin. Finding that it 
did not disappear after a few days, she entered Roosevelt Hospital, 
where she was treated for a short time, but no operation was done. 
Ever since that time she has felt a weakness in the right groin, and 
on exertion a tumor would appear, which could be reduced. She has 
never worn a truss. 

Ten days ago, after a severe strain, the tumor appeared, was painful, 
and increased in size. The bowels were constipated, and she suffered 
somewhat from nausea. On admission, examination revealed a tumor 
in the right groin below the inner third of Poupart's ligament, globular 
in shape, about one inch in diameter, elastic to the feel, slightly pain- 
ful on pressure, and dull on percussion. 

A portion resembling a pedicle extended down toward the femoral 
canal. Before admission attempts had been made to reduce it by 
taxis, but without success. The attempt was renewed after admission 
with no result, except to occasion local inflammation and considerable 
pain. She was ordered strict decubitus and the cold coil was applied. 

The tumor was considered to be an incarcerated femoral hernia; 
contents chiefly omentum, and after consultation I determined to per- 
form Banks's operation, hoping to make a radical cure. 

On February 5, 1886, she was put on the table, ether was adminis- 
tered, and she was quickly brought under its influence. The integu- 
ment of the groin and neighborhood was shaved, scrubbed and ren- 
dered aseptic. An incision about two inches long was made over the 
convexity of the tumor and the dissection was carefully made down to- 
ward the sac. The connective tissues in this neighborhood were matted 
together, thickened, and extensively adherent to the sac itself. These 
adhesions were carefully dissected away and the sac was opened, allow- 
ing the escape of some yellowish fluid. When brought into view, the 
contents of the hernial sac were found to be a sheet of omentum en- 
veloping about three inches of the vermiform appendix, the distal por- 
tion of which was doubled upon itself, allowing the knuckle thus 
formed to project above the omentum, resembling a gland, for which it 
was indeed mistaken until the unraveling of the tissues determined its 
true character. The contents were adherent to the sac, but were dis- 
sected free, and the vermiform appendix and omentum were separated 
down to the ring, where each was separately ligated with stout catgut 
and cut off. The portion of the appendix vermiformis removed was two 
inches and a half long, and of about the size of a goose-quill. The 



1 8 GEORGE A. PETERS. 

sac was now tied off, and, with the stump which was left just at the 
femoral ring, was stitched through and through with catgut. A rub- 
ber drainage-tube was now inserted to the bottom of the wound and 
the skin closed over with fine catgut suture. During the operation the 
wound was frequently irrigated with a solution of bichloride of mer- 
cury, I to I, GOO. The dressing was iodoform gauze and a spica band- 
age. 

The first dressing was not disturbed until February loth, when the 
drainage-tube was removed, there being perfect union, except where 
the tube emerged. During the progress of the cure a small collection 
of pus occurred which somewhat delayed the healing. 

She was discharged cured March 9, 1886. 

Early in May, 1883, a gentlemen, Mr. S , set. 65, presented himself 
with a condition of the penis to which I had never seen a parallel. 
For more than two years past he had complained of pain in that 
organ, and changes in structure had taken place which occasioned 
him much mental worry, and made him decidedly hypochondriacal. 

On examination, I found the glans and body of the penis, for about 
an inch from the end, hard and unyielding to the touch. The prepuce 
was very hard to the feel, inelastic, and embracing the glans very 
closely; it could not be drawn back sufficiently to expose it. The 
portion of the glans penis which could be exposed had the same hard 
feel, and was mottled with two or three small, red, smooth spots not 
ulcerated. Pain, although not severe, had been a constant symptom. 
There was also much itching and burning. 

His general health had been considerably affected, but apparently 
more from mental agitation than from actual disease. The organ was 
not increased in size. There was no syphilitic or glandular taint. 

Fearing that, if left unaided, it might degenerate into epithehoma, I 
determined to amputate the penis, which was done May 9, 1883. 

The operation was done about one quarter of the distance behind 
tlie corona glandis with a circular sweep of the knife. The urethra 
was then dissected out, drawn forward, and stitched with fine sutures 
to the skin, in order to prevent retraction. The wound healed verj' 
kindly, and he returned to his home in the country, May 2 2d, thirteen 
days after the operation. 

The specimen was handed to Dr. Frank Ferguson, pathologist, who 
made the following report : 

"Examiration of the penis from amputation by Dr. George A. 
Peters, on May 9, 1883. 

"The organ was amputated just behind the corona glandis, the pre- 



OPERATION FOR RADICAL CURE OF HERNIA. 1 9 

puce being also removed. The meatus is small, admitting only a No. 
15 French sound, and the tissues around it are anaemic and of a pe- 
culiar transparent color. The urethra behind the meatus bears the 
normal relation to a penis of this size. The mucous membrane cov- 
ering the glans and inner surface of the prepuce is normal. There is 
a zone of inflammation products in the prepuce and glans throughout 
their entire extent, and, although generally a considerable distance 
from the surface (in the glans along the periphery of the corpus caver- 
nosum), in places there extend from the inflammatory zone limited 
areas which reach the mucous surface. This zone is composed of 
small round cells (young cells) ; in places accumulations of considera- 
ble size are seen, as in the formation of abscesses, but nowhere is seen 
any tendency to break down. Some of the blood-vessels in the neigh- 
borhood of this zone of young cells are filled with similar small round 
cells, while the vessels which pass up through the diseased parts to the 
mucous membrane are empty. The vessels of the corpora cavernosa 
are generally distended with blood. 

^''Diagnosis. — Inflammation of the submucous tissue of the glans 
penis and prepuce. 

'■'■Note. — I. The inflammation is extensive, its products found at the 
line of incision in the amputation. 

"2. There are no epithelial cells found in the glans or prepuce be- 
neath the mucous membrane, nor anything indicating carcinoma or 
sarcoma. 

"3. There has been general pressure on the vessels and nerves by 
the inflammatory products." 

On presenting the.se two cases of operation for the radical 
cure of hernia, I desire to call attention to complications oc- 
curring in both of them. In the case of McGowan, who took 
ether badly, on opening the sac, a large mass of intestines 
was forced, by his efforts to vomit, through the distended and 
flabby ring, and was a source of much embarrassment and 
considerable danger until it was returned to its home. The 
principal assistant should guard very carefully the open ring 
and head off the first attempt at escape. The danger from 
shock will be much lessened if the truant gut is kept carefully 
protected by hot wet sponges. 

In the case of femoral hernia, a complication presented — 
namely, the appendix vermiformis — which I do not remember 



20 GEORGE A. PETERS. 

to have seen in any hernial sac which I have opened. In 
this case it was, when first seen, supposed to be a gland, but 
as the mass was unrolled its identity was established. As the 
hernial mass was adherent to the neck of the sac, it was de- 
termined to ligate the entire protrusion so that it might act as 
a plug. On examining the appendix after its removal, it was 
found to be pervious down to the very tip, but contained no 
faecal matter. The wound of operation healed kindly, and the 
presence of the divided appendix seemed in no way to retard 
the cure. 

Of all the methods which have been adopted for the radical 
cure of hernia, the one described above and introduced to the 
notice of the profession by Banks, of Liverpool, is the most 
rational to the student and captivating to the surgeon. 

The experience which most of us have had with the opera- 
tion of Heaton by injection and with the needles and wire has 
not, I will venture to say, been so satisfactory as to convince 
us that nothing better can be devised. 

The methods of procedure adopted vary according to the 
theories or experience of different surgeons. Some use the 
silver wire, others aseptic silk thread, and others again carbol- 
ized catgut. The result of my experience and observation in- 
clines me to advocate the catgut properly prepared so that it 
will not dissolve too readily. 

Union by first intention in the wound is not so desirable as 
might at first seem. A sufficient amount of inflammation to 
procure a dense thickened mass of tissue, provided this is the 
result of suppuration and granulation about the ring and 
canal, is to be preferred. 

That the operation is a reasonably safe one is, I think, 
proved by the results already obtained. When the cases are 
properly selected and the operation is done Avith all modern 
precautions, the percentage of recoveries is as large as in the 
cases reported by Banks and others abroad. Even when such 
precautions are not observed, the statistics show a death-rate 
of only one in eight. 

In cases where the hernia is large and subjects its owner to 
much pain and discomfort, where it can not be entirely re- 



OPERATION FOR RADICAL CURE OF HERNIA. 21 

turned or, if returned, can not be kept in place with a truss, 
this operation is indicated. Even if it should not result in a 
perfect cure, the patient will be so much improved as to be 
able to wear a truss with comfort and become again a bread- 
winner. 

The case recorded above in which I resorted to amputation 
of the penis is unique in my experience. Dr. Ferguson also 
states that it is the first of the kind which has been brought to 
his notice. The operation is to my mind justified by the fact 
that Mr. S. is now in good health, and there has been no ex- 
tension of the disease. The relief to his mental condition 
would in itself sanction the operation. 



EDITORIAL ARTICLES. 



THE SURGICAL TREATMENT OF PERITONITIS. 

An important monograph upon the surgical treatment of peritonitis 
by Dr. H. True, of Lyons,' has recently appeared. Its scope is more 
extensive than that of the memoir of Mikulicz,- already reviewed in 
these pages,* for it includes a study of almost every variety of peri- 
tonitis, collecting the many facts scattered through the current periodi- 
cals. 

It is written from an unusual standpoint, the author beheving that in 
any case the peritonitis is the principal indication for treatment ; if, in 
developing our therapeutic attack, we find the cause of the peritonitis 
still existent, we should treat that also. 

True rejects the division of purulent peritonitis into septic and 
aseptic; "purulent peritonitis is more septic or less septic, but it does 
not appear to be sometimes septic, sometimes aseptic." Both chni- 
cal and experimental studies support this view, giving a graduated 
series, puerperal peritonitis and the forms due to fecal extravasation 
being the most septic of all. 

Simple peritonitis without effusion^ showing pathologically only a 
congestion of the membrane, does not encourage surgical interference. 
Knowsley Thornton, whc has operated twice in this condition without 
success, holds that the operation will be justifiable only when we can 
by it in some way diminish the peritoneal congestion.* 

The fatality of puruletit peritonitis is too well known to need the 
repetition here of Kaiser's^ statistics. These cases were formerly 

'"Traitement chirurgicale de la peritonite." These de cone, pour 1' agi-egation, 
Paris, 1886. 
^Volkmann's Samml. klin. Vortrage, No. 262. 
*Ann. Surg., May, 1886, p. 386. 
*Brit. Med. Jour., 1885, I., 538. 
'Deutsche Arch. f. kUn. Med., 1876, XVII., 74. 
(22) 



SURGICAL TREATMENT OF PERITONITIS. 23 

treated by puncture or incision when they pointed as abscesses. Dis- 
satisfied with the results thus obtained, the modern surgeon prefers 
laparotomy, and eight successful cases of this operation f )r general 
simple peritonitis are already on record — those of Tait,' Elias,^ Stu- 
densky,^ Kronlein,^ Bertels,^ of St. Petersburg), Caselli," Schmidt(Cen- 
tralbl. f. Chirurgie, 1882, p. 772) and Valerani (ibid, 1886, p. 269), 
unless the last is to be considered a local peritonitis. Against these 
are to be placed three failures — the cases of Morrant Baker,' Samuel 
West,* and Wade,* in all of which the operation was undertaken with 
the patient in collapse and death occurred within twenty-four hours. 
As True remarks, these statistics are too incomplete and the totals too 
small to be of any value ; but a careful study of the successful cases 
shows that immediate improvement followed the operation, while the 
result could hardly have been other than fatal had the disease been 
left to its natural course. True formulates his conclusions thus : Sup- 
puration in the peritoneal cavity should be treated like suppuration in 
the pleural or articular cavities ; the results will correspond to the 
promptness and thoroughness of the treatment ; and laparotomy is the 
best treatment, for it allows thorough evacuation of the pus, careful 
cleansing of the cavity, the destruction of adhesions (which may en- 
capsule small collections of pus) ; the removal of exudation and per- 
fect drainage. Laparotomy, moreover, allows thorough examination 
of the whole abdomen and may result in the discovery and removal of 
the cause of the inflammation. 

In stxxdymg puerperal peritonitis we must first exclude the hyper- 
acute form which terminates life in two or three days, or even in a few 
hours, for this form is merely a local manifestation of a severe general 
septic infection, and allows of no treatment. Fortunately, in most 

ifirit. Med. Jour., 1883, I., 304. 

2Rev. des sciences med. (Hayem) 1882, II., 682. 

3Centrall)l. f. Chir., 1886, p. 172. 

*Arch. f. klin. Chir., 1S86, XXXIII., 518. 

^Quoted by Dupaquier, Th. de Paris, 1885, No. 233. 

^Lemaine medicale, 28 avril, 1886, p. 179. 

^Lancet, 1885, II., 950. 

«Ibid. 

^Lancet, 1886, I., 343. 



24 EDITORIAL ARTICLES. 

cases of puerperal peritonitis the peritoneum becomes first affected 
and there is time to remove the dangerous material before absorption 
and general systemic infection occur. True divides the modem treat- 
ment of puerperal peritonitis into three varieties — prophylactic, pal- 
liative and curative. The first has accomplished wonders, and puer- 
peral peritonitis is now an uncommon disease. The palliative treat- 
ment, however, is of litde importance ; and curative, that is, surgical 
treatment, gains ground daily in the favor of the profession. He finds 
two indications for treatment — excessive tympanites and effusion into 
the peritoneal cavity. 

DepauP first successfully treated tympanites by capillary punctures 
and his case entirely recovered. The experience of surgeons with this 
method has not been encouraging, for the relief has been only tempor- 
ary. We would add that it is also a question whether capillary punc- 
tures, no matter how carefully the operation is done, is so free from 
danger as True and the other advocates of the method would have us 
believe. An extraordinary ease, showing the great advantages to be 
gained by relieving the tympanites in some cases, is that reported by 
Reibel,^ of which we give a summary, as the original account is not 
easy of access : A girl, aet. 8, was attacked by general peritonitis, 
and death seemed at hand, when on the 19th day of her illness, Reibel 
performed median laparotomy, but found neither pus nor gas in the 
peritoneal cavity. The intestines were adherent and an accidental 
wound was made in the gut, from which issued fedd gas and fecal mat- 
ter. The wound was dressed, but not sutured. The next day im- 
provement was manifest, and a stool occurred. Slow recovery took 
place. As True remarks, this was a happy .chance, and the case 
teaches nothing except the improvement obtained by providing for a 
permanent escape for the gas. 

In this connection the following rare ease (of which we were wit- 
ness, and which we publish by the kind permission of the operators) is 
of great interest; July 30, 1884, Dr. T. Gaillard Thomas, assisted by 
Dr. James B. Hunter, performed laparotomy upon a woman, ast. 35, 

'Gaz. hop., Paris, 1871, p. 335. 

^Gaz. med. de Strasburg, 1883, p. 2 — quoted by True, p. 75. 



SURGICAL TREATMENT OF PERITONITIS. 2 5 

for a fibro-cyst of the uterus. The cyst was incised, the edges of the 
opening sewed to those of the abdominal wound, and a glass drainage- 
tube inserted in the cyst cavity. Careful toilet of the peritoneum was 
made, the rest of the abdominal wound closed without drainage, and 
a light antiseptic dressing applied. Dr. Hunter then took charge of 
the case. The cyst cavity was irrigated daily, and rapidly contracted. 
The temperature, 10372° at first, fell to normal by August 7; the 
pulse remaining throughout at 110 to 120. Some tympanites existed 
from the beginning, but on Augut 10, after a sudden movement by 
the patient, it began to increase rapidly. Great dyspnoea and cya- 
nosis came on, and early on August 12 the patient lay at the poiat ot 
death, making only four gasping respirations per minute. Dr. Hunter 
then inserted the small needle of an aspirator in the median hne 
above the umbilicus and gave issue to a strong jet of odorless gas, 
which lasted for an hour, reducing the enormously distended abdomen 
to normal dimensions. Very fetid flatus was soon after passed per 
anum. The tympanites did not return, and speedy convalescence fol- 
lowed. It seems almost certain that the gas in this case was con- 
tained in the peritoneal cavity and not in the intestines. 

The second indication, the removal of the peritoneal effusion, may 
be met by simple puncture when the fluid is serous, but more energetic 
methods are needed when it is sanious or purulent. True has col- 
lected eight cases of the purulent form treated by puncture or small 
incision ; one case of evacuation by the bistoury through Douglas' cul- 
de-sac, and five cases of laparotomy — those of Bojie,' Kaltenbach,^ 
Playfair,* Molokendoff",* and Sonnenburg.^ Sonnenburg's case can 
only be included by a litde forcing, as the operation was done for a 
general peritonitis set up by a puerperal perimetritic exudation. Only 
one death occurred in all fourteen cases — Molokendoff^s, and it seemed 
to be due to carbolic acid poisoning. True then relates the histories 
of two hitherto unpublished cases of laparotomy for septic puerperal 

iSchmidt's Jahrb., 1877, CLXXV., p. 173. 

2Gynecologie operatoire, 18S5, p. 412. 

3Brit. Med. Jour., 1883, 1., 455. 

■*Rev. de sciences med. (Hayem), 1883, II.. 266. 

^\rch. Tocologie, 1885, p. 381. 



26 



EDITORIAL ARTICLES. 



peritonitis done by Bouilly at a more acute stage in the malady than 
any yet recorded. 

The patients developed peritonitis on the second day after normal 
labors. In spite of the use of intra-uterine douches the patients grew 
worse, and laparotomy was done on the fifth and sixth days (respect- 
ively) after their confinement. The peritoneal cavity contained in one 
case some "yellowish, viscous" fluid, and in the other a large amount 
of sero-purulent fluid, and in both cases was irrigated with a weak bi- 
chloride of mercury solution. Death occurred in one case in fifteen 
hours after the operation, and in the other in three hours. 

Bouilly thinks that his operations were practiced too late. He holds 
that one should not wait for the formation of peritoneal effusion, or 
for high fever, but act as soon as tympanites, great iliac or pelvic pain, 
and a marked systemic reaction are observed, only bearing in mind 
that the first two symptoms are uncertain and may disappear spon- 
taneously. We venture to suggest that in this difficult situation an 
important indication as to our action would be furnished by the effect 
produced by the intra-uterine douche. If its effect is decidedly bene- 
ficial, laparotomy would be unnecessary ; but if little or no improve- 
ment is noticed during the use of the douche for twenty-four hours, it 
would be evident that disaster was impending, and laparotomy must be 
resorted to as a forlorn hope. 

It seems to us, moreover, that this very treatment of puerperal sep- 
ticaemia by intra-uterine injection furnishes the strongest argument by 
analogy in favor of laparotomy and peritoneal irrigation in puerperal 
peritonitis. We are chnically familiar with the wonderful effects often 
produced by these douches, and in spite of the risk which attends 
them, they are now universally employed. Why are we not justified in 
assuming in severer cases the greater risk of applying similar treatment 
to the peritoneal cavity? We agree that it is necessary to remove 
from the uterine cavity all material which may by its presence there 
add to the septic infection already existing — whether we believe that 
material to contain infecting micro-organisms and the soil they flourish 
in, or hold some more intricate theory of septic infection. At all 
events, it has been demonstrated that the peritoneal effusion contains 



SURGICAL TREATMENT OF PERITONITIS. 27 

the same micro-organisms and other constituents which are found in 
the uterine contents, and the conclusion logically follows that the peri- 
toneal effusion should also be removed, or at least exposed to the 
action of the chemicals used in antiseptic injections. This seems to 
us a far closer analogy than the one suggested by True — the curetting 
of the axilla in cases of septic lymphangitis originating in the finger. 
Passing to the peritonitis caused by 7ion-traumatic perforation of the 
stomach and intestine, we find in this memoir three cases hitherto un- 
pubHshed: Robert — peritoneal abscess, near umbilicus, puncture and 
drainage, recovery ; Reynier — symptoms of intestinal obstruction for 
five days, laparotomy, purulent peritonitis, but no obstruction found, 
death in seven hours, autopsy showed perforation of ccecum ; A. Pon- 
cet — case identical with last, except that the autopsy showed gangrene 
of the vermiform appendix without any recognizable perforation. 
Confining ourselves to the cases treated by laparotomy, we find that 
True has collected three besides the above — the case of Chapnut and 
LeFort,^ and the two of Kronlein.- To these should be added the 
cases of Polaillon'' and Mikulicz,* making a total of seven. In five of 
these cases the operation was done under the diagnosis of intestinal 
obstruction. In four the perforation was not found during the opera- 
tion. In all seven the operation was performed after a delay of from 
three to ten days, and too late to be of service, unless we hola that 
some might have been saved if the perforation had been found. But 
it is this very delay which renders the proper examination of the ab- 
dominal contents so difficulty. Certainly, if there is anything to be 
learned from these cases, it is the fact that intervention, to be useful, 
must be undertaken early. True counsels against laparotomy m cases 
of typhoid, dysenteric and tuberculous ulcers, on account of the feeble 
condition of the patient usually found in these maladies, but the atti- 
tude of Mikulicz appears to us the correct one — to operate in every 
case of perforative peritonitis, if the patient is not already in a state of 



'Progres med., 1883, p. 103. 
2Arch. f. Klin, chir., 1886, XXXIII., 514-522. 
^L'Union med., 1884, XXXVII.. p. 14. 
*Saminl. kl. Vortrage, No. 262, p. 2313. 



2-8 EDITORIAL ARTiCLES. 

collapse, and at an earlier date than has as yet been the custom. 

In peritonitis from the rupture of abscesses into the peritoneal cavity 
True quotes the successful cases of Tait/ Treves,' and Israel,^ and we 
might add to them the case of Burchard^ (although in it the rupture 
took place just as the abscess was incised, and laparotomy was done 
at once), all showing that laparotomy and thorough cleansing of the 
peritoneum can save the patient. 

Rupture of ovarian cysts and of the fcetal cyst in extra-uterine preg- 
nancy demand immediate laparotomy, but if delay occurs and peri- 
tonitis develops, it is no contraindication to the operation. 

Of peritonitis with strangulated hernia True has found two cases 
treated by herniotomy and drainage — Horsley's,^ local peritonitis, re- 
covery ; and Godlee's,*^ general, death. He gives three cases treated 
by laparotomy by Ceci,'' Israel,^ and Oberst f to which we would add 
those of Desnos,"' Fitzgerald," and Hall'- — six in all, if we admit Israel's 
case. In all, the abdomen was opened by extending the incision for 
herniotomy. In Israel's case the peritonitis was caused by a peri- 
typhlitis, strangulated hernia complicating — recovery. Desnos' and 
Ceci's cases had perforation of the small intestine, not discovered 
until autopsy. Oberst found perforation of the small intestine, and 
made an artificial anus — death. Fitzgerald found and sutured a per- 
foration — death. Hall found perioration of the vermiform appendix ; 
and resected the latter — recovery. Although only Israel and Hall 
saved their patients, we may safely deduce from these cases (with 
True) the necessity for an exploration of the abdomen whenever, in 



'Brit. Med. Jour., 1S83, I., p. 303. 
-Lancet, 1885, I., 475. 
aSemaine med., 1884, p. 159. 
^N. Y. Med. Jour., 1885, II,, 173. 
^Med. Times, Lond., 18S5, II., 431. 
«Med. Times, Lond., 1885, I., 678, 
^Gaz. med. di Roma, 1883, No. 17, 193. 
^Semaine medicale, 1884, 159. 
"Centralblatt f. Chirurgie, 1885, 345. 
'OBul. Soc. Anat. de Paris, 1879, LIV., 571 
'lAustralian Med. Jour., 1883, V., 264. 
12N. Y. Med. Jour., 1886, I., 662. 



6- UK GICAL TREA TMENT OF PERU ONI J 1^. 29 

the operation of herniotomy, that cavity is found to contain purulent 
or septic fluid. This may be done by enlarging the incision upwards, 
or by median laparotomy. The case of Oberst, in which death seemed 
to be due partly to innutrition on account of the artificial anus, partly 
to the existence of many small collections of pus encysted between the 
folds of the peritoneum, emphasizes the necessity of thorough explora- 
tion of the abdomen, which can only be carried out by median lapa- 
rotomy. But if haste is necessary, as in Hall's case, his example 
might be followed, and the adhesions broken down by the hand intro- 
duced upwards through the incision in the iHac region. 

It is fortunate that the results of laparotomy for intestinal obstruc- 
tion are so satisfactory, considering the impossibility of distinguishing 
it from perforation of the intestine, for one can operate at once with 
the knowledge that the treatment is suitable to either condition, and is, 
moreover, curative for a peritonitis dependent upon intestinal obstruc- 
tion. Even septic peritonitis is not a contraindication. In lapa- 
rotomy for intestinal obstruction, a careful toilet of the peritoneum is 
necessary, but drainage may usually be dispensed with. 

\n perityphlitis True favors early operation (as soon as pus can be 
detected), but not so early as is urged by Bull,^ Fitz,^ and others. The 
modern tendency seems to be in the direction of explorative opera- 
tion — even laparotomy, without waiting to discover pus. The inroads 
of Tait's operation upon the old theories oi pelvic peritonitis have 
thrown the pathology of that afiection into such an uncertain state as 
to make it impossible to reach any satisfactory conclusions at present, 
and omitting Truc's views upon it, we will give his deductions from a 
study of localized peritonitis in general. They are briefly these: (i). 
Serous or hemorrhagic cysts require treatment only when they are of 
large size or when their contents become purulent. (2). Purulent 
encysted peritonitis demands prompt evacuation of the pus, the smaller 
cysts adherent to accessible parts of the abdominal wall being treated 
by simple incision ; those not so placed, the large collections and all 



IN. Y. Med. Record, 1886, I., 265 (and disscusion, 285). 
-Am. Jour. Med. Sciences, 1886, II., 321. 



30 EDITORIAL ARTICLES. 

cases in which the diagnosis is uncertain being treated by laparotomy. 
(3). Tendency to external spontaneous opening should hasten the 
operation ; but if discharge takes place into any of the hollow organs, 
the surgeon may wait, holding himself ready to operate at once in case 
of retention of pus, functional disturbance of any kind, or deteriora- 
tion of the general condition of the patient. This last conclusion ad- 
mits of some criticism, for in most cases of such internal opening, the 
danger of septic infection is so great that one would not be disposed 
to blame the surgeon who should make an external incision at once. 

\xi peritonitis after surgical operations upon the abdomen, the ad- 
mitted treatment is to at once supply free issue to septic or purulent 
collections by drainage and irrigation, thus removing all danger of gen- 
eral infection. But Terillon^ has shown (and we might in this connec- 
tion also refer to Engelmann's paper on "Insidious Septicaemia")'- that 
this peritonitis often develops with obscure symptoms — vomiting, 
pain and even anxiety being frequently absent ; tympanites is the most 
constant symptom. This obscure form of peritonitis, however, a form 
without any effusion into the cavity, does not yield to any treatment, 
and its recognition is as yet of no practical importance, for the sur- 
geon is powerless against it. 

Truc's study of traumatic peritonitis caused by wound or rupture of 
stomach or intestine is not very satisfactory. His list of cases is far 
from complete, and he (and Mikulicz also) does not at all consider the 
question of explorative laparotomy. He says of these cases: "When, 
in the absence of an external wound, the diagnosis is uncertain, medi- 
cal treatment is alone suitable," admitting surgical intervention only 
when the doubt has been removed by the development of peritonitis. 
In many cases of simple contusion of the abdomen without visceral 
injury, the symptoms are as severe at first as in the cases with rupture 
of the stomach or intestines, and the diagnosis is impossible until peri- 
tonitis develops. Even the loss or persistence of dulness on percus- 
sion over the liver is not a thoroughly reliable sign. In penetrating 
gun-shot and pistol-shot wounds of the abdomen the successful cases 

iBuU. therap., 1883, CIV., p. 175. 
^Trans. Am. Gynecol. Soc, 1884, p. 259. 



SURGICAL TREATMENT OF PERITONITIS. 31 

already on record show that the surgeon is justified in performing lapa- 
rotomy before peritonitis sets in, for he may be confident that he will 
find a wound of the stomach or intestines in almost every case. The 
only contra-indication would be the probable existence of a wound of 
the liver with severe hemorrhage. 

It is true that the successful cases of Bouilly^ and Mikulicz- (as well 
as the non-traumatic cases of Kronlein, Hall and others, already 
given), prove that peritonitis with fecal extravasation may be success- 
fully treated by laparotomy. But this is so much the exception that it 
seems to us to be one of the tasks of modern surgery to give explora- 
tive laparotomy a trial in certain cases of contusion of the abdomen, 
in order to gain for these cases also the advantages found in perform- 
ing laparotomy for gun-shot wounds of the abdomen before peritonitis 
has developed. 

Dennis,-'' indeed, would apply the principle of exploring the abdo- 
men to every injury in which it was piobable that intestine or stomach 
had been wounded. He performed explorative laparotomy in one 
case ot penetrating stab-wound of the abdomen, without finding any 
injury of the viscera, and his patient made an excellent recovery, thus 
giving the theory the support of one case to show that the operation 
does not necessarily endanger life. 

True is an earnest advocate of explorative laparotomy, however, 
in cases of purulent peritonitis, and we may fittingly close with his 
own words : " The opening of the abdomen has lost much of its 
gravity, and we believe that we have demonstrated that certain forms 
of peritonitis can be cured by opportune and methodical surgical 
treatment; that is enough to condemn systematic refusal to operate. 
* * * Instead of continuing to be a contra-indication, it (peritoni- 
tis) should become a positive indication. Death, in the cases of 
which we speak, is certain. We have seen that the operation may 
save the patient. Why hesitate to give the latter some chance of re- 
covery?" B. Farquhar Curtis. 

iBull Soc. de Chir., Paris, 1883, IX., 698. 
^Samml. klin. Vortrage, No. 262, p. 2315. 
3Med. News, Phil , 1886, I., 225, 253. 



32 EDITORIAL ARTICLES. 

KUEMMELL ON HIGH-LYING STRFCTURES OF THE RECTUM. 

A paper on this subject recently read before the Hamburg Medical 
Society^ by Dr. Hermann Kiimmell will be found interesting and in- 
structive, as the subject deserves more attention than is usually 
accorded it. Under the term " high-lying strictures of the rectum " 
the author does not mean, generally speaking, all strictures of the 
upper portion of the rectum caused by the pressure of intra-pelvic 
growths or inflammatory products, or brought about by displacement 
or adhesion of the rectum to other organs, nor stenoses resulting from 
mahgnaijt or benignant neoplasms. On the contrary, the term is ap- 
plicable only to a certain group of cicatricial strictures caused by 
ulcerative processes consequent to chronic infectious diseases. 

Strictures situated lower down in the rectum are, as a rule, easy of 
diagnosis by means of simple digital exploration. In this respect 
those lying higher up differ greatly, not being accessible to the sarne 
means of examination. The author includes also among these latter 
strictures those found in the sigmoid flexure. The lowest boundary 
for these high-lying strictures should be placed at about 12 ctm. above 
the anal opening, the uppermost at about 35 ctm., which would cor- 
respond to the junction with the descending colon (counting 15 ctm. 
for the rectum and 20 ctm. for the sigmoid). Ferret collected 60 cases 
of strictures, examined in the cadaver, and it is interesting to note the 
relatively small number of high-lying strictures among the number. 
In 4 cases the strictures originated in the anus, in 32 cases below 6 
ctm., in 3 cases at about 6 ctm., in 7 between 6-9 ctm., in 5 cases 
over 9 ctm. above the anus, and in 6 cases the point of union of rec- 
tum and colon was the seat of trouble. In 4 cases several strictures 
were found. 

Two chronic infectious diseases, namely, dysentery and syphilis, are 
the chief causes, etiologically speaking, for this trouble ; catarrhal 
ulcerative processes the more seldom. But in rare instances tubercu- 
lous processes may give rise to strictures of this kind, as demonstrated 
by the author in a very interesting case. 

'Volkmann's collection ol clinicallecturcs, No. 265. (Chirurgie, No. 8S). 



HIGH- LYING STRICTURES OF THE RECTUM. 33 

The patient was a man, aet. 25, in whom the symptoms of a disease 
of the rectum developed consecutive to an obstinate catarrhal inflam- 
mation of the intestines. Heart and lungs were normal, but on ex- 
ploration of the rectum with the hand, a stricture about 14 ctm. above 
the anus was discovered. The flat tumor-hke mass causing the strict- 
ure, involved about two-thirds of the circumference of the intestine 
and was adherent to the sacrum. Patient was placed under anti-syph- 
ilitic treatment and dilatation of the stricture begun by means of 
bougies. Improvement was steady for some three months, when he 
began to complain of increasing pain in the loins. A deep-lying, visi- 
bly-fluctuating abscess on both sides of the sacrum was discovered 
and incised, releasing a large quantity of purulent matter. Nearly the 
whole of the posterior and the lower part of the anterior surface of the 
sacrum was carious. Patient became rapidly weaker, symptoms of 
general tuberculosis appearing. Death fifteen months after com- 
mencement of the rectal disease. In the autopsy the stricture was 
found almost completely dilated. The cavity of the sacrum was cov- 
ered with firm cicatrices and numerous tuberculous ulcers, the intes- 
tines being firmly adherent to the same. 

It is not always easy, but for therapeutic purnoses of much import- 
ance, to determine which of the two mentioned diseases is the causa- 
tive element in these cases. The author, for instance, reports two 
cases where the patients who had in former years both contracted syph- 
ihs, resided for many years in the tropics. Each of them suffered then 
from repeated attacks of intestinal catarrh, but never with dysentery. 
Nothing resulted from anti-syphilitic treatment, and thus nothing was 
gained from an etiological point of view. The relatively small num- 
ber of high-lying strictures, however, found, in more northern coun- 
tries, in consequence of the infrequent and less malignant occurrence 
of dysentery, on the one hand, on the other the fact that almost with- 
out exception the afflicted persons have resided for long periods in the 
tropics and attribute the commencement 'of their illness to their resi- 
dence there, and finally, the positi^^e observations concerning the de- 
velopment of this trouble, directly following an attack of dysentery, 
would sufficiently prove that the latter disease is the principal causa- 
tive influence for this form of stricture. 



34 EDITORIAL ARTICLES. 

In most cases, says the author, the autopsy will shed no light on the 
primary cause of the trouble. Above the stricture the intestine is usu- 
ally much distended from stagnation of fecal matter. In consequence 
of the frequent energetic contractions, hypertrophy of the muscular 
walls takes place, and these losing more and more of their elasticity, 
become gradually very stiff and rigid. If dilatation of the obstructed 
part is not undertaken, the irritation of the mucous surface caused by 
the impacted feces, etc., will soon lead to an ulcerated condition and 
loss of substance of the mucous membrane. The muscul£\,ris will be- 
come involved, the serosa undermined, and finally fistulous passages 
formed. 

The stricture itself is seen mostly as a cicatricial ring surrounded 
by hard connective tissue. Sometimes it has but a very small open- 
ing, in other cases we find it in the form of a more or less long rigid 
tube with a narrow or wide lumen. Occasionally two or three strict- 
ures separated by partially healthy mucous membrane are met with. 
The patients complain of a feeling of pressure and sensation of burn- 
ing and soreness in the region of the stomach. Loss of appetite, 
flushing, irregular heart-action, drawing sensation in the lower limbs, 
nervous irritability and often deep hypochondriasis, are some of the 
chief symptoms. Obstinate diarrhoea often exists, furthermore. Graa- 
ually the local symptoms become more prominent ; drawing pains in 
the loins and frequent desire to stool develops. For these high-lying 
strictures the sudden desire to stool on awakening in the morning is a 
characteristic symptom. Instead of feces, only mucous matter is 
passed with much straining. The ribbon-like form of the feces often 
gives a clue to the disease in strictures near the anus, but in strictures 
situated high up in the rectum the feces usually have their normal 
form. They are sometimes, however, similar to those of sheep, small, 
hard balls. The patient rarely has the feeling of complete evacuation 
of the bowels. The mucous secretion becomes more and more abun- 
dant, obstipation increases. In the worst cases, if no dilatation of 
the stricture takes place, the stagnation of the feces leads to peritonitis 
and death. A very important symptom appearing relatively early in 
the course of the trouble and pointing to its grave nature, is the rapid 



HIGH-LYING STRICTURES OF THE RECTUM. 35 

wasting away of the patient, the loss of strength and cachectic ap- 
pearance, differing scarcely from that of those afflicted with carcinoma. 
A careful examination per rectum will show in most cases the real 
nature of the disease. Kiimmell advises in all cases, where there is 
protracted catarrh of the large*- intestine, which has resisted treat- 
ment, and is undermining the strength of the patient, that a careful 
examination of the rectum be made, either digital or instrumental. An 
ordinary oesophagus sound is well suited for the diagnosis of high-lying 
strictures. Through it water may be injected to distend the folds of 
mucous membrane obstructing its introduction. Sounds of whale- 
bone with olive-shaped ivory heads are also useful instruments for this 
purpose, as is furthermore AUingham's rubber balloon constructed for 
a like object. The author uses a whale-bone sound having a sponge 
attached to its further end, the sponge being, when introduced, in a 
compressed state, and ghding easily through the strictured part. On 
withdrawing the sound more or less force must be exerted, as the 
sponge, swollen and much increased in size, is obstructed by the strict- 
ure. In this manner the position and size of the latter may quite well 
be determined. For the diagnosis and knowledge of the relative 
positions of several stnctures, repeated examinations must be made. 
In some cases it will be necessary to dilate the lowermost stricture be 
fore anything positive regarding those higher up can be arrived at. 

Errors in the diagnosis of these high-lying strictures are frequently 
made, and numerous cases of this kind have been recorded. Such a 
case was pubHshed by Syme. The obstruction to the sound on its in- 
troduction, which was supposed to be a stricture, was found, in the 
autopsy, to have been the promontory. When a stricture is present, 
its nature should be, if possible, determined ; whether, namely, of 
cicatricial origin, or arising from compression of the rectum by patho- 
logical conditions of the uterus, bladder, prostate, or by exudations or 
tumors in the smaller pelvis, etc. In some cases it will be extremely 
difficult to determine whether the stricture be due to a cicatricial pro- 
cess or a malignant neoplasm. This is, of course, of great importance 
in the treatment. The following case of the author's will be instruc- 
tive from this point of view: Patient, a man, set. 56, had experienced 



36 EDITORIAL ARTICLES. 

a sudden large hemorrhage from the rectum, followed, however, by no 
further symptom of disease. But gradually pains in the loins and 
limbs, general weakness and debility developed, causing him to seek 
medical assistance. Carcinoma of the rectum was suspected by his 
physician, but digital examination gave negative results. On intro- 
ducing bougies, however, a stricture was felt about 13 ctms. above the 
anus. It was passable for an instrument of 12 mm. thickness. Grad- 
ual dilatation was kept up, the health of the patient improving rapidly. 
When seen by the author, about four months after the haemorrhage 
had occured, he did not at all present the appearance of an invalid. 
This favorable condition, however, changed shortly afterwards, the pa- 
tient showing the almost unmistakable look of one afflicted with car- 
cinoma. Nine weeks later a digital examination detected the existence 
of a carcinoma. Radical extirpation was followed by recovery. In 
cases of doubtful diagnosis the patient should be kept under observ- 
ance for some time before a positive expression of opinion is given. 
The cases are numerous and well known where syphilitic strictures, ac- 
cessible to view and touch, have been treated as malignant growths. 

For dilating high-lying strictures the so-called elastic and wax 
bougies are the best. They should be employed, however, with some 
care, and are not sufficiently long to be serviceable in all cases. Those 
of AUingham are thick and hollow, and composed of the same mate- 
rial as Nelaton's catheters. If this bougie is compressed in the strict- 
ure, it may be filled with water, quicksilver, fine shot, etc. There are, 
furthermore, sohd soft rubber bougies, long and elastic, with olive- 
shaped points. Before introducing a bougie the bowels should be 
evacuated and the rectum irrigated with warm water. The patient lies 
on a bed or sofa, with the breach protruding over the edge. A grad- 
ual, slow introduction of the well oiled bougie, with frequent inter- 
missions, will easily overcome any painful and disagreeable sensations 
in the anus, contractions of the sphincters, etc. It is not advisable to 
allow the bougie to remain too long, as no permanent dilatation of the 
stricture will be attained by this procedure, but the intestinal catarrh, 
present in all these cases, will be aggravated. Five to ten minutes 
will suffice for the desired effect. Nor will it be wise to introduce 



HIGH-LYING STRICTURES OF THE RECTUM. 37 

more than two different instruments at one sitting. At the commence- 
ment of treatment, the bougies should be introduced every two to 
three days ; later on, when dilatation has progressed considerably, less 
often. Even after all symptoms of disease have disappeared, the 
bougie should be occasionally employed, to prevent, if possible, any 
recurrence of the stricture. Absolute rest will be necessary in nerv- 
ous, irritable and anaemic individuals, especially at first. Symptoms of 
peritonitis, irritation, painful fissures, etc., may cause the treatment to 
be suspended at times for a while. Such incidents happen in spite of 
the greatest care. The use of a bo'ugie by the patient himself in these 
cases of high-lying strictures should therefore be but sparingly allowed, 
and only then in the advanced stages of the treatment and after the 
patient has shown his abiUty to do this. Froriep reported a case where 
the instrument, slipping from the patient's grasp, perforated the intes- 
tinal wall, causing death. Troublesome symptoms, such as the 
catarrh,, etc., should be removed as far as possible. Irrigation 
with warmed solutions of alum, tannin, corrosive subUmate, 
once or twice daily, especially after defecation, are bene- 
ficial. In cases where ulcerations exist, Konig advises the use 
of a weak solution of the chloride of zinc, which acts well on 
the ulcerated parts, but does not affect the normal mucous membrane. 
Burning sensations in the rectum, tenesmus, etc., may be relieved by 
warm sitz baths, suppositories of opium, etc. AUingham recommends 
in cases of pain and burning in the pelvis and for the intense neural- 
gia often felt about the sacrum, the use of an ointment composed of 
morphium and bismuth. For its proper appHcation to the membrane 
of the rectum, he has constructed a hard rubber bougie on the plan 
of a syringe. This is passed, closed into the rectum, and its contents 
then ejected from the numerous lateral openings. Disturbances of the 
digestive organs, from which these patients invariariably suffer, will re- 
quire suitable treatment. Nourishing and easily digestible food should 
be given. For the constipation light laxatives may be employed. 
Diarrhoea, on the other hand, generally resulting from irritation of the 
hard, impacted feces, will disappear usually after the instrumental 
treatment has begun. Preparations of bismuth, naphthalin, etc., may 



3^ EDITORIAL ARTICLES. 

be employed, however, but the use of opiates and styptica should be 
guarded against. It will be advisable in those cases, where the patient 
shows the consequence of long-standing intestinal occlusion, with 
meteorismus, symptoms of peritonitis, debiHty, etc., not to delay with 
attempts at dilatation, but to proceed at once to the establishment of 
an artificial anus. When these symptoms have disappeared and the 
health of the patient permits, treatment of the stricture may oe under- 
taken, and the attempt made to bring about defecation in the normal 
way. 

The prognosis will be favorable in those cases when the strictures 
are accessible to treatment with bougies, and this is not too long de- 
layed. As regards the results of the treatment, much will depend on 
the greater or less extent of the destruction in the mucous membrane, 
and on the patience and energy displayed by both patient and physi- 
cian. Kiimmell gives the histories of two cases which illustrate the 
above-mentioned symptoms, etiology, diagnosis and result of treat- 
ment, in a very characteristic manner. 

Case I. Male, aet. 51, has resided for nine years in the tropics. In 
1873 he contracted syphilis and suffered in 1879 from an attack of 
dysentery, which gradually assumed a chronic form, resisting all treat- 
ment. Patient returned to Europe in 1880, and, alter a month's so- 
journ at a cold-water bathing estabHshment, was discharged cured. A 
short time afterwards, however, the old symptoms of disease returned. 
He consulted a physician, being then very much reduced in strength, 
anaemic and complaining of much pain in the loins, occasional diar- 
rhoea and frequent desire to stool, especially on rising in the morning. 
Only some mucous, bloody matter and small amount of hard feces 
would be passed, the patient only finding rehef after two or three 
movements of this kind. Digital exploration of the rectum revealed 
nothing abnormal. On introducing a bougie, however, an obstruction 
was felt about 14 ctm. above the anal opening. Bougie introduced 
daily and left for fifteen minutes to an hour. After treatment in this 
manner for about eight months, patient was cured, all objective and 
subjective symptoms having disappeared. Failing, however, to follow 
the advice of having a bougie introduced from time to time, to pre- 



HIGH-LYING STRICTURES OF THE RECTUM. 39 

vent any possible return of the stricture, the old troubles reappeared 
in 1884, two and a half years later. When seen by the author, patient 
was in great suffering. The stricture was discovered 14 ctm. above 
the anus, and was not passable for a medium-sized sound. Symptoms 
of peritonitic irritation and a painful fissure of the anus caused fre- 
quent interruptions in the treatment. The general condition of the 
patient improved, however, as the dilatation of the stricture pro- 
gressed. In the course of six to seven months the troublesome symp- 
toms subsided, and the stricture admitted the largest sized bougies. 
Defecation was normal and painless, appetite excellent and general 
appearance healthy. Bougies are still employed every five to six 
weeks. Patient is well and strong, eats and digests the heartiest kinds 
of food. 

Case II. Male, aet. 42, has resided eleven years in the tropics, where 
he has suffered from several violent attacks of diarrhoea, but with no 
symptoms of dysentery. From time to time he has been troubled 
with disturbances of the digestive organs, and these being attributed 
to climatic influences, patient returned to Europe, He was treated 
for a long time for gastric catarrh, as all the symptoms seemed to 
point to the stomach as the seat of his trouble. For past two years 
large quantities of epidermis-like masses and mucus have been passed 
in defecation. The feces are small and hard. Patient never has the 
feeling of complete evacuation of the bowels after defecation. Chest 
organs normal, and digital examination of the rectum gave no result. 
Catarrhal condition of the mucous menibrane of rectum. On intro- 
ducing an elastic bougie, an obstruction was felt, about 13 ctm. above 
the anus. A whale-bone sound with a medium-seized ohve-shaped 
head could be passed through the stricture, and detected the existence 
of a second stricture about three to four ctm. above the hrst. Dilata- 
tion with heavy rubber bougie daily. In two months' time both strict- 
ures were passable for very large sounds. A third stricture, circa 3 
ctm. in length, was then discovered lying about 21 ctm. above the 
anus. Dilatation of the latter was difficult at first, but in the course 
of fifteen months the lower strictures were completely removed, and 
the uppermost was passable for the thickest instrument. There was 



40 EDITORIAL ARTICLES. 

Still some catarrh of the intestine. Patient is well at present and en- 
joys normal appetite and good digestion. A large bougie is intro- 
duced from time to time. C. J. Colles. 



OSTEOCLASIS.' 

(Contini-ed from Vol. IV., p. 421). 



Collin's apparatus. The first instrument invented by M. Collin (in 
1879) made use of the leverage of the leg in order to break the femur. 
It had consequently the fault of exerting its strength on the ligaments 
of the knee, and has given place to another form, produced according 
to Pousson, after M. Collin had seen how M. Robin had avaided this 
defect. It is, therefore, not necessary to describe Colhn's first ap- 
paratus in this article. Nevertheless, very good results were obtained 
by this machine, including the successful breaking down of a mal- 
united Pott's fracture. Pousson gives an illustration of the osteoclast 
of Taylor, of New York, and compares it with CoUin's first ap- 
paratus. It. however, obviously works with much less leverage, and 
could be made to break the femur near either extremity without strain- 
ing the ligaments of the knee. No statements are made as to its 
safety or danger. 

Robifi's apparatus. Its great merit is that it reduces to a mini- 
mum the length of leverage required and thus, for example, enables the 
surgeon to break the femur just above the condyles without throwing 
the slightest strain on the knee. Therefore, in producing his osteo- 
clast, M. Robin solved the main problem in connection with instru- 
mental osteoclasis. 

Robin's apparatus consists of a wooden plank to support the thigh 
(the patient hes on his back), of a metal plate to He on the front of 
the thigh, and therefore slightly gutter-shaped with the concavity on 
the lower surface (that which touches the thigh), of two steel bands or 
hoop-segments, of four screws, of a leather collar and a lever. 

^De L Osteociasie, par le Docteur Alfred Pousson, I'aris, J. B. Bailliere et fils. 
Paris. 1886. 



OSTEOCLASIS. 4 1 

The plank is placed on the table in such a way that the whole 
length of the femur lies upon it, the patient being on his back. This 
disposition is absolutely necessary, for, otherwise, a movement of rota- 
tion and a consequent oblique fracture may be expected at the mo- 
ment of operation. The plank is in two parts which can be ap- 
proached or separated so as to adapt the appliance to thighs of dif- 
ferent lengths. The plank is padded with leather, especially at the 
upper and lower edges. The upper (steel) plate or gutter is similarly 
padded. It embraces the upper surface of the thigh. It is not much 
arched downwards at the sides, lest it should interfere with the lateral 
expansion of the soft parts and imprison the hmb too tightly. 

The steel hoop-segments are placed across the steel plate, one near 
each end, and are then screwed down to the plank by four perpendicu- 
lar screws. In this way the thigh is fixed between the wooden plank 
below and the steel plate above. The screws are driven home by a 
key, which has a spring near the handle so arranged as to indicate 
when the screw force used is sufficient, but not dangerous. 

It IS absolutely necessary to screw the plate firmly down on the thigh 
and thus fix the latter absolutely. Otherwise, a neat and precise frac- 
ture at the exact spot desired cannot be expected. 

The compression process above described forces the artery and the 
sciatic nerve towards the inner side of the femur and does not com- 
press either. 

The knee must be extended before the screws are tightened, other- 
wise the skin will be dragged on. 

The leather collar is placed on the condyles, and its extremities, 
pierced with eyelet-holes, are hooked on to the runner of the lever. 
The collar should be short, and the lever thus brought as near to the 
patella as possible. 

The popliteal vessels lie snugly between the condyles, safe from 
pressure. 

Having thus adjusted each part of the apparatus, the surgeon 
seizes the lever and produces a succussion (secousse), continuous for a 
few seconds, rather than violent, for he otherwise might exceed the de- 
gree of force just necessary to determine complete fracture. 



42 EDITORIAL ARTICLES. 

As soon as ever the fracture is completed the hmb must be freed. 
A simple mechanism premits this to be done in a moment. 

Passing to the new osteoclasts, the author gives a number of experi- 
ments, nineteen in all, made by Demons, of Bordeaux, and by himself 
upon the femora of adult subjects, with Robin's apparatus. All these 
tended strongly to prove the precision, safety and high value of the 
procedure. It is true one serious accident occurred, namely, tearing 
away the anterior crucial ligament from the condyle. But the experi- 
menter blames his own inexperience for this (it was his second experi- 
ment), and the series as a whole tends to show that, with experience 
in the use of the machine, came wonderful precision and neatness in 
the place and character of the fracture 

Four experiments of fracture ol the leg by Robin's osteoclast are 
given. The first produced disastrous results, the second was less mis- 
chievous, the third and fourth were very successful. The author at- 
tributes these various results to the proper use of padding in the latter 
cases, and to the neglect of it in the former. 

Satisfactory experiments on the lower end of the radius are also de- 
scribed. 

A very favorable account is also given of the results produced by 
ColUn's osteoclast (his new form). This chiefly contrasts with Robin's 
in that it acts sideways while the latter breaks from antero-posteriorly. 

After-treatment, sequcela and accidents of the operation. 

M. Robin does not rectify the position of the broken bone until six 
or eight days after osteoclasis. During the first week a splint is ap- 
plied molded to the limb in its deformed state before operation. 
"Thanks to this mode of proceeding," we are told, "rupture and strip- 
ping up of the periosteum, and, consequently, general and local reac- 
tions (fever, pain, swelling, hydrarthrosis), are avoided." 

Quite exceptionally, after the apphcation of Collin's apparatus, Mr. 
M. Reclus, Gillette and Verneuil have observed the appearance of a 
small, grayish and numb spot in the skin, which, however, never morti- 
fied. Billroth once noticed temporary paralysis of the external poplit- 
eal . 

Serious injuries to the joints, ^. ^., relaxation of ligaments, hydrar- 



OSTEOCLASIS. 43 

throsis, have occurred, but less frequently than the above related ex- 
periments on the dead body might lead one to expect. 

In a small minority of cases there is a slight febriie reaction after 
the operation. 

Modifications of Robin's machine can be applied to any part of any 
of the limbs. 

When the knee is ankylosed at a right or acute angle and it is de- 
sired to break the femur just above the condyles, the limb is placed on 
its outer side, and the osteoclast, specially modified for the purpose, 
breaks it from without inwards. 

Some excellent cases are given of the correction of mal-united 
Pott's and Colles's fracture. 

Inwiediate effects of osteoclasis — Anatomical lesions which it causes. 
The results of M. Aysaguer's numerous experiments on manual osteo- 
clasis are thus summarized: In young chi'dren about 2 years old the 
bones have such flexibility that complete fracture is not generally ob- 
tained. They bend and straighten again like a fresh branch of a tree, 
and there is no solution of continuity in the periosteum. There is 
"infraction," not true fracture. Above 4 or 5 years of age there is 
almost always rupture of the periosteum and true fracture. This frac- 
ture is always simple, generally transverse, slightly dentated. The 
peripheral soft parts are constantly uninjured, presenting neither 
ecchymoses nor bruises. The rupture of the bone (the tibia) always 
takes place at the spot where the thumbs (on the knee, if it be used) 
are applied. In half the cases the fibula gave way exactly at the same 
level as the tibia. In the others it was produced one or two centi- 
meters above or below. But these observations apply to osteoclasis of 
the diaphyses. When the manual brisement force is appHed with a 
view to curing genu valgum the anatomical lesions are very variable 
and sometimes considerable to an alarming extent. At all events, such 
is the case where the oatients are passed the age of childhood. M. de 
Santi experimented on subjects between 18 and 22 years of age, and 
m 12 limbs, there was no epiphysal separation, but nine times rup- 
ture or detachment of the external lateral Hgament, and twice a bit of 
the condyle was torn away with it. Once the condyle was broken 
away bodily, making a fracture into the joint. 



44 EDITORIAL ARTICLES. 

Collin's first apparatus was effective in separating the epiphysis ev^n 
in adolescents from 14 to 20 years of age, but it produced other 
lesions, considerable and even alarming. Even the semi-lunar cartil- 
ages have been displaced by it. 

There is not unfrequently intense pain for from twenty-four to forty- 
eight hours after the operation. It often coincides with hydrarthrosis. 
Both soon disappear. 

Before the use of the new osteoclasts one or two very serious cases 
of arthritis and periostitis were reported. Loose joint has also re- 
sulted, and even one pseudarthrosis (Boeckel). In the last case the 
parents removed the spHnts in the fifth week, and may, therefore, be 
blamed for the evil result. 

Then follows an excellent chapter containing numerous statistical 
facts respecting the application of osteoclasis to mal-united fractures. 
This chapter concludes, however, with a valueless and narrow com- 
parison of osteoclasis with osteotomy which, for example, quite fails to 
take into account that osteotomy has often been only undertaken after 
osteoclasis has failed. 

The number of osteotomies taken for comparison is 37 ; of these 7 
were attended with abundant suppuration or erysipelas. 

I will only remark that I have myself done eleven antiseptic osteot- 
omies for mal-united fracture, and should have been grieved and sur- 
prised to have seen one suppurate. 

Valuable tables of cases of osteoclasis are added. 

Osteoclasis applied to the treatment of rachitic curvatures. 

M. Pousson, after discussing the indications for osteoclasis in these 
affections, compares it with osteotomy for the same diseases, some- 
what to the advantage of the latter. He gives 98 "osteoclases" with- 
out a death, and, indeed, without any serious complication. 

M. Delens, who had given up osteoclasis for MacEwen's osteotomy, 
has now, after seeing and using ColHn's osteoclast (second form), given 
up osteotomy in favour of machine osteoclasis. Even Demons (of 
Bordeaux) the French translator of MacEwen's book, has been con- 
verted from the advocacy of osteotomy for genu valgum to that of 
osteoclasis. 



OSTEOCLASIS. 45 

That theoretically possible accident, arrest of growth as a conse- 
quence of injury to the epiphyseal cartilage, has not once been ob- 
served. 

There is a dearth of observations made years after osteoclasis. 
Lannelongue says that cases operated on in the old way afterwards suf- 
fered from an extreme sensitiveness in the knee-joint to changes of 
temperature and a tendency to the formation of osteophytes at the Hne 
of fracture or epiphyseal separation. 

The duration of treatment is somewhat long after manual osteo- 
lasis of adults owing to the sprain, etc, inflicted on the joint. 

The force required to break a bone has by no means any fixed rela- 
tion to the age and strength of the patient. 

The new machine osteoclases contrast with the old notably in that 
only a small minority of the former, but the large majority of the lat- 
ter suffer from lively and prolonged pains in the neighbouring joint 
after operation. 

Consolidation and bony union take place as quickly after the new 
mode of osteoclasis as after a simple transverse fracture caused by 
accident. Age has a considerable influence on this process. The 
younger the patient the more rapid the union. 

Two, three or four weeks more, generally, suffice for complete recov- 
ery of the strength and suppleness of the Hmb. 

In comparing osteoclasis for genu valgum with MacEwen's osteot- 
omy, M. Pousson regards both as absolutely without danger. He 
points out that as osteoclasis requires complicated apparatus, many 
surgeons, especially those resident in remote districts, will prefer oste- 
otomy. He concludes, from a study of the cases recorded, that con- 
valescence and complete functional restoration of the Hmb are notably 
quicker after osteoclasis by the new machine method than after 
MacEwen's osteotomy. 

Osteoclasis applied to the treatment of ankylosis and of some other 
articular affections. 

M. Pousson analyzes 36 osteoclases of this class, of which 18 were 
of the hip, and 14 of the knee. He says that the orthopaedic results 
were : 



46 EDITORIAL ARTICLES, 

Perfect in - 24 

Satisfactory in 3 

Tolerably satisfactory in i 

Bad in 2 

The original affections leading to the ankylosis were : 



Traumatic arthritis 

Tubercular " 

Puerperal " 

Scarlatinal " 

Typhoid " 

Epiphyseal " 

Rheumatic " 

Suppurating " 

Indetermined '' 



Times. 

5 
7 
2 
2 

I 
I 

4 



In none of these cases did osteoclasis produce any relapse, although 
in one case, originally a traumatic arthritis, where the splints, etc., 
were removed too hastily, a violent inflammation resulted. But 
this did not attack the joint itself, only the seat of osteoclasis. Two 
or three years had usually elapsed between the date of the original 
disease and that of operation. All the patients were adolescents or 
more or less young adults. 

When an ankylosis is at a too acute angle for one osteoclasis to 
remedy it satisfactorily, Robin suggests two, one above, the other be- 
low the joint. The alternative is a cuneiform osteotomy. 

M. Pousson's comparison of osteoclasis with osteotomy in this class 
of affections is like his other similar comparisons, very inferior in value 
to the rest of his admirable book. He cites only 22 linear osteoto- 
mies of the hip, with 2 deaths. Now, I have myself done 22 without 
any fatality, and all with excellent result, and I expect that Volkmann 
has done nearly as many, though he prefers the wedge operation. 
When osteoclasis comes to be done everywhere in isolated cases by 
surgeons who have had no previous experience of the c peration, we 
may hear of some mischief being done. I consider osteotomy of tlie 
hip to be as safe as that of the femur for genu valgum, when the sur- 



OSTEOCLASIS. 47 

geon knows how to do it. M. Pousson, however, comes to the con- 
clusion that it is a very grave business. 

I cannot conclude this article without formally offering my thanks to 
the author of the book under notice for the complete, logical, honest, 
and altogether excellent manner in which he has laid before the pro- 
fession an account of what is evidently destined to be a surgical pro- 
cedure of high value and of frequent applicabiUty. The work is both 
practical and scholarly. C. B. Keetley. 



INDEX OF SURGICAL PROGRESS. 



GENERAL SURGERY. 



I. Treatment of Erysipelas. By Dr. W. Otto (Rudolph Hos- 
pital, Vienna). In 1883 Barwell reported five cases of erysipelas very 
successfully treated by exclusion of air. For this purpose he used 
white lead paint. Dr. J. Breuer related to the author a favorable case 
similarly treated with liquor gutta-perchae as an air- excluder. Otto 
uses a solution of 2 parts wax, 20 parts dryer and 100 linseed oil. 
With this he makes repeated applications over tlie affected part and a 
hand's breadth beyond. Five hospital cases are described and four 
dispensary patients mentioned. In all the temperature very soon fell, 
the pain stopped and no further extension occurred. The fact that 
er}fsipelas spreads through the upper layers of cutis may possibly de- 
pend on the accessibility of oxygen. [Local applications of lead paint, 
collodion, vaseHne smeared on thick, etc., are esteemed by many 
American practitioners. Reptr.'\ — Wien. Med. Woc/i. 1S86. No. 43. 

II. A Contribution to the Pathogenesis of Actinomycosis 
of the Lung. By Dr. J. Israel (Berlin). Israel's present case was 
that of a Russian driver, aet. 26, who had usually slept on straw or in 
hay lofts, and sometimes drank from the same trough as his horse. 

After some pain in the left side of the chest in October, 1886, ab- 
scesses formed below the left nipple; these increased in number and 
developed ulcers. On admission in August, 1885, there was marked 
emaciation and considerable contraction of the left side of the thorax — 
the latter covered with abscesses and sores whose secretion contained 
abundant actmomycosis-granules. The muco-purulent sputum* — at 
times tinged with blood — always contained the same. Death the end 

(48) 



GENERAL SURGERY. 49 

of March, 1886, from diarrhoea, resulting from amyloid degeneration of 
the abdominal organs. 

A single focal cavity in the lower part of the left upper pulmonary 
lobe, close to the anterior surface. From this the process had freely 
perforated the front wall of the chest. 

In the actinomycotic pulmonary cavity was a lentil-sized foreign 
body which proved macroscopically, microscopically and chemically 
to be a fragment of a tooth. 

This is the first positive of proof of the view which I. had previously 
advocated, viz., that pulmonary actinomycosis does not result from 
the inspiration of germs in the air 'but from the aspiration of germs 
from the oral or adjacent cavities, carious teeth evidently being one of 
the primary seats. 

In the discussion, Roser (Marburg) noted an acute and a chronic 
form of actinomycosis. Konig (Gottingen) spoke of seeing dispensary 
cases frequently. Esmarch had seen ten cases with one death. The 
patients are almost always cattle men. — Centbl.f. Chirg. 1886. No. 
24. Report of XV. German Surgical Congress. Arch. f. klin. Chirg. 
Bd. 34, Hft. I. 

\V. Browning (Brooklyn). 

III. A Case of Actinomycosis of the Lung. By A. J. 
OcHSNER, M.D., (Chicago). Male, aet. 56, stock-raiser by occupa- 
tion. After a history of severe pain in the antrum for some months, a 
spontaneous discharge of pus into the pharynx, with estabhshment of 
a permanent fistula, gave relief^this in 1878. Some of the discharge 
finds entrance into larynx during sleep, exciting severe cough. In 
1880 antrum was trephined from the mouth, scraped and irrigated, the 
irrigation being continued daily for two years. In 1882, simultaneously 
with change of residence, Northern Mexico, and the territory be- 
tween it and Colorado, the antrum closed and the general health was 
much improved. In 1S85 pulmonary symptoms, consisting of suffoca- 
tive sensations and cough began to trouble him. Expectorates mucus 
and blood, and in this sputum the characteristic fungus of actinomy- 
cosis is readily found by microscopic examination. His position is 



so INDEX OF SURGICAL PROGRESS. 

Stooping, the chest is full in front, and there is a decrease of motion 
on the left side, with dulness, roughened respiratory sounds and numer- 
ous mucous rales. Below the upper border of the fifth rib, and through- 
out the right side the sounds are normal. 

The man has been engaged in raising, buying and selhng, and hand- 
ling large numbers of cattle for more than forty years. Among these 
animals there were many suffering from the disease known as lumpy- 
jaw, and it was the practice of the patient to cure the animals thus 
affected, by freely opening the abscess by crucial incision, extirpating 
as much as possible of the lump and introducing about one drachm of 
powdered arsenic into the cavity. Repeating this once or twice, 
usually effected a permanent cure. — Chicago Afed. Jour, and Exam. 
Dec. 1886. 

L. S. PiLCHER (Brooklyn). 

IV. A Case of Actinomycosis. Dr. Wm. O'Neill (Lincoln). 
A farmer, set. 50, had been "dressing" calves affected with what he 
called " ring-worm." In a few weeks he was attacked Avith a pustular 
eruption on the left wrist and forearm, and a sHght, apparently glandu- 
lar swelling under the right ear. When (one month afterward) he 
first consulted Dr. O'Neill, there were also four or five smaller swell- 
ings in the neighborhood of the clavicles and one in the left axilla. 
Iodine and arsenic given internally, citrine ointment locally. Skin 
eruption almost disappeared in a iQ'w weeks, tumours slowing dimin- 
ishing. But, after two months of treatment, tonsillitis and aphthous 
looking state of mouth. 

Next month, mouth better, but two or three new enlargements ap- 
pear ; some of old ones larger. The one below the ear was as large 
as a small hen's egg, smooth, nearly painless, elastic, and sUghtly mov- 
able. Other smaller swellings, one beneath chin, one on back of 
head. 

Now, sublimate and pot. iod. internally, iodide of ammon. ointment 
externally. 

Next month, appearances much better, but unfortunately severe 
bronchitis set in. On its subsidence, the tumour, etc., are left much 



I 



GENERAL S UR GER } . 5 ^ 

" The tumours in the angle of the neck had extended in all direc- 
tions, more especially downwards. It had also suppurated, and two or 
three sinuses gave exit to a whitish purulent fluid, which frequently 
contained small yellowish particles. The sore generally presented a 
reddish granulating surface, but occasionally dark colored scabs would 
form on it. Several of the smaller tumours on the lower part of the 
neck had nearly disappeared, but the one under the chin was still large 
enough to be uncomfortable, and the tumour on the back of the head 
had become as big as a walnut, and, although unulcerated, was so 
painful that he could hardly sleep on his back. A small swelling had 
also formed under the left ear." The increase of temperature and 
pulse-frequency less than might have been expected. 

At this stage iodide and bromide of ammonium were commenced. 
But, the tumours continuing to enlarge, the opinion of Mr. A. E. Bar- 
ker was sought with a view to surgical, operative treatment. 

Dr. O'Neill found the micro organisms " supposed to be peculiar to 
the disease." 

Speaking of the calves with so-called " ring-worm," Dr. O'Neill 
says, " there are no lumps at present under the jaws, or in or about 
their mouths. Ring-worm began in them, as well as in several others, 
by the hair faUing off, a reddening or inflammation of the skin, and 
the formation of ash-colored scabs, more or less thick, according to the 
severity of the disease in the part affected. The disease is caused by 
a fungus which can be destroyed by sulphur or by mercurial prepara- 
tion, notably by corrosive sublimate." But Dr. O'Neill had not, up to 
the date of his paper, identified the fungus of the calf s disease with 
that of actinomycosis. 

Up to recent years, actinomycosis has probably been confounded 
with scrofula and cancer, with the former in its early stages, and with 
the latter in its ulcerated stages. 

About one-half of the pubHshed cases have been fatal. The dis- 
ease may attack almost any organ in the body. 

O'Neill thinks that iodine, arsenic and mercury have some power 
over the disease in its early stages. 

But, after all, where actinomycosis appears in the shape of externa \ 



52 



INDEX OF SURGICAL PROGRESS. 



tumours, he thinks that the most expeditious and the best treatment 
would be removal by surgical operation. 

Actinomycosis appears to have been first discovered by ItaHan vet- 
erinary surgeons and accurately described by Revolta in 1868. Bolhn- 
ger rediscovered it, and named it in 1877, and, in the follo\\ang year, 
Israel described the first case in man. 

C. B. Keetley (London). 

OPERATIVE SURGERY. 

I. New Method of Amputation at the Ankle-joint. By 

Prof. A. C. Tauber (St. Petersburg, Russia). After having criticized 




Fig, I. Stump Troduced by Tauber's Method. 

the methods of operation at the ankle-joint, introduced by Syme, Mal- 
gaigue, Roux, Sedillot, Le Fort and other surgeons. Prof. T. has dem- 
onstrated in the first congress of the Russian physicians his own 
method which is a modification of PirogofiPs. Fig. i shows a stump 
made according to Tauber's method. His operation Prof. T. per- 
forms as follows. 



OPERA Tl VE S UR GER Y. 



53 



He begins an incision at the attachment of the tendo Achillis (A, 
Fig. 2) and carries the knife forward, below the malleolus, to the 
Chopart's line (B, Fig. 2), and then across to the dorsum of foot, 




Fig. 



Line of Incision Along Outer Side of Ankle. 



down, (from B to C, Fig. 3) ; on having reached the middle line on 
the plantar surface (D, Fig. 2), the knife is carried backward to the 
heel and then upward to the startin^^ point (D E A, Fig. 2). In this 




Fig. 3. Line of Lncision Along L\ner mde of Ankle. 

first stage of operation Dr. T. cuts the skin and other soft tissues to 
the very bones. 



54 



INDEX OF SURGICAL PROGRESS. 



In the second stage Prof. T. opens the ankle-joint in the usual man- 
ner, that is, he cuts ligaments in this order, hg. fibulare-tah post., hg. 
fibulare calcaneum, and lig. fibulare-tali ant. ; then arkr. lig., and at 
last the deltoid lig. 

In the tliird stage Dr. T. dissects out the astragalus and cuts off the 
foot in the Chopart line. While an assistant firmly holds the os calcis 
by forceps, Prof. T. saws off the external half of the bone, in the line 



imd^Adlb 




^sa J, 

a.flant 



Fig. 4. The Flap Completed. 

corresponding to thejone first made in the skin (B C Fig. 3). Thus 
the interior flap of the heel contains a thick, almost square part of the 
OS calcis and the poster, tibial artery not injured (see Fig. 4). 

In \he fourth stage Prof. T. saws off the malleoH, puts ligature on 
the arteries, severs and adjusts the two surfaces of the bones to each 
other, which is easily done without any extension of the tendo Achillis, 
as can be seen in Fig. 4. Lastly the wound is united with sutures. 



NER VO US AND VAS C ULAR S YS TEMS. 5 5 

The advantages of this method consists in the following points : 
The poster, tibial artery remains intact, saved for the stump (see Figs. 
3 and 4) ; the tendo Achilhs and bursa mucosa retro-calcanea remain 
uninjured, and the surfaces of the bones sawn off will correspond 
to each other (see Fig, 4), thus favoring the process of ossifica- 
tion. 

In 1877, during the Turko-Russian war, when there were many sol- 
diers with frozen feet, Prof. Tauber tried his method with gratifying 
results. He believes that in his method preserving the poster, tibial 
artery there is far less danger from the necrosis of flaps than in the 
other methods. As to the technique of the operation Tauber's method 
seems to be less complicated than those of the surgeons mentioned 
above. However, experience is needed to prove all that Prof. T. claims 
for his method. — Fr^/M (St. Petersburg). No. 5. Jan. 30, 1886. 

P. J. PoPOFF (Brooklyn). 

VASCULAR SYSTEM. 

I. Laparotomy in the Treatment of Spontaneous Gluteal 
and Sciatic Aneurism with a Report of Three Cases, in 
One of which Both Internal Iliac Arteries were Tied at the 
Same Time for Double Gluteal Aneurism of Simultaneous 
Development. By F. S. Dennis, M.D., (New York), (i) Lap- 
arotomy in no way increases the |dangers of the operation of liga- 
ture of the internal iliac artery. (2) Laparotomy prevents a series o f 
accidents which have occurred during the performance of the opera- 
tion of hgature of this artery by the older methods. Among these ac- 
cidents may be mentioned the division of the circumflex and epigas- 
tric arteries, wounding the vas deferens, including the ureter in the liga- 
ture, puncture of the iliac or circumflex veins, tying the genital branch of 
the genito-crural nerve, stripping up and tearing the peritoneum, in- 
jury to the subperitoneal connective tissue and other accidents of a 
like nature. (3) Laparotomy enables the surgeon to apply the liga- 
ture at a point of election, and affords him an opportunity of obtainmg 
information as to the exact extent of disease in the main arterial trunk. 
(4) Laparotomy averts the dangers which were likely to follow ligature 



56 INDEX OF SURGICAL PROGRESS. 

of the internal iliac artery by the older operations, among which may 
be cited peritonitis resulting from tearing up the peritoneum poste- 
riorly, cellulitis, purulent oedema, pelvic abscess, septicaemia and py- 
emia. (5) Laparotomy occupies much less time for its performance 
in order to expose the internal iliac artery than was occupied to reach 
the vessel by the incision of Cooper or Abernethy. As gluteal an- 
eurism, as a rule to which there is but one exception (which is doubt- 
ful), progresses steadily and rapidly to certain death from haemorrhage, 
expectant treatment is out of the question. 

Other methods have not proven eminendy successful, the operation 
of Antyllus giving according to Holmes, four recoveries out of five 
cases ; that of Anel, two recoveries out of four cases ; perchloride of 
iron injection, four recoveries out of six cases; proximal compression 
on the aorta with direct compression, failure ; ligature of the internal 
iliac by an incision parallel with Poupart's ligament and pushing back 
the peritoneum, six recoveries in eleven cases. It being recognized, 
however, that the Hunterian method of ligature of the main artery on 
the proximal side gives the best results, particularly where elastic com- 
pression is inapplicable as in the present instance, it remains to find a 
satisfactory way of applying it ; from the recapitulation at the begin- 
ning of this abstract, laparotomy would seem to supply the desider- 
atum. The author relates three cases, two of which occurred in his 
own practice : A. The first case occurred in a woman, Kt. 60, who 
presented pulsatile tumours in both gluteal regions, the tumours dating 
back a year and a half, and pain in the region, three years back. The 
external parts being thoroughly purified, an incision in the median 
line from the umbilicus to the symphysis pubis was made, the pelvic 
viscera, which would have hindered the operation, drawn without into 
warm moist sponges and towels, the internal iliac arteries of both sides 
ligatured in succession with catgut, the viscera returned, the external 
opening closed and antiseptic dressing applied; the patient died with 
suppression of urine and slight parenchymatous nephritis on the third 
day thereafter. B. The second case occurred in the practice of Dr. 
W. L. Chew, of Birmingham, Ala., and was a gluteal aneurism of the 
right side of a male negro, Kt. 46, the trouble dating back seven 



NERVOUS AND VASCULAR SYSTEMS. 57 

months. By a curved lateral incision the abdomen was opened, owing 
to the violent efforts of the patient and the difficulty of manipulation, 
a few coils of intestine drawn out, strong silk Ugature applied to the 
internal iUac, the parts cleansed, the incision closed and antiseptic 
dressing applied. Prompt adhesion occurred with rapid diminution of 
the tumour and cure. C. The third occurred in a female, aet. i8, and 
was associated with an aneurismal varix, the left side being affected ; 
the trouble dating back many years. Under careful antiseptic pre- 
cautions, the abdomen was opened, the incision finally extending 
from the symphysis to some distance above the umbilicus, the intes- 
tine drawn out sufficiently to permit the exposure of the vessel, 
a double twisted catgut ligature applied to the left internal iUac, the 
guts returned, the external incision closed and antiseptic dressing ap- 
plied ; the patient rallied quickly and the bowels moved normally on 
the fifth day ; a shght acute albuminuria due to congestion uf the kid- 
ney from the ligature of the main trunk of the internal iliac appeared 
on the following day, but soon disappeared. The aneurism together 
with the aneurismal varix was perfectly cured. These cases would 
seem to demonstrate satisfactorily the availabiUty of this method of 
treatment, the only real obstacle to the succesful issue of the operation 
being the occurrence of acute albuminuria, toward the prevention of 
which the study of surgeons should be directed. — Med. News. Nov. 

20, 1886. 

James E. Pilcher (U. S. Army). 

II. Basdor's Operation for Aneurisms of the Arch of the 
Aorta and of the Anonyma, By Dr. J. Rosenstirn (San Fran- 
cisco) . This article contains details and statistics not only of the 
cases collected by Pilz and by Koch (von Langenbeck's Archiv., Vols. 
IX and X) and notably by Wyeth (Am. Jour.. Med. Sci., 1881), but 
also of the scattered cases since published besides a new one of R.'s 
and one from Gerster (New York.) 

The operation was doubtless first performed by Mott in 1820, though 
the first pubhshed case was that of Wardrop (London, 1825), 

Only of late years has the operation been adopted in Germany. 

R. has brought together a total of 99 cases. These he divides as 
follows : 



5 8 INDEX OF S UR Gl CAL PRO GRESS. 

Ligature of Carotid and Right Subclavian, 38 cases 



WITHOUT ANTISEPTICS. 


WITH ANTISEPTICS. 


Cured. 


Improved. 


Not 
Improved 


Died from 
Operation. 


; Cured. 

i 


Iviproved. 


Not Im- 
proved. 


Died from 
Operation. 


2 


- 


I 


3 


14 


5 


5 


8 



ligature of the same vessels with an interval between, 10 CASES. 



LIGATURE OF THE RIGHT COMMON CAROTID, 31 CASES. 



ligature of THE RIGHT SUBCLAVIAN, 5 CASES. 






LIGATURE OF THE LEFT COMMON CAROTID, lO CASES. 



2 11 2 2 — 



Under the second class Smith's case (cure) is not included. Besides 
the above there are four other cases. 

a. Schede, 1884, ligature of left carotid and later of left subclavian, 
with improvement for a time. 

b. Busch, 1880-1, ligature of left carotid and axillaris. Death three 
days p. o. 

c. Wilhelm, 1826, left subclavian vein mistaken for the artery and 
tied. Death on seventh day. 

d. Morris, 1882, internal jugular tied by mistake instead of the right 
carotid. Death on fourteenth day. 

Co-ligature of left carotid and subclavian has never been performed, 
although Busch's case above approximated this. 

R.'s patient was a Swedish woman, aet. 42. Present trouble began 
two and a half years before. Other forms of treatment unavailing. 
Pulsatmg. Tumour size of a hen's egg displacing trachea, causing 
great pain, loss of flesh, etc. He tied the right common carotid and 



HEAD AND NECR. 59 

the subclavian November 26, 1883, in the German Hospital at S. F. 
The subclavian was readily secured. While freeing the carotid the an- 
terior mediastinal space was punctured and some air dra^vn in when 
a compress closed the opening. Silk ligatures. Drainage tube and 
stitches removed at second change of dressing fourteen days later. 
The right radial pulse did not reappear until January 20, the temporal 
until March, 1884. The tumour slowly diminished, though it is still 
detectable. Pulsation at first diminished also, but of late has returned 
fn full force. Patient last seen in April, 1886. She was again able to 
fill her place as housekeeper, and was free of her former suffering. 
Atrophy and wasting of the right arm, following the operation, were 
remedied by electricity and massage. 

Despite the views of Holmes and Marsh (1885) and Kiister, R. con- 
cludes from a study of the cases that co-ligature of both vessels is 
preferable to two separate operations. Ligation of the subclavian is 
certainly the more important part. In several of the cases subsequent 
autopsy showed the carotid to be still partially open. After briefly re- 
viewing other methods of treatment and their results, he decides that 
ligation is far the most successful. — Arch. f. klin. Chirg. 1886. Bd. 
34. Hft. I. 

HEAD AND NECK. 

I. The Formation of a New Nasal Skeleton from the 
Frontal Bone. By Prof Konig (Gottingen). In cases where the 
bony framework of the nose has been destroyed, all attempts hereto- 
fore at reconstructing a proper profile have failed. 

In view of four fairly successful cases, K. here presents a method 
which he has devised. First, the soft parts (tip and alae) are made 
mobile by a transverse cut through the most sunken (saddle) portion 
of the nose. If this lower part is then drawn down into its normal 
position, a broad gaping defect appears. This is first bridged over by 
cutting a ^/^ to i^j ctm. wide oblong flap from the forehead perpen- 
dicularly upwards from the bridge of the nose. This flap includes 
skin, periosteum and cortical layer of frontal bone — the latter being 
cut around by a chisel. The whole is then loosened by following down 



6o 



INDEX OF SURGICAL PROGRESS. 



through the diploe with a chisel the exact width of the flap ; at its 
lower end, just at the beginning of the nose, it is bent straight over 
downwards in front. This brings the skin side of the flap to face the 
interior of the nose and leaves the bone exposed. Of course, the size 
of this flap has been so calculated that it just covers the above men- 
tioned defect. At its free end it is so sewed to the apex that the (ex- 
ternal) cutaneous border of the latter remains free. To this free edge 
of skin as well as around the defect, he now sews a cover-flap ^taken 
laterally from the forehead. 

Hence, the bone-periost-skin flap constitutes the inner lining of the 
nose. The bony profile of the nose is thus given an ample promi- 
nence. Some little corrections may still be necessary about the root 
of the nose. 

His 4 cases included 2 from syphilis, i from injury, and i in a boy, 
set. 15, from necrosis. The good results have proved lasting — t^^\.^_^ 
years, 2^2 years, and in two i year, have passed since the operation. 
All his flaps, even when a little less than i ctm. wide, have proven via- 
ble. 

It is better not to operate so long as there is ozoena from ne 
crosis or ulceration. Wood-cuts and lithographs accompanying the 
article. * 

K. states that he is trying this method in cases of total loss of the 
nose. — Arch.f. klht. Chir., 1886, Bd. 34, Hft. i. 

II. On the Mortality of Operated Hare-lip and Cleft Pal- 
ate. By Dr. A. Hoffa (Wiirzburg). This article adds 80 cases from 
various operators in Wiirzburg and Freiburg — 1870 to 1885 — to pre- 
vious statistics \y. Annals, 1886. Jan., p. 80-83], Of the whole 80, 
24 (30%) have since died. Of 64 under one year old, 19 (30%) died 
before the end of that year. The collective statistics for the first year 
give 373 cases, with 129 (35%) deaths. Hoffa endeavors to deter- 
mine how far the fatal results were due to the operation, and how far 
to the malformation itself. The normal death-rate the first year from 
an average for various countries, he gives as 25%, leaving 10% due to 
one or both of the causes mentioned. To determine between these 



HEAD AND NECK. 6 1 

he divides the respective cases of Fritzschl, Gotthelf, Abel and himself 
into three classes, according as the chief deformity was : I, hare-lip ; 
II, complete fissure ; III, bi-lateral fissure : 

Group I. 114 cases, with 27 deaths (23.7%) 
" II. 1 1 1 cases, with 43 deaths (39%) 
" III. 41 cases, with 24 deaths (59%). 

From these figures, showing progressive mortality as the trouble in- 
creases, it cannot be doubted that the malformation itself has a great 
influence on the mortahty. This conclusion is opposed to that of 
Gotthelf, who blamed the severer operation for the increasing mortality. 
Those of the III class are usually born weak and atrophic, and with 
great tendency to respiratory and digestive troubles. The respiratory 
troubles are remedied to a far greater extent by the operation than are 
the digestive. H. endeavors by other statistics to further establish his 
view of the prevailing influence of the malformation itself, rather than 
the operation, on the mortality, but decisive facts are wanting. 

By adding up 620 published cases of all ages, he finds the mortaUty 
for the first two weeks p. o. to have been 60 (9 6%) ; from the second 
week to the end cf the third month in 439 cases it was 67 (15%)- 01 
336 cases 55 (16%) died between the third month and the end of the 
fourth year. Of 39 cases of bi-lateral cleft palate Avith os prominens 
operated under one year of age, 25 (63%) died within a couple of 
years. By comparing two curves, one representing the normal death, 
the other that of the operated children during the first year, he finds 
that the second to the sixth month, inclusive, is the most favorable tniie 
for operating. Dentition, which then begins, shows a deleterious influ- 
ence. As an evidence of the advantage of operating early he cites a 
case where the fip was treated, and at the end of three years the pre- 
viously existing alveolar and anterior palatal fissure had completely 
healed o\M.—Arch.f. klin. Chir., 1886. Bd. 33, Hft. iii. 

III. Contributions to the Theory of Goitre. By Dr. J. 

ScHRANZ (Hopfgarten in Tyrol). A two years' experience with this 
trouble in a region where it is endemic, furnished the incentive to an 
article on certain points in connection with goitre, especially on the 



62 INDEX OF SURGICAL PROGRESS. 

dependence of alterations in the cardiac action on volume-changes 
in the thyroid gland. With the enlargement of the thyroid the author 
has frequently observed that abnormities appear in other organs of the 
body — heart affections being one of these. 

His collective cases represented 739 goitres amongst 3,304 individ- 
uals living and dead — 750 private patients with 117 goitres, 557 
school children with 245, 1,700 autopsies at the Innsbruck Pathologi- 
cal Institute with 308, and 227 insane at Hall with 68 goitres. 

All cases, even the lighter forms, are included, though in younger 
patients it sometimes subsides later. These figures show that the Ger- 
man Tyrol is as much afflicted by goitre as even the worst parts of 
Switzerland. Still, cretinism and deaf-mutism is rare, the trouble be- 
ing rather extensive than severe. 

In the upper classes in school it was more frequent than in the lower, 
in harmony with Bircher and others. 

Of the 739 cases of goitre, 344 were also the subject of heart 
trouble ; 47 of the latter had valvular lesions, the balance hypertro- 
phy, dilatation, fatty or other degeneration, or clinically, abnormal 
heart-action. In the same region heart affections in the non-goitrous 
and phthisis, are not very frequent, e. g., of 174 heart cases amongst 
1,307 individuals (school children and private patients), 115 also had 
goitre. His statistics, like those of other observers, show a slight ex- 
cess of females amongst the goitrous. When the affection is one- 
sided, it has a great [)redilection for the right, collectively 92 r. to 19 
1., the separate lists also bearing this out. 

Hill residence slightly tends to increase the number of goitrous 
(10:9) as might, a priori, be expected from their greater physical strain. 

As to geognostic conditions, argillaceous slate regions showed a 
maximum of goitrous, sandstone a minimum. 

In a table are shown the results of examination of the drinking 
water in the various districts where the school children lived. From 
these, however, he is unable to draw any positive conclusions. 

To return to the influence on the heart, he says: " There is no 
doubt that enlargement of the thyroid and abnormities of the heart 
very frequently occur together." As to the innate connection between 



HEAD AND NECK. 63 

the two, various possibilities have to be considered. The symptoms 
point to a disturbed and especially a weakened heart-action. The re- 
turn of blood to the heart is impeded partly by direct pressure on the 
veins, partly by compression of the trachea and interference with res- 
piration. The introduction of a more or less volummous vascular net- 
work into the circulation also directly increases the strain on the heart. 
In the one case dilatation, in the other over-action and hypertrophy 
result, and in both cases, finally, degeneration of the heart. This re- 
sult (hypertrophy or dilatation, with or without fatty degeneration) is 
observed in all autopsies of long-standing cases where the goitre has 
exerted pressure. In many cases heart trouble is certainly caused by 
goitre, but there are reasons for thinking that the reverse also occurs, 
amongst others the fact that in several cases goitre developed imme- 
diately after over-action or hypertrophy of the heart, and repeatedly 
disappeared again as soon as the heart trouble subsided. 

That the enlargement of the thyroid may in many cases be the re- 
sult of a vasomotor neurosis seems to have been first suggested to him 
by the following case : A girl with a small goitre, but no sign of heart 
trouble, was attacked by a pecuHar, almost continuous, cough for three 
days and nights, with further symptoms (almost imperceptible radial 
pulse, increased second pulmonary sound, dry rhonchi, face pale, ex- 
tremities cool, etc.) pointing to spasm of the vaso-motors, forcing an 
over-quantity of blood into the lungs. Meanwhile the goitre 
became smaller. A half year later, after an exhausting 
foot tour, an enormous goitre developed within forty-eight 
hours — the customary cough disappearing entirely, the heart acting 
steadily, face and extremities natural. This was the exact opposite of 
the earlier condition. S. beHeves it to have been but the expression 
of a relaxed condition of the vasomotors, a somewhat similar relaxa- 
tion being normally observed after like exercise. Again, a boy suf- 
fered an extensive burn of the/<2^^. During exfoliation and suppura- 
tion a goitre developed. When the wouads healed the goitre disap- 
peared. This S. explains by the fact that irritation of the skin causes 
a local anemia, followed by vasomotor paralysis. For further cor- 
roboration, he makes a comparison with Graves' disease. In the early 



64 INDEX Oh SURGICAL PROGRESS 

Stages bromide, not iodide, is in place. When, however, hyperplasy 
has resulted, the iodides are of value. In this, as in Graves' dis- 
ease, though less often, similar cardiac conditions occur. Sudden 
death is common to both forms. 

Physiology teaches us many agencies which depress the vas- 
cular tonus — straining work of any kind, tiresome marches, cHmbing, 
forced playing on wind instruments, difficult births, rapid temperature 
changes, lowered atmospheric pressure, use of alcohol, etc. The re- 
sulting condition may in these cases become permanent. These are 
also the most frequent causes of goitre, as S.'s cases show. Seacoasts 
are also free from goitre, whilst the Alps, Cordilleras and Himalayas 
are its home. In his region the atmospheric pressure is from 40 to 60 
mm. Hg. lower than at the sea level. A variety of other factors, such 
as temperature changes and greater physical strain, combined with the 
lowered atmospheric pressure in elevated regions. 

In harmony with this theory is the fact that goitre occurs more fre- 
quently in youth and amongst women, their vascular tonus being more 
mobile. 

The goitrous tendency might be gradually developed where genera- 
tions continue under favoring conditions. 

This alteration in the vasomotors would explain the heart troubles 
as well as the goitre. The five drunkards amongst the lunatics were 
all goitrous, and four had also cardiac affections. 

As to the relation of goitre to cretinism, cachexia strumipriva, etc., 
he merely makes suggestions. 

He remarks that any procedure requiring narcosis or in any way 
straining the heart is in the goitrous especially dangerous, and that 
their fate depends on the heart. — Arch.f.klin. C/nV., 1886, Bd. 34, 
Hft. i. 

W. Browning (Brooklyn.) 

IV. CEdematous Laryngitis. Tracheotomy. Glossitis 
Terminating in Abscess. Severe Haemorrhage from 
Tongue. Recovery. By D. H. Charles, M. D. The patient 
was a healthy man, set. 44, who had had a slight laryngeal inflammation 



I 



BEAD AND NECK. 05 

from exposure to cold a month before. This subsided, but recurred 
soon after, and he had suffered more or less with his throat for three 
weeks prior to the severe attack now described. 

He was suddenly attacked, whilst at work, with urgent dyspnoea, 
and with difficulty got home. Soothing medicated inhalations, diapho- 
retics and a purge were at once employed, with bUstering and hot com- 
press over the larynx. When Dr. Charles saw him, two days later, 
he had all the characteristic symptoms of oedematous laryngitis; and 
the laryngoscope showed great reddening and swelling of the epi- 
glottis and false cords. The affected parts were swabbed with nitrate 
of silver solution (3j: ^i), followed by great and almost immediate re- 
lief. Ten hours later he was seized with urgent dyspnoea and almost 
asphyxiated. 

Laryngo-tracheotomy was now performed, and was followed by im- 
mediate relief of all the alarming symptoms. He was surrounded by 
an atmosphere of steam vapour. 

I Next morning the tongue was greatly swollen and purplish, and pro- 
truded between the teeth. It was incised in two places. Fed through 
a tube. 

Next day, breathing still easy. The tongue greatly enlarged. 
Swelling and tenderness of right side of neck from ear to clavicle. 

Tongue again incised, and one ounce of blood escaped. This re- 
Heved him, and three days later there was considerable discharge of 
fetid pus from the tongue. 

Purulent matter and blood continued to be discharged from the 
mouth during the next two days. 

On the third day there were six attacks of haemorrhage, the exact 
source of which could not be ascertained. Solution of perchloride of 
iron applied on lint lo right side of tongue. 

Next day there was severe haemorrhage from a ragged cavity at 
right side of root of tongue, which was stuffed with lint soaked in 
pemitrate of iron solution. Plug removed two days later. There were 
slight recurrences of haemorrhage, one on the day after the plug was 
removed and two subsequently, but the patient progressed favorably 
and is now quite well, with the exception of some wasting and loss of 



66 INDEX OF SURGICAL PROGRESS. 

power in the right side of the tongue. This, however, is getting less. 

In his remarks on the case, the author refers to the marked but only 
temporary rehef afforded by the application of nitrate of silver. He 
contrasts this with the complete and permanent relief of dyspnoea, fol- 
lowing laryngo-tracheotomy, and justifies the choice of this operation 
rather than tracheotomy on the ground (first) of its being easier to 
perform under unfavorable circumstances (/. ^., with little assistance 
and in inconvenient position), and (secondly) for a reason which is less 
obvious — " to keep the incision as high as possible." He considers 
the inflammation of the tongue as an extension from the epiglottis. 

He regrets (we think rightly) not having made much more extensive 
incisions in the tongue. Might not the epiglottis and anterio-epi- 
glottidean folds have been scarified in the first instance ? 

With reference to the haemorrhages which occurred, Dr. Charles 
speaks of being prepared to tie the external carotid. (Why not the lin- 
gual 1) He thinks the wasting and loss of power of the right side of 
the tongue due to inflammatory degeneration of the muscular tissue. 

The mortality of the affections which he gives, according to Sestier, 
as 158 out of 213, and, as reported by Bayle, 16 out of 17 seems ex- 
cessive. Durham gives 19 out of 30 — Brit. Med. Journal., Nov. 6, 
1886. 

B. Wainewright (London). 

V. Two Cases of Acute Glossitis. Dr. Totherick. Both 
cases occurred in the Wolverhampton General Hospital. 

Case I. E. R., set. 21, tongue covered by thick, brown fur, hard, 
immensely swollen, tip projecting half an inch beyond teeth ; immova- 
bly fixed. Great pain and tenderness on pressure. Salivation profuse. 
Breath very offensive. Deglutition difficult. Headache, pulse in- 
creased, and temperature slightly raised. Gradually completely recov- 
ered. 

Case H. J. P., set. 27, sudden swelling of tongue. The condition 
was exactly similar to preceding case. Slight albuminuria. There was 
some slight superficial sloughing under tongue and gums. In this case 
an incision was made on either side of median line of tongue. Made 
a good recovery. 



! 



HEAD AND NECK. 6/ 

As a rule, acute glossitis ends in resolution. It may, however, extend 
backwards to the larynx and render laryngotomy necessary. In a few 
cases suppuration occurs ; and still more rarely, permanent thickening 
may be left. The most usual cause for it is said to be " catching cold," 
and it is supposed by some authorities to be catarrhal in its origin. — 
Lancet, Oct. i6, 1886. 

VI. Malignant Cysts of Neck. Mr. F. Treves. The clinical 
course of the three cases on which this paper was founded were all 
similar. Tue growths were considered to be cystic on account of their 
containing a very small amount of solid material. One cyst con- 
tained pure lymph, in the other two the contents were mucinoid. One 
specimen (still alive) was shown. The first case when seen was fifty- 
three years of age. The tumour was situated in the left side of the 
neck, the skin over being red and brawny. It commenced as a small 
mass, apparently beneath the sterno -mastoid muscle, and was regarded 
as a chronic abscess, until an exploratory puncture gave exit to a clear, 
glairy fluid, which was pronounced on chemical analysis to be mucin. 
The cyst proved to be deeply attached. It discharged continuously, 
was treated with injection of iodine ; the discharge became purulent, 
and finally haemorrhage took place and closed the scene. At the post- 
mortem there was an imperfect cyst, whose walls were nowhere more 
than half an inch thick. The inner aspect of the walls resembled the 
cclumnse carneoe of the ventricles of the heart. The second case was 
that of a woman, set. 52, in which the soUd carcinoma formed one-sixth 
part of the whole mass. This cyst was removed during life ; the internal 
jugular vein was cut, and the brachial plexus exposed ; patient died ten 
days aftc. The cyst closely resembled the preceding one. The third 
was epitheUomatous. The patient in whom it occurred was 43 years of 
age, and had been operated on for epithelioma of the right side of the 
tongue. Fourteen months after the tumour appeared on the left side 
of the neck. The skin over it was red and brawny, and on being 
tapped yielded a fluid chemically similar to lymph. Bleeding also oc- 
curred in this case. The cyst wall was not more than a quarter of an 
inch thick in any part. No secondary deposits. — Lancet, 1SS6, Oct. 23. 



68 INDEX OF SURGICAL PROGRESS. 

VII. Acute Myxoedema Following Thyroidectomy. Sir 
William Stokes. A woman, set. i8, was admitted into the Rich- 
mond Hospital with extensive disease of both lobes of the thyroid. 
Health good, fresh complexion, well nourished; family histor}' good. 
Her chief trouble was dyspnoeic attacks, usually at night. It was de- 
cided to remove the gland. Sir William removed it by the method ad- 
vocated by Kocher. He mentions the great difficulty he experienced, 
and the profusion of the hemorrhage, which at times seemed uncon- 
trollable and threatened the patient's lite. In the end only the left 
lobe was got away. The patient made a good recovery, was relieved 
of the dyspnoea and the right lobe somewhat diminished in size. This, 
however, did not last long, as the lobe again began to enlarge and 
dyspnoea came on again. With still greater difficulty and danger the 
lobe was removed. Within fourteen days puffy swelling was noted 
about eyelids, backs of wrists, and over metatarsus of both feet. Also 
some mental torpidity. She also had fits, characterized by great livi J- 
ity of face, stertorous breathing, dyspnoea, quick pulse, eyes staring 
and protruding, pupils dilated, and carotids throbbing, ending in copi- 
ous perspiration. No albuminuria. All these symptoms increased, 
and pulmonary infiltration supervened. She died nineteen days after 
the last operation. Sir William draws attention to the marked myxoe- 
dematous symptoms and to their rapid onset. He then mentions two 
other cases of thyroidectomy done by himself, in one of which he par- 
tially removed the gland with permanently good result. In the other, 
division of the isthmus was followed by a satisfactory issue. — Brit. 
Med. Jour., Oct. i6, 1886. 

VIII. On the Surgical Treatment of Certain Tumours of 
the Neck. Frederick B. Jessett, F. R. C. S. Mr. Jessett advo- 
cates a somewhat bolder surgery in dealing with deep tumours of the 
neck. He views with very little fear ligature of both carotid artery 
and internal jugular vein. Even division of vagus, sympathetic, 
phrenic, laryngeal nerves have been divided with " only temporary in- 
convenience." 

In one of the cases operated on there was a large growth, which 



HEAD AND NECK. 69 

had formed slowly, deeply seated and extending from the ear nearly to 
the clavicle, and quite immovable. No pain, but congestion of con- 
junctiva, some opacity of cornea with a central ulcer, also ptosis. Left 
half of face redder than the right, and apparently warmer. Treatment 
left condition of eye unaffected. The growth was then removed and 
found to consist of caseous glands. The man made a good recovery, 
and within a week the ocular troubles disappeared. Mr. Jessett goes 
on to narrate several cases of both innocent and malignant growths 
which have been extirpated with good results, and sums up as follows : 
(i). All innocent tumors in these regions may be removed. (2). 
That malignant growths may be removed when situated in the tri- 
angles of the neck, provided they are freely movable, that the skin and 
superficial structures are not implicated, notwithstanding their size and 
the possibility of the large vessels being implicated in the growth. — 
Brit. Med. Jour., Oct. 16, 1885. 

IX. Adenoid Growths in the Pharynx. Sir William 15. 
D.\LBv. These growths can be removed by many methods, and if 
done thoroughly the result is always satisfactory. If the operator is 
possessed of an efficient finger-nail, nothing can be better, but all sur- 
geon's fingers are not sufficiently adapted to and strong enough to re- 
move some of the firmer kinds of growth. In these cases Sir Wil- 
liam Dalby recommends his artificial finger-nail. The instrument is so 
made that the sensitive tip of the finger is uncovered, and is most use- 
ful in estimating by touch what is being done. By this method also 
the head can be bent forward, and by this means the blood is pre- 
vented from running downwards. Then, again, the artificial nail 
works so thoroughly that all growth can be removed at one sitting. In 
children it is best to employ an anaesthetic. Besides, the departure of 
the three symptoms, viz, the tendency to Eustachian obstruction, 
the consequent deafness (which generally directs attention to the 
trouole), and the nasal obstruction — which follows the removal of the 
adenoid growths, there are other advantages to be reckoned, such as 
the better prospects of recovery in cases of diphtheria or scarlet fever 
occurring, with an empty rather than a blocked pharynx, as well as the 
better chances of the middle ear escaping destruction during diseases 



/O INDEX OF SURGICAL PROGRESS. 

The improvement also of the general health, with free nasal breath- 
ing, as well as diminished tendency to bronchial affections, require only 
mention to be appreciated. — Lancet, Oct. 2, 1886. 

H. H. Taylor (London). 
X. Congenital Stenosis of the Trachea from Ab- 
normal Curvature of the Cartilage Rings. By Dr. M. 
ScHxMiDT (Cuxhaven). Female child, £et. 6 months, well developed 
and nourished, had, since her birth, always much difficulty in breath- 
ing. At times violent attacks of dyspnoea with accompanying cyanosis 
of the lips and cold sweats, especially during the night. Loud inspira- 
tory stridor always present. Nostrils much distended, especially on 
inspiration. The deep inspiratory drawing-in of the epigastrium and 
lower sides of the thorax, where not only the intercostal spaces, but 
large portions of the thorax-walls were sunken in even, very noticeable. 
Nothing abnormal about the neck, nor did a digital examination of the 
orifice of the larynx, per os, reveal anything that could cause the symp- 
toms above mentioned. The inspiratory stenosis-murmur resembled 
closely that of laryngeal croup, and pointed to the larynx as the point 
of obstruction to the breathing. Tracheotomy proposed. Four days 
later crico-tracheotomy performed and a canula introduced. This had 
no beneficial influence whatever on the dyspnoea, and the condition of 
the patient remained unimproved. Collapse soon followed, the pulse 
became weak and frequent, and death ensued the next day. At the 
autopsy it was found that the larynx, oesophagus, thyroid and thymus 
glands were normal. The trachea was dissected free of its surround- 
ings, and nothing abnormal observed when inspected posteriorly. On 
opening it, however, (in the usual manner, posteriorly in the middle) 
and spreading it out, the upper cartilage rings yielded easily to the 
pressure as usual. Lower down, on the contrary, the left sides of the 
rings were stiff, offering considerable resistance to the pressure made 
on them in this way, and turning more slowly inward. When the whole 
trachea was spread out it was seen that the curvature of the upper 
rings was quite flattened out, while the left sides of the lower rings 
formed with their anterior portions a sharp angular crease. This 
caused a veritable ridge in the lower portion of the trachea, appearing 



HEAD AND NECK. / 1 

on the mucous surface of the organ as a vertical line at the boundary 
of the anterior and left lateral parts. Along the line the curving of all 
the lower rings was broken by the angular bend inwards. In the lower 
portion of the trachea on the left wall was also a somewhat concave 
impression as if caused by the pressure of an egg-shaped body. This 
reached down to the bifurcation ; the angle, where the left bronchus 
joins the trachea, appearing in consequence, somewhat rounded out. 
The length of the affected portion of the trachea, from the bifurcation 
upward, measured 2.8 cm., the whole length of the trachea to the cri- 
coid cartilage being 4.6 cm. No cause for the stenosis was found. 
This deformity of the trachea would satisfactorily explain the phenom- 
ena observed during life. The stenosis, while great enough to give 
rise to the dyspnoea and continued stridor, had not been sufficiently 
large to cause death. Complication with the operative trauma was 
followed by fatal results. The opening made in the trachea being sit- 
uated above the stenosed portion, and the lower end of the canula not 
reaching it either, of course no beneficial result to the patient could 
take place. Inferior tracheotomy alone could have accomplished any- 
thing. Author considers the case one of congenital stenosis of the 
trachea, caused by faulty curvature of the cartilage. His case is in- 
structive, as demonstrating that in similar cases where tracheotomy is 
indicated, it will be well to do this as low down as possible. — Deutsch. 
Med. Wochefischrift. No. 40. Oct. 7, 1886. 

XI. Isolated Extirpation of the Cricoid Cartilage for Ec- 
chondroma. By Dr. A. Bocker (Berhn). Rokitanski reported cases 
of hyperostosis and exostosis of the ossified larynx cartilages, but to 
Virchow we are mdebted for our knowledge of ecchondroma of the 
larynx. They are found as diffuse and smooth growths, also as knotty 
circumscribed excrescences, on both the thyroid and cricoid cartilages, 
having the general tendency of growing inwards, into the lumen of the 
larynx. Ecchondroma may be easily mistaken for polypi, being cov- 
ered with normal mucous membrane. They are not operative from 
above. The number of published cases is small. Those of Macilvain 
(1831) and Ryland (1835) should not be included, as it is somewhat 



72 lADEX OF SURGICAL PROGRESS. 

probable that both were cases of hyperplasia of the connective tissue, 
as we often see in syphilis. The first authenticated case is that of 
Froriep, published in 1834. The chondrom, the size of a walnut, was 
situated on the inner surface of the larynx, extending far into the lu- 
men and resting on the right vocal chord. A second case was re- 
ported by Mackenzie in 1880. The chondroma, as large as a hen's 
egg, arose from the cricoid cartilage, growing downwards and in front 
of the anterior surface of the trachea. Turck reported the first laryn- 
goscopical observation (/. e., on the living subject) of such a tumour, 
in 1863, and to this must be added a case of Stork in Vienna, one pub- 
lished by Ehrendorter, and lastly a case reported by Asch, in 1884, 

The author gives the following cases : 

Case I. Male, aet. 23, healthy in appearance, and showing nothing 
abnormal about the neck. Laryngoscupical examination disclosed a 
small tumour, the size of a bean, covered with normal mucous mem- 
brane, lying just beneath the right vocal chord quite near its anterior 
attachment. It arose from the inner surface of the thyroid cartilage 
near the anterior line of union. The anterior end of the right chord 
was raised upwards somewhat and displaced outwardly by the tumour. 
The membrane of the rest of the larynx was normal. Examination 
with the sound showed the tumour to be hard and knotty and firmly 
attached to the lamella of the thyroid. Attempts to grasp it with a 
forceps were unsuccessful. Its entire removal was finally effected with 
the help of a cutting forceps, constructed on the plan of those of Luer. 
The speech of the patient was completely restored. The tumour con- 
sisted of hyaline cartilage. 

Case II. Male, set. 62, of middle size, pale and slender appearance. 
Had had difficulty in breathing for some time, which had increased of 
late. No pulmonary catarrh. A distinct stenotic murmur heard 
during quick inspiration. Laryngoscopical examination. Larynx 
showed no inflammatory process. On intonation the vocal chords 
closed in the normal manner. On inspiration, however, a somewhat 
rounded, oval tumour was seen extending into the lumen of the larynx 
from its posterior wall just beneath the posterior end of the vocal 
chords. It arose from the whole inner surface of the lamella of the 



CHEST AND ABDOMEN. 73 

thyroid and the neighboring left arch of the cricoid cartilage, reducing 
the lumen of the larynx so much that but a sickle-like aperture re- 
mained for breathing. Tumour had a smooth surface, being about 
the size of a hazelnut. Swallowing easy. Extirpation advised. Tra- 
cheotomy first, with division of the three upper rings. Digital exam- 
ination showed the lumour to be immovable, its place of attachment 
being the same as described above. A tampon-canula of Hahn was 
introduced, the cricoid cartilage divided in the median line. The cri- 
coid was so much involved in the neoplasm, that the removal of the 
tumour alone was not possible. The incision, therefore, lengthened 
upwards to the hyoid bone and the whole cricoid excised. Haemor- 
rhage was considerable. Wound washed out with solution of corro- 
sive sublimate and plugged with iodoform gauze. No fever followed 
the operation. Patient could eat and drink without difficulty or 
discomfort. A secondary haemorrhage occurring five days later, ex- 
hausted the patient somewhat, but did not otherwise affect his recov- 
ery. Discharged cured in five weeks. The tumour had the structure 
of hyaline cartilage and showed a regressive metamorphosis of the cel- 
lular elements. Various changes in the larynx of the patient took 
place after removal of the cricoid. The chords appeared shortened 
and wabbled somewhat on intonation. The arytenoid cartilages ap - 
proached nearer one another, and on inspiration the chords rested 
against each other. Patient wears a canula, closing it when speaking 
or using a simple ventilated canula of Bruns. His voice is distinct 
but hoarse and rough. He is healthy and feels well and strong. 
Bruns lately operated a case of ecchondrosis of the larynx, arising from 
the plate of the cricoid, by chiseling it off. The canula could, of 
course, be dispensed with afterwards in this case. — Deutsch. Med. 
Wochen. No. 43. Oct. 28, 1886. 

C. J. COLLES (New York). 

ABDOMEN. 

I. Contributions to the Theory of Hernia. By Prof. E. 

KuESTER (Berlin). Besides the hernia inguino-properitoneaUs of 
Kronlein and the h. inguino-interstitialis of Goyrand (v. Annals, 1886. 



74 INDEX OF SURGICAL PROGRESS 

March. P. 242), Kiister here makes out a third probably related 
form which he calls hernia inguino-superficialis. The first form is 
characterized by the diverticle, which forms the hernial sac in the com- 
mon external inguinal rupture, being forced in between peritoneum and 
transverse fascia; the second form by the second part of the sac lying in 
front of the transverse fascia between the muscular layers of the front 
belly-wall ; whilst in the third variety, here distinguished, the sac comes 
out through the anterior inguinal ring, does not sink into the scrotun. 
or only partially, but turns either up and outwards under the skin of 
the abdomen, or out and downwards under the skin of the leg, or 
backwards under the perineum. 

He gives the history of three new illustrative cases, two of which 
were operated, one of the two giving an opportunity for a post mortem 
examination. 

The peculiarities of the three cases are summed up as follows : 

1. The hernial sack is an open peritoneal diverticle, in which lie 
testicle and spermatic cord. Consequently they are exclusively con- 
genital (in the sense of being existent but not developed). The her- 
nial opening is wide, and traverses the belly-wall directly from front 
backward. 

2. The testicle has not descended into the scrotum, but is in the 
vicinity of the external inguinal ring, sometimes at a distance from it 
but always ectopied. 

3. The testicle is always atrophic, the spermatic cord in most cases 
too short. 

4. In two cases the spermatic cord did not lie on the median side of 
the hernial sack, as is otherwise the case in inguinal hernia without ex- 
ception, but on the lateral side. 

5. The sack is covered exclusively by skin and the attenuated su- 
perficial fascia. The infundibuliform fascia and cremaster muscle are 
either entirely wanting or but slightly developed. 

A fourth double-sided case he mentions having seen, and includes 
abstracts of the few more or less corresponding cases to be found 
in the literature. 

K. next considers the operative technique in hernia of such viscera 



BONES, JOINTS, ORTHOPAEDIC. 75 

as are not wholly covered by peritoneum, coecum, colon, etc. In this 
case a wide displacement of the peritoneum may have drawn the at- 
tached intestine along into the sack. Such ruptures are either con- 
genital, or at least old and large. 

A variety of difficulties may arise in operating, and as no definite 
plan of procedure seems to have been laid down, K. gives a case to 
show his method. It consists essentially in preparing back the sack 
and adjacent peritoneum, thus allowing reposition. In congenital 
cases this is interfered wiih by the fan-like constituents of the sper- 
matic cord as they course over the sac. However small the testicle 
is usually atrophic. It can be removed and the radical operation com- 
pleted.— .4 rr//. /. /(-/m. C/z/r^'-. 1886. Bd. 34. JIft. I. 

W. Browning (Brooklyn). 

EXTREMITIES. 

I. Treatment of Ingrowing Toe-nail with Tannin. Philip 
MiALL (Bradford). A communication from Switzerland in the British 
Medical Journal for October 23 recommends the local application of 
perchloride of iron with rest. I have for' many years used tannin for 
the same purpose, and do not find rest necessary. A concentrated 
solution (an ounce of perfectly fresh tannic acid dissolved in six 
drachms of pure water with a gentle heat) must be painted on the soft 
parts twice a day. '1 wo cases recently had no pain or lameness 
after the first application, and went about their work immediately 
which they could not before. After about three weeks of this treat- 
ment the nail had grown to its proper length and breadth, and the cure 
was complete. No other treatment of any kind was used, though for- 
merly introduced lint under the ingrowing edge in such cases. One of 
the patients was a mill-girl and the other a housemaid, and both were 
on their feet many hours a day. 

BONES, JOINTS, ORTHOPEDIC. 

I. Excision of the Elbow-Joint with Suture of the Ole- 
cranon to the Lower End of the Ulna. Mr. C. F. Pickering 
(Bristol). A strumous girl, aet. 15. Longitudinal incision over back 



7^ INDEX OF SURGICAL PROGRESS. 

of joint. Tip of olecranon then cut off with a sharp chisel, and joint 
thus opened, '' Diseased ends of bones" were then removed, After- 
wards tip of olecranon was united by a strong wire suture to the sawn 
surface of the ulna. Patient made a good recovery. 

Operation was in February. In September, " the power of exten- 
sion is good, better than that of flexion ; the latter has been delayed 
by the greatly wasted condition of the biceps." Wire left in. — Lan- 
cet, Oct. 2, 1886, p. 62S. 

C. B. Keetlev (London). 

II. Five Hundred and Sixteen Cases of Compound Frac- 
ture with Points of Especial Interest Observed in Connec- 
tion v^^ith them. By F. S. Dennis. M. D., (New York). In this 
paper the author states that he has modified his former opinion that 
the dressing in compound fractures should remain undisturbed during 
the entire period of repair, and, as a result of certain unhappy experi- 
ences where displacement had taken place under the dressing and 
marked deformity resulted, he now inspects the fracture after eight 
days and then again after ten days, after which no serious deviation 
can occur. He strongly emphasizes the desirability of early antisep- 
sis, and advises antiseptic irrigation as soon as the patient is seen and 
the appHcation of a temporary dressing before the patient is removed 
to the hospital. In a case of fracture of the skull with meningeal 
haemorrhage in which, after exposing the bleeding point A\ath the 
trephine.he was unable to seize it with artery forceps on account of the 
dura mater receding before them, he passed a tenaculum through the 
dura in such a manner as to include the artery in its curve, relaxing 
that portion of the membrane so that the traditionally difficult manoeu- 
vre of ligature of the meningeal artery could be performed with ease ; 
no inflammatory trouble ensued. He also relates two cases of the 
formation of a surface clot, resulting from epidural haemorrhage 
by co7itre coup, without fracture, and recommends exploratory trephin- 
ing in case such a condition is suspected. After a few remarks upon 
fatty embohsm and insanity after fracture of the skull, he expresses his 
belief in the origin of certain cases of sarcoma in fracture of the 



BONES, JOINTS, ORTHOPEDIC. 77 

affected bone, and relates two cases in which the growth could be 
traced directly to that causation; epitheUoma may also develop in the 
tendo Achillis,the hamstrings, or any other tendons, whose section may 
render reduction or the maintenance in reduction more satisfactory. 
After a brief discussion of the greater infrequency of amputation 
after compound fractures in the present than in the past, which he very 
correctly attributes to the adoption of antiseptic methods of treatment, 
he concludes with a brief analysis of his 516 cases, which may be tab- 
ulated as follows : 



78 



INDEX OF SURGICAL PROGRESS. 



Parts affected. 



Skull 



Arm 

Forearm 

Thigh 

Leg 

Fingers and toes 

Involving shoulder, 
elbow or wiist- 
joint (result of ac- 
cident or opera- 
tion 

Involving hip, knee 
and ankle joints. 



Involving carpal 
and metacarpal, 
tarsal and meta- 
tarsal joints. 

Superior and infe- 
r i o r maxillary 
bones (4 required 
suturing by silveri 
wire). 

Ribs and 1 asal 
bones. 

Ilium 



^^ 



107 



15 

53 
150 



Total, 



28 



5if^ 



S'S 



68 



14 
22 
48 

36 



24 



Died from causes\-^.'^. 
other than sep- I ^ 
tic ittfection. § ^ "^ 



7.— (1). From ex 
haustion and inan 
ition, one month 
after trephining 
with wound perfect- 
ly healed (2 and 
3). From irrepara-l 
ble damage to the 
brain ; in one casej 
the lock of a gun 
[being driven 
through the skull in- 
to the brain, and 
a fracture of the 
base existing in the 
other. (4, 5, 6). 
These cases died 
from cerebral soft- 
ening situated at a 
distance from the 
wound. (7). Cause 
of death not noted. 



436I 48 



2. — (i). From tu- 
berculous meningi- 
tis, following some 
weeks after a resec- 
tion of hip-joint. 
( 2 ). Chronic 
Bright's disease 
soon after wiring 
the patella. 






19 



GENITO' URINA R V OR GAA^S. 79 

Excluding the 48 cases which terminated fatally during forty-eight 
hours, the 19 cases which required primary amputation and the 2 
cases Avhich were iiumediately transferred from the hospital at their 
own request, and there remain 447 consecutive cases of compound 
fracture with only 2 deaths, giving a mortality of less than .5%; if, 
now, the 61 cases of compound fracture of the bones of the hand and 
feet be excluded as too insignificant, in accordance with the custom 
among all surgeons in their statistical reports of cases, there still re- 
mams 385 cases of compound fracture w-ith but a single death, giving 
a mortality of less than ^j-^^/c- In comparison with this, attention is 
called to the fact that previous to the adoption of antiseptic methods, 
the rate of mortahiy in the best of tables varied from 20 to 60 %. — 
Med. NeiL's, Nov. 13, 1886. 

James E. Pilcher (U. S. Army). 

GENITO-URINARY ORGANS. 

I. On the Pathology of Haematocele. P. Reclus (Paris). In 
a long article on the pathology of haematocele M. Paul Reclus, basing 
his remarks on the fact that inflammations of serous membranes are 
secondary to those ot the organs they envelop, suggests the term 
" pachy-vaginahtis " as giving an exact notion of the disease and re- 
lating it to similar lesions in the meninges. The cause is nearly always 
an injury or some habitual irritation, so slight sometimes as to escape 
notice ; for example, the frequent contusion of the testes on the pom- 
mel of the saddle in riding. The gland must here suffer more than the 
serous covering. It becomes irritated, the circulation is slackened, a 
small quantity of blood fibrine spreads out over the serous membrane, 
and this is repeated, so that fresh layers form. It will be found that 
the epididymis being more vascular and less protected than the testi- 
cle, which has its tunica albuginea, suffers more than the latter, and 
that the different layers of blood have it generally as their centre, the 
internal ones being those which are thickest and most recently formed. 
— Gaz. hebd. de Med. et de Chir., Sept. 24, 1886. 

L. Mark (London). 



8o INDEX OF SURGICAL PRO GRESS. 

II. Against Distending the Bladder for Epicystotomy. 
By Prof, vox Dittel (Vienna). Last year Von D. Reported 400 
cases of operation for calculus (v. Annals, 1885. Oct. Pp. 334-5) 
to which 50 later cases are now added. 

He first criticizes the oi late favorite plan of injecting the bladder 
before the suprapubic operation. In a former article he suggested the 
possible superiority of air for such injection, as it would first distend 
the crest of the bladder instead of the fundus, and might cause less 
harm if it ruptured through into the tissues. But this latter advan- 
tage would be slight unless, as he then supposed, the tear was in the 
anterior wall. Experiments on twenty cadavers have shown, amongst 
other things, that such is not the case. The quantity of water requi- 
site to produce rupture of the bladder ranged from 300 to 5,000 grms. 
(in subjects from 2 to 74 years of age). Of 15 ruptures from injection 
with water 7 were through the anterior and 8 through the posterior 
wall. The exact localization of the tear depends on many conditions, 
as the remains of previous morbid processes, the great variation *in the 
general shape of the bladder and the arrangement of its detrusor fibres, 
etc. The effect of such filling in raising the peritoneal fold in front 
also varies widely. As to air, owing to its compressibility, more is toler- 
ated. Three experiments gave 1,200, 1,650 and 2,100 cc. respectively; 
in a fourth, after injecting 3,000 cc. air, it required 300 grm. water to 
rupture; in another, where 1,800 cc. air was borne, 1,800 grm. water 
caused rupture. In the first three the tear was through the posterior 
wall. 

It may be urged that such quantities are not required m practice, 
though this does not hold for three of his experiments where 300, 600 
and 800 grms. caused rupture. Moreover during life cases are met 
with where the bladder contracts so strongly that even under deep 
narcosis nothing can be injected into the bladder. 

Any operative method must be decided by clinical observation and 
this also shows the danger of injections. In a case of Prof. Weinlech- 
ner's on a child the high operation was done after a small injection 
into the bladder. It was found at the autopsy, that a small diverticle 
near the mcision had bursted. A like fatal result in a 5-year-old boy 



GENITO-URINARY ORGANS. ol 

with a large calculus was reported by Von D. in his previous list. After 
loo grms. had been injected the resistance diminished. Operation. 
Death in three days. Rupture of posterior vesical wall, starting from 
a small diverticle. Another case of Weinlechner's on a man aet. 67, 
is here reported. After washing out the bladder for a few days 200 
grms. were injected provisional to operating. Bloody fluid came back 
for the first time, probably, as the autopsy indicated, from beginning 
rupture though the man had a stricture. A colpeurynter containing 
200 grms. was introduced (into the rectum) and 300 grms. fluid in- 
jected into the bladder ; 200 more were needed before the bladder 
appeared. Fluid tinged with blood in the prevesical tissues showed 
that rupture had already occurred. Death in twenty-four hours. There 
was an obhque circular tear through mucous membrane and subjacent 
muscular layer, extending from the posterior wall around on the left to 
anterior. The mucous membrane was polypous, oedematous, injected, 
and in wide patches cicatricial resembling a serous membrane. A 
fourth case is quoted from Guyon (v. Annals, 1886. April. P. 347. 

He does not doubt that some way of avoiding this danger will be 
devised, but holds that for the present the method involves too great a 
risk. [It will be noticed that this article deals almost wholly with the 
volumes injected, but gives no exact data as to pressure.] 

His last 50 cases include i lateral, i median and 9 suprapubic op- 
erations, 2 Hthotripsies and 37 litholapaxies. Of the 9 epicystotomies 5 
died, 2 certainly from the operation, 3 perhaps only in part ; in no 
case did infiltration of urine into surrounding tissues occur. The 39 
operations by crushing gave no fatal results ; ditto the 2 perineal op- 
erations. — Wien. Med. Wochen. 1886. Nos. 42-46. 

Wm. Browning (Brooklyn). 

III. Use of Cocaine for Litholapaxy. By T. J. Vdovikov- 
SKY,M. D. (Odessa, Russia). Having paid a glowing tribute to the 
American surgeons (Bigelow, Otis, Weir, etc.) who have brought about 
a radical reform in the treatment for stone in the bladder. Dr. V. de- 
scribed four cases of his own in which he used cocaine for litholapaxy. 

Case I. N. K., male, aet. 30, for six years had the symptoms of 
stone in the bladder; was admitted to the hospital on January 11 > 



S2 



LVrEA' or SCItCICAL FXOCKESS. 



iSSd. He kad a stone 4^ . ctm. in diameter, hard, movable; also 
puniknt caiairii of the bladder. On Januaiy 20 litholapaxy was per- 
ftxmed in one atting. Ha>nng washed the bladder and urethra 
irith 4^ solution of boracic add, 2% solution of hydrochlorate of 
cocaine was injected in the amount of 3^/, ounces. After 12 minutes 
the large lithotrite of Bigelow was introduced, the stone was seized at 
once, and in nine minutes it was crashed 24 times. By aspiration 
many fragmeats of stone were bpought ouL Then the lithotrite of 
Refiqnet was introduced, and the larger fi^gments of stone were 
crashed; again aspiration. Thai the lithotrite of Thompson was 
used twice, and all the fragments of stone were washed out. There 
was no oHitraction of the bladder at afl. The patient began to feel 
pain onty 35 minutes after tibe commenoement of the operation. No 
fever followed the operation. On the third day the traces of blood 
in unne dSsappeareo <".-- -^- ■-■" """e '^-'.^ode- ^-:-- cured in twelve 
da3ps. 

Case II. M. P., 3ii,ilc. .^u .:c. u-as sufcnug n-om stone for 16 years. 
On examination a stone was found, 6 ctm. long. hard, smooth and 
movaUe. On Feteuaiy 10, 1SS6. operation. Four per cent, solution 
cDcaini muiiatica was injected and after 15 minutes Bigelow's litho- 
trite was introduced After aspiration the lithotrites of Rehquet and 
Thompson were used Tlie cg>eration lasted i hour and 53 minutes. 
In 35 minutes the patiaii began to feel pain, and in 40 minutes the 
dSect oi cocaine seaoaed 10 have passed away, therefore the second 
half of the opoation was painfol, and toward the end of the operation 
die bladd^ b^an to ctmtract. No fever after the operation. Ace- 
tate erf" lead, nitrate <rf silvia^ and elearidty were used for purulent 
catarrh of the bladdea-. The patient left hospital cured iNIarch 20. 
1SS6. 

Case III. V. Z., male. «t. 22, entered the MiHtaiy Hospital on 
Maich 12, 1SS6. He was suififering from the stone for eight years. A 
stone was found, 3^/5 cm, in diameter. On April 3 Dr. V. per- 
fonned the operation in presmice of several mihtary surgeons who have 
found out that cocaine had no eS^i on temperature, pulse, respiration 
and the pujuS of the ejes. The <^>erati<Hi lasted about half an hour. 



GENITO- URINAR Y OR CANS. 8 3 

and was painless ; no contraction of the bladder was noticed. On 
the sixth day the patient left the hospital cured. 

Case IV. Dr. I. H., aet. 59, for years was suffering from rheuma- 
tism, asthma and stone in the bladder ; he was nervous and very sensi- 
tive to pain. Dr. Vdovikovsky hardly could persuade his colleague to 
submit to the operation. The stone was only 2 cm. in diameter, but it 
was hard and smooth. The operation was performed on April 2. 
Four per cent, solution of cocaine was used, and Thompson's litho- 
trite. The operation lasted only 12 minutes, was quite painless, and 
the patient was very much surprised when he was told that it was all 
over. The patient was quite well on the fourth day after the opera- 
tion. 

Dr. Vdovikovsky comes to the conclusion that the use of cocaine 
alone is quite satisfactory when stone is not large and the operation 
can be performed in half an hour, which is the limit of cocaine's effect. 
In cases of large stones chloroform is preferable, but even then, if con- 
tractions of the bladder are noticed, cocaine is properly indicated. — 
Chirurgitchesky Vestnik, (St. Petersburg), Aug. 1886. 

P. J. POPOFF (Brooklyn). 



IV. Two Cases of Supra-pubic Cystotomy. By M. C. F. 
Gavin, M. D., and A. T. Cabot, M. D. (Boston). Gavin's case oc- 
curred in an old ex-soldier of dissolute habits, set. 52, with stricture of 
the urethra (which contained two fistulous openings, the result of false 
passages in attempting catheterization), and partial ankylosis of the 
lower extremities, by which litholapaxy and perineal lithotomy were 
both rendered impossible. The fistulse prevented satisfactory disten- 
tion of the bladder, but after the inflation of a bag in the rectum, an 
incision in the median line four inches long exposed the bladder, which 
was readily caught and opened. Some difficulty was experienced in 
seizing the stones, which were encysted in pockets in the thickened 
vesical wall ; they were finally, however, seized with lithotomy forceps 
on being pushed up by an assistant's finger in the rectum. The peri- 
toneum was not seen during the operation. 

Cabot's case occurred in a debilitated man, aet. 49, who had suffered 



84 . INDEX OF SURGICAL PROGRESS. 

from stone for a number of years ; a stricture almost obliterated the 
lumen of the membranous urethra. The stone was found to be large 
and, the strictured urethra contraindicating Htholapaxy, the supra-pubic 
operation was decided upon. After introduction of sixteen fluid 
ounces of water into the bladder, the supra-pubic region was still tym- 
panitic on percussion, but became duller on the distention of the rec- 
tal bag, although it never reached flatness. On incision, the peri- 
toneum was seen to extend nearly down to the pubis, but after incising 
what appeared to be a prolongation of the transversalis fascia below 
it, it could be drawn up out of the way. The bladder was then in- 
cised and a very large heart-shaped stone, weighing i,i8o grams, re- 
moved without trouble. Both patients recovered well. — Boston Med. 
and Surg. Jour.^ Nov. ii, 1886. 

V. Observation on the Male Urethra with Applications 
to Endoscopy, Litholapaxy and Catheterization. By Otis K. 
Newell, M.D., (Boston). The author has made a number of obser- 
vations for the purpose of obtaining the length of the shortest instru- 
ment that can be introduced through the male urethra into the bladder, 
and finds that, as the pendulous portion of the urethra can be folded 
together so that its long axis occupies not more than from 172 to 2 
inches, for surgical purposes the length of the urethra is but 4 inches, 
increased in cases of hypertrophy to a possible six, and an instrument 
Mrith a length of 5 inches or more is sufficient for any normal subject. 
Bearing in mind also the large size of the evacuators used in lithola- 
paxy, he has constructed an endoscope having a 30-calibre, with the 
visceral opening oblique, especially designed for the inspection of the 
bladder and permitting, what has hitherto not been done, the introduc- 
tion of instruments through it, so that with suitable forceps, a foreign 
body can be removed without operation through it. The shortness of 
the urethra justifies him in shortening the distance between the orifices 
of the tube of Bigelow's evacuator for litholapaxy from 15'/^ to 10 
inches, by which he greatly shortens the period for the evacuation of 
the contents of the bladder in that operation ; the tube is staight, 
which also adds to the readiness of evacuation. The author claims that 



GENITO-URJNARY ORGANS. 85 

the modified evacuator removes fragments four or five times as rapidly 
as Bigelow's instrument. He also advocates the shortening and in- 
creasing the diameter of the lithotrite, believing six inches to be long 
enough for any divulsor. When a catheter or tube is to be used for 
washing out the vesical cavity, it should be as short and of as large a 
calibre as possible, so as to best admit the free passage of fluids, 
thick mucus, or other matter, although a longer size for convenience 
of manipulation, is desirable tor ordinary purposes. The illustrations 
of his endoscope do not show the instrument clearly, and his descrip- 
tion is greatly wanting in lucidity. — Boston Med. and Surg. Jour. 
Nov. II, 1886. 

VI. Rules for the Application of Electrolysis in the 
Treatment of Urethral Stricture. By Robert Newman, M,D.. 
(New York). In a critical paper showing the causes of failure in 
treating stricture of the urethra by electrolysis, to be due to (i) the in- 
competency of the operator, (2) mismanagement of the treatment, (3) 
mistaken diagnosis and (4) faulty instruments, the author presents the 
following rules as a safe guide to practitioners : i. Any good galvanic 
battery will do which has small elements and is steady ; the twenty-cell 
Drescher battery, carbon and zinc, is an excellent instrument sufficient, 
particularly, for the beginner. 2. The fluid for the battery ought not 
to be used too strong. 3. Auxiliary instruments, as galvanometer, 
etc., are important to the expert, but not necessary for the beginner. 
4. For the positive pole, a carbon electrode is used, covered with 
sponge moistened with hot water, and held firmly against the patient's 
hand, thigh or abdomen. 5. For the absorption of the stricture, the 
negative pole must be used. 6. Electrode bougies are firm sounds in- 
sulated with a hard-baked mass of rubber ; the point is a metal bulb, 
egg-shaped, which is the acting part in contact with the stricture. 
7. The curve of the bougie is short ; large curves are mistakes. 8. 
The plates must bp immersed in the fluid before the electrodes are 
placed on the patient, and raised again after the electrodes have been 
removed. 9. All operations must begin and end while the battery is 
at zero, increasing and decreasing the current slowly and gradually by 



S6 



INDEX OF SURGICAL PROGRESS. 



one cell at a time, avoiding any shock to the patient. lo. Before 
operating, the susceptibility of the patient to the elec- 
tric current should be ascertained, ii. The problem is to absorb the 
stricture, not to cauterize, burn, or destroy tissues. 12. Weak cur- 
rents at lojig intervals. 13. In most cases a current of six cells, or 
from 2'/, to 5 milliamperes, will do the work, but it must be reg\ilated 
according to the work to be done. 14. The seances should be at in- 
tervals, not too frequently in succession. 15. The best position for 
the patient to assume during the operation is that which is most com- 
fortable for himself and the operator. I prefer the erect posture, but the 
recumbent or others may be used. 16. Anaesthetics I like to avoid ; 
I want the patient conscious so that he can tell how he feels. 17. 
Force should never be used ; the bougie must be guided in the most 
gentle way ; the electnlcity alone must be allowed to do the work. 18. 
During one seance, two electrodes in succession should never be used. 
19. All strictures are amenable to treatment by electrolysis. 20. Pain 
should never be inflicted by the use of electrolysis ; therefore it should 
not be applied when the urethra is in [an acute or even subacute in- 
flammatory condition, In conclusion, he remarks that in every case 
that is inteUigently and judiciously undertaken, success must and will 
follow. In the strictest sense of the word there can be no lailure in 
dissolving away the dense tissue that constitutes a stricture, for elec- 
trolysis is based upon a fixed chemical action of the constant current 
on these animal tissues. Electrolysis cannot fail, but operators may 
and A0.--N. Y. Med. Rec. Sept. 25, 1886. 

J. E. PiLCHER (U. S. Anny). 

WOUNDS— INJURIES— ACCIDENTS. 

I. Severe Injury from Dynamite. Amputation of Fore- 
arm. Ligature of Femoral Artery. Gangrene of Leg. 
Amputation of Thigh. Pyaemia. Severe Reactionary Haem- 
orrhage. Transfusion of Blood Four Times. Recovery. 
By Messrs. Annandale and J. M. Cotterili.. J. P., set. 23, a quar- 
ryman, was admitted on Januar}' 8, 1886, suffering from the results of 
the explosion of some dynamite cartridges. The proper apparatus for 



WOUNDS, INJURIES, ACCIDENTS. 8/ 

the purpose being out of order, the patient had been warming some of 
the explosive in an ordinary iron kettle at a " chaffer," when the dyna- 
mite exploded. The left hand was completely shattered, and the fore- 
arm badly lacerated by the pieces of metal ; the posterior aspect of the 
left thigh was deeply gashed in all directions, the fragments of metal 
splintering the lower end of the femur, and lying in great quantity 
among the deep structures of the thigh. The right hand and leg were 
also severely injured, but to a less extent than the left. Five hours 
after the accident the hand was removed by Mr. Cotterill by a modi- 
fied circular amputation above the wrist, and large pieces of the kettle 
were extracted from the tissues of the forearm and thigh. Amputa- 
tion of thigh was out of the question, owing to the extreme weakness 
of the patient, caused by the loss of blood and the shock. Chloro- 
form sickness which supervened after the operation was subdued by a 
few fifteen drop doses of a 20% solution of cocaine. 

The wound of the thigh havmg sloughed extensively, on January 10. 
Mr. Annandale tied the femoral artery at the apex of Scarpa's triangle 
so as to lessen the risk of secondary haemorrhage. Three days after- 
wards signs of gangrene appeared in the calf of the left leg. The 
temperature ran up to 107° F. in the evening, and the patient became 
delirious. On the following day the gangrene having spread to the 
knee, amputation through the upper third of the thigh was performed. 
On January 15, at i A. M., a very profuse reactionary haemorrhage, 
from a branch of the profunda artery having taken place, the patient 
was transfused by Dr. Dading, the blood being given by Dr. Thomson. 
Four ounces of blood were injected, together with two ounces of solu- 
tion of phosphate of soda, and the condition of the patient at once 
began to improve. The patient being still ver>' weak, and at times 
delirious, Mr. Annandale performed transfusion at midday, injecting 
six ounces of blood with two ounces of saline solution. Marked im- 
provement again followed. On January 16 symptoms of septic ab- 
sorption being present and the patient profoundly weak, transfusion, 
to the extent of six ounces of blood and two of the saline solution was 
again performed. The great improvement which followed was main- 
tained for thirtv-six hours ; but on January 18 there was a falling off, 



o o INDEX OF S UK GICAL PR O GUESS. 

and transfusion was practiced for the fourth time. Seven ounces of 
blood and two of the saline solution were injected. About half an hour 
after the operation the patient had a rigor, and the temperature rose 
to io6°, but it rapidly fell to 99 2°, and the coqjuscles were found in 
the evening to have increased by 250,000 per cubic millimetre since the 
morning. From this period convalescence slowly began. Several large 
pyaemic abscesses formed, and were opened in various parts of the body. 
The patient was discharged in very good health on April 9. 

The author considers that the operation of transfusion is destined to 
hold a far more prominent position than it has hitherto done, owing to 
the fact that the method of appHcation has been simplified and per- 
fected. It is somewhat remarkable that the use of the saline solution, 
introduced by Dr. B. Hick in 1878, has not come into more general 
use, as it certainly deprives the operation, as usually performed, of 
most of its difficulties and dangers. 

The author first employed it in Edinburgh about two years ago in a 
case of severe haemorrhage from gastric ulcer, and was struck with the 
ease and safety of 'the method. The steps of the operation will be 
found recorded in the British Medical Journal of April 10, 1886. P. 
697, to which description he wishes to add that the blood should not 
take more than five or six minutes to inject, though it does not coagu- 
late before twenty minutes at least in the majority of cases ; and that 
this operation, like all others, should be done with such antiseptic pre- 
cautions as commend themselves to the common sense of the operator. 
— British Med. Jour., Oct, 2, 1886. 

H. Percy Dunn (London). 

GYNECOLOGICAL. 

I. Subserous Papillary Cystomata of the Ovary; two 
Cases, the one being a Tubo-Ovarian Cyst. Ovariotomy 
in both Cases followed by Recovery. In one Case for In- 
ternal Strangulation Laparotomy four Months later. Re- 
covery. By Dr. F. Lange (New York). Both of these cases had 
this in common, that the tumour was of moderate size, situated on the 
right side, and rested with broad base between the layers of the broad 



G YN.^ COLO GICAL. 89 

ligament covered by peritoneuiu, without in any way showing the for- 
mation of a pedicle. 

In both the internal surface of the sac showed papillary formations, 
which in the one case were very numerous and well developed, so that 
in some parts they gave to a large extent to the inner surface a papil- 
lary aspect. Both cases were operated in such a way that the tumour 
was gradually shelled out of its peritoneal covering under due consid- 
eration of preventing hemorrhage by mass ligatures. In one case the 
peritoneum was thin, and could only incompletely be preserved. In 
the other it was fastened to the lower part of the abdominalVound, and 
the parietal peritoneum in such a way that the peritoneal cavity was 
entirely shut off. In the other this peritoneal partition was incomplete. 
In both cases the wound surface in the depth of the peritoneum was 
filled loosely with iodoform-gauze, which was removed on the second 
or thira day to be replaced by less gauze and finally a drainage 
tube. In this way gradual diminution of the cavity took place, but in 
one of the case.*, where the closure had been imperfect, a fistula has 
remained, through which so far some coarse silk sutures have been dis- 
charged and more are to come out. The patient moves about without 
much discomfort. The specimen of this latter case presents the rare 
variety of tubo- ovarian cyst, the fallopian tube being in free communi- 
cation with the inside of the cystic sac. Its canal was found dilated, 
the mucous membrane hypertrophied,and the contents a bloody mu- 
cus. The content of the cyst itself at a puncture several months pre- 
vious to the radical operation was clear, yellowish and thin, containing 
a great deal of cholesterin crystals. 

The other case had the following interesting history. The patient, 
after having recovered from the operation sufficiently, went to the Cats- 
kill mountains. She was then suffering from unmistakable tubercu- 
losis of the lungs. About four months after the operation she devel- 
oped symptoms of obstruction of the intestine suddenly, apparently 
after an indigestion. At the end of three days, when first seen by Dr. 
L., the obstruction was complete and stercoraceous vomiting had oc- 
curred repeatedly. Without much delay the patient was brought to 
New York, and after the stomach pump and carbonic acid enemata had 



90 INDEX OF SURGICAL PROGRESS. 

been tried without success, laparotomy was done on the evening of 
September 17. The obstruction was due to constriction of a loop of 
intestine about the size of a duck's egg by a sharp peritoneal band 
which spread between two points near the attachment of the mesentery 
to the small intestine. Under this band a coil of intestine had appar- 
ently slipped, and was so tightly strangulated, that it looked almost 
gangrenous. Around it there was a .small gathering of brownish bloody 
fluid, just as w^e find it in cases of strangulated hernia. There was no 
connection with the original field of operation. The peritoneal sac, re- 
maining after the ovariotomy, had shrunk to a small, hard lump. Some 
adhesions of the omentum to it were removed. Numerous tubercles 
were found to be spread over the peritoneum, also one larger, cheesy 
nodule wnthin the omentum. 

No disturbance followed the operation from the side of the abdom- 
inal cavity. The function of the gut returned about forty-five hours 
after the operation, and has since then remained normal. 

During the second week, however, the lung trouble became more 
serious and the formation of a cavity in the right upper lobe of the 
lung could be clearly made out. The present condition of the patient 
now, four weeks after the operation, is tolerably good, though there is 
no doubt that finally she will die from tuberculosis. — Proceedings Neiv 
York Surg. Soc, Oct. 11, 1886. 

II. Six Cases of Abdominal Section for Pyosalpinx of 
Gonorrhceal Origin. — By Joseph Price, M. D. (Philadelphia). In 
the belief that they show beyond doubt the causal relation between the 
diseased condition of the tubes and ovaries and a previous gonorrhoea, 
the writer presents the following cases : i . History of a past attack of 
gonorrhoea with present symptoms of trouble in the ovarian region ; on 
examination, the right ovarj' was found to be enlarged and its tube, 
large, distended, tortuous and firmly adherent. Abdominal section 
revealed large adherent ovaries and tubes filled with pus and removed 
with great difficulty. They were enucleated and the patient made a 
speedy recovery. 2. Clear history of specific trouble with ovarian 
pain and general debility ; examination showed the left tube distended 



GYNECOLOGICAL. 9^ 

and closely attached by its lower' border to the broad ligament; the 
ovary was large, and both it and the tube were extensively adherent to 
the pelvic viscera. On abdominal section, a large tabe filled with pus* 
together ^\^th a cystic ovary was removed, the pavilion of the tube con- 
taining pus sacs from which leakage had probably occurred into the 
peritoneal cavity. Recovery was rapid. 3. A prostitute in whom the 
uterus was small and pushed forward by large tortuous and distended 
masses, situated posteriorly on the right and left. Abdominal section 
revealed a large tube containing purulent cheesy matter, and many 
strong adhesions, which rendered ir impossible to remove the right 
ovary : although amid the most filthy surroundings, the patient made a 
good recovery, with the exception of a small sinus, probably leading to 
pus pockets connected with the other tube or ovary. 4. History of 
active gonorrhoea and symptoms of ovarian or tubal trouble ; examina- 
tion showed both ovaries enlarged, with a tortuous irregular tube down 
in the retro- peritoneal pouch, with extreme tenderness, showing prob- 
ably pyosalpinx. On abdominal section, both tubes were found filled 
with pus and both ovaries cystic, and were removed. The adhesions 
were strong and intimate. A tear of all the coats of the intestine except 
the mucous, made in detaching the right tube and ovary, was sutured 
and did not interfere with an uninterrupted recovery. 5. History of 
gonorrhoea, examination showing the right tube and ovary to be dis- 
eased and general peritonitis to exist. The cyHndrical, tortuous and 
sausage-like tube, boggy to the touch, was enucleated with difficulty, 
owing to the strength of the adhesions, and there were small necrosed 
points from which constant leakage had taken place. Patient did well 
for a while, but finally died owing to the neglect of her nurse. 6. Con- 
stant discharge and pelvic pain for a year, and, on examination, hard, 
firm, irregular bodies extending from the right and left posteriorly. Ab- 
dominal section showed the inlet of the pelvis choked by adhesions, 
and the tubes and ovaries firmly adherent to the surrounding pelvic 
viscera ; left tube tortuous and filled with pas and both tubes and ova- 
ries required complete enucleation; recover)^- in a month. — N. Y.Med. 
Jour.. Oct. 23, 1886. 

J.AMES E. PiLCHER (U. S. Army). 



REVIEWS OF BOOKS. 



How We Treat Wounds To-Day. A treatise on the subject of anti- 
septic surgery which can be understood by beginners. By Robert 
T. Morris, M.D. Second edition. 12 mo. P. 165. New York 
and London: G. P. Putnam's Sons. 1886. 

This little book has evidently been written with a purpose ; it is 
both a missionary tract and a primer of antiseptic technique. There 
is, withal, a breezy dogmatic flavor to its sentences that will not fail to 
attract attention to what is said, whether it commands assent or not. 
It is not an elaborate treatise on the treatment of wounds, nor a de- 
scription of the many varieties of antiseptic technique that are in 
vogue. The author is very plain and detailed in what he does say, 
and the very limitation of his directions to one hne really increases the 
value of his book to those who wish to know just what to do in order 
to conform their work to the demands of the most approved antisepsis. 
The methods detailed are those which are to be found in the best of 
the German clinics at the present time, and which look to the obtain- 
ing of aseptic wounds and infrequent dressings. Full descriptions of 
all materials required for this Tcind of work, how to prepare them or 
where to obtain them, as well as how to use them, are given. The 
book will do much to popularize thorough antiseptic wound treatment. 
There is so much of superficial, so-called antiseptic work being done, 
that such a clean-cut, positive detailed setting forth of what consti- 
tutes real antiseptic work, as this is. is called for. 

L. S. Pilcher. 

Die Aseptische Wundbehandlung in meinen chirurgischen Pri- 
vat-Hospitalern. Von Dr. G. Neuber, Docent fur Chirurgie a. d. 
Universitat zu Kiel. Kiel, Lipsius und Tischer. 1886. New York, 
G. E. Stechert. 

Aseptic Wound Treatment in my Private Surgical Hospitals. By Dr. 
G. Neuber, Instructor of Surgery at the University of Kiel. 

In this pamphlet of 36 pages, the former assistant of Prof. Esmarch, 
of Kiel, relates his efforts to replace the present method of antiseptic 
treatment of wounds by simple aseptic treatment. 

Believing wound-diseases to be caused by the action of germs, he 
seeks to avoid their presence by a general improvement of hospital 
hygiene, rather than by locally combatting them with antiseptic solu- 
tions and materials. 



NEURER ON ASEPTIC WOUND TREATMENT 93 

The work is of interest as it is the first one of its kind, coming from 
a German surgeon, while our own literature offers a relatively large 
number of similar propositions. No results are as yet recorded — the 
buildings and internal arrangements having scarcely been completed. 
A detailed description of the three separate hospital buildings and ac- 
cessories is given, illustrated by numerous wood-cuts •. and in the ac- 
count of the operating rooms many hints are interspersed, which are 
well worthy of attention. 

We notice a few of them more particularly. The operation rooms, 
which are situated on the ground floor, are five in number ; a separate 
room being used for the treatment of acutely inflamed, chronically in- 
flamed and recent wounds, injuries not complicated with wounds, and 
rectal and genito-urinary diseases respectively. Each room possesses 
its own proper instruments and pnraphernalia. 

The walls, ceiling and floor are all smooth and coated with oil-paint, 
so as to be easily cleansed, and much of the stationary furniture, etc., 
is let into the walls. 

The floor slopes to a drainage-hole at one side, which leads through 
a tube directly into the outer air. From the end of this tube the waste 
fluids fall into a receiving funnel, from whence they are conducted by 
pipes to the sewer. By this arrangement the author hopes to escape 
the effects of sewer-gases. The other waste-pipes of the house are 
simply trapped with water. 

The air admitted to the operating room passes first through a fur- 
nace and then through a cotton filter. 

The author intends to use only sterilized water for irrigations. He 
places his instruments in a i % carbolic solution, after boiling them 
for fifteen minutes. He gives the greatest attention to the personal 
cleanliness of all the attendants, and has all articles of furniture as 
well as the aprons and boots of the surgeons soaped off" and cleansed 
with sublimate solution (2 pro mille.). The sponges, after having been 
thoroughly cleansed, are kept in a 5 % carbolic solution. 

Separate bath-tubs are provided for patients affected with different 
diseases, septic infections being prevented from all contact with recent 
wounds. The skin is disinfected before operations with sublimate so- 
lution. 

By such means as these — though they can scarce claim the title of 
simple aseptic as opposed to antiseptic precautions, as the author 
would have it, Dr. Neuber hopes to do away with the drainage of 
'wounds altogether, to avoid changing the dressings and to escape all 
dangers of poisoning by antiseptic substances. 

W. W. Van Arsdale. 



94 REVIEWS Oh BOOKS. 

Pathologie und Therapie der seitlichen Rueckgratsverkruem- 
MUNGEN. Von Dr. Adolph Lorenz, Decent fiir chirurgie, etc. Vien- 
na, t886. Alfred Holder. New York, G. E. Stechert. (Pathology 
and Treatment of Lateral Curvature of the Spine. 

The book appears in large octavo, containing about 200 pages of 
text, and is handsomely illustrated by means of nine lithographic and 
eleven photographic plates. 

About one-third of the bulk of the book is devoted to the patholog- 
ical and theoretical aspect of the subject of scoliosis, and about one- 
fourth each to the clinical side of the subject and to treatment. 

The author admits a torsion of the spinal column in scoliosis (contra 
Nicoladoni), but does not beUeve that such torsion is produced by a 
relative rotation of the bodies of the vertebrae upon each other (since 
no alteration of the articular surfaces is to be observed), but maintains 
that the column is rotated as a whole. 

Theories to account for the manner in which the rotation originates, 
as advanced by H. von Meyer, Drachmann, Schenk and others, are 
refuted. The author beUeves that when the bodies of the vertebrae 
are forced to one side in consequence of pressure from above, the vei- 
tebral arcs do not participate to the same extent in the motion, but 
are, as it were, left behind. 

Anatomical changes occurnng in the ribs, the sternum, the thorax, 
the pelvis, the ligaments and muscles of scoliotic individuals are sep- 
arately described. 

As to the theories of the genetic origin of scoliosis, the author first 
refutes, both anatomically and cUnically Eulenburg's theory, (that the 
relaxation of the hyperextended muscles on the convex side of the 
curved spine cause the disorder), and sharply criticises H liter's hypo- 
thesis of the pressure of the ribs during the growth of the parts. He 
also attacks other less recent theories relating to muscular action, as 
well as that of Lorinser, who believes scoliosis due to some insidious 
ostitis. The so-called physiological scoliosis he believes to be an op- 
tical delusion referable to the flattening of the left half of the bodies of 
the middle thoracic vertebrae. 

To Roser and Volkmann he gives the credit of having first thrown 
light upon the subject of scoliosis, by adducing static moments, and 
thus originating the theory of pressure by weight in habitual scoliosis, 
which he explains at length. 

In the clinical portion of the work we find chapters on the symptom- 
atology of typical forms of scoliosis, on the relative frequency of these 
different types, on the cHnical course of the disease, and on the methods 
of the clinical examination of patients. As to the notation of results of 



LORENZ ON LATERAL CURVATURE OF SPINE. 95 

such examinations the author prefers the combination of photographic 
views of the back, and the data obtained with the help of Mikulicz's 
measuring apparatus and the lead wire. 

Chapters descriptive of the static, rhachitic and other forms of scolio- 
sis are given, and a practical one on the prophylactic treatment of the 
deformity in which the author describes a novel school-bench. 

Under the heading of treatment, the author expresses himself as not 
in favor of Swedish movements for scoliosis, since he does not agree 
with Eulenburg's myogenetic theory. Sayre's treatment is extensively 
commented upon ; in the author's opinion suspension alone is msuffi- 
cient to correct the existing deformities, and therefore the corset is 
too ineffective, especially as it prevents correction of the position of the 
ribs. Poroplastic felt is condemned as not sufficiently easily applicable. 

The antistatic method, consisting in the use of an inclined seat, etc., 
is not suitable for the correction of thoracic forms of scoliosis, 

The author's method of treatment of lateral curvatures of the spine 
consists in a combination of forced corrections (redressement) of the 
position of the parts, together with the use of a removable plaster -of- 
Paris corset between the sittings. A cushioned wooden cylinder is 
fixed horizontally at a height corresponding to the axilla of the patient 
(supposed to be suffering from a deviation of the spinal column, in its 
thoracic portion, to the right side), and over this support the patient 
bends backwards and laterally, in such a manner that the cushion 
presses upon the prominent portion of the thorax at a point where the 
diagonal axis of the chest emerges ,and in such a posture that the sup- 
port is at right angles to this axis. The patient grasps a strap attached 
to the floor, with her left hand raised above her head. By pulling on 
this strap she can raise her feet from the floor, and the whole weight of 
the body now rests on the support, while the weight of the lower ex- 
tremities (augmented, if need be, by suitable weights) tends to correct 
the compensatory curvature of the lumbar portion of the spine. This 
exercise he calls lateral suspension. In applying theplaster-of-Paris 
corset the author endeavors, by padding it in certain places with 
pieces of felt, to compress the thorax diagonally, sufficient room be- 
ing maintained to permit a proper expansion in a plane situated at 
right angles to the one of compression. The author also makes an 
extensive use of narrow plaster-of-Paris jackets or belts, by means 
of which he endeavors to obtain a lateral shifting of the entire upper 
body on the pelvis, as it were. 

These bandages are appUed while the patient assumes certain ap- 
propriate positions, extension apparatus, lateral traction, etc., being 
frequendy made use of. 



96 REVIEWS OF BOOKS. 

In addition the author gives a number of his cases, illustrated by 
photographs, which, it must be acceded, show very good results. 

W. W. Van Arsdale. 

On Cancer of the Mouth, Tongue and x^limentary Tract. 
Their Pathology, Symptoms, Diagnosis and Treatment. By 
Frederic Bowreman Jesset, F.R.C.S. Eng., Surgeon to the Can- 
cer Hospital, Brompton. Octavo, pp. 302 London. J. and A. 
Churchill. 1886. 

As the introduction states, the object of the author in writing this 
book is to collect the more recent information on the subjects treated 
of, and to contrast the experience of other surgeons with his own at 
the Cancer Hospital, Brompton. Although nothing new has been at- 
tempted, Mr, Jesset has succeeded in presenting a clearly written and 
judicious resume of our knowledge of the subjects which he has under- 
taken to discuss. Where so much Uterature has to be read on every 
subject, a reliable work, such as the present, is of much service, and 
enables those in busy piactice to keep abreast of the advances of 
the day. 

The contents are divided into nine chapters with the following 
heads : Cancer of the Lips; Cancer of the Gums and Antrum; Can- 
cer of the Jaws; Cancer of the Tongue; Cancer of the Tonsil; Can- 
cer of the Pharj'nx and QEspphagus; Cancer of the Stomach; Cancer 
of the Intestinal Canal, and Cancer of the Rectum and Anus. 

It is unnecessary to review at length the contents of each chap- 
ter as it is equally true of them all to say that they give a full and 
careful digest of the pathology, symptoms, diagnosis and treatment 
of the cancerous affections in each case. Statistical tables on ques- 
tions of importance are quoted from various writers, and similar ones 
have been compiled Dy way of contrast from the records of the 
the Cancer Hospital, The latter tables, however, do not seem to 
differ in any essential way from those previously published, but in 
so far as they confirm them they are of value as pieces of corrob- 
orative evidence. 

A number of important cases are narrated at length at the end 
of the book. These have been selected from published records and 
from the author's case book and exemplify the text. 

A good index makes a reference to any part of the contents at 
all times easy. 

The spelling of Kocher's name as Kocker is a mistake which has 
been carried throughout the book. This, along with certain other 
typographical errors, will doubtless be remedied in a future edition. 

The practical experience, wide reading, and judicious selection man- 
ifested in this work cannot fail to be appreciated. 

Charles W. Cathcart. 



ON THE RADICAL CURE OF OBLIQUE INGUINAL 
HERNIA BY INTERNAL ABDOMINAL PERI- 
TONEAL PAD, AND THE RESTORA- 
TION OF THE VALVED FORM 
OF THE INGUINAL 
CANAL. 

By WILLIAM MACEWEN, M. D., 

OF GLASGOW, 

SURGEON TO THE ROYAL INFIRMARY, AND LECTURER ON SYSTEMATIC AND CLINICAL 

SURGERY IN THE ROYAL INFIRMARY SCHOOL OF MEDICINE. SURGEON TO 

THE HOSPITAL FOR SICK CHILDREN. 

IN the many operations for radical cure of hernia, as a^ 
present performed, the sac is either retained in the canal 
(being dealt with in various ways), or a ligature is placed on 
its neck and the remainder of the sac is cut off. Wood's op- 
eration is the type of the former, while that which Mr. Banks 
has described may be taken as illustrative of the latter. The 
treatment of the sac in the operation about to be described, 
differs from these, inasmuch as, while the sac is preserved, it is 
completely returned beyond the limits of the canal and formed 
into a pad which is placed on the abdominal aspect of the cir- 
cumference of the internal ring. 

When the sac is left in the canal it acts as a plug. Plugs 
tend to widen instead of obliterating the canal and prevent the 
pillars from coming in direct apposition. Organic union is 
difficult to secure between portions of tissue which have not 
had their surfaces refreshed, such as the canal with its inter- 
vening sac. To overcome this the wires in Wood's operation 
are twisted firmly down so as to excite plastic effusion which 
it is hoped will suffice to mat the tissues together. This is un- 
doubtedly secured in many instances, while in others it is not 
attained. Both when the sac is dealt with in this manner and 
when its neck is ligatured, there remains a funnel-shaped puck- 

(89) 



90 WILLIAM MA CE WEN. 

ering of the peritoneum, the apex of which presents in or at 
the internal ring. When the liquid movement of the intestine 
as it glides over the peritoneum is thrown into the form of a 
wave by the sudden impulse of straining or coughing, it is 
carried into this pouch which guides it into the canal where it 
expends its force. It thus acts as a wedge widening and tend- 
ing to open up the canal. 

With the view of obviating these defects, the sac in the op- 
eration about to be described, is carefully separated, not only 
from the entire inguinal canal, but also from the abdominal as- 
pects of the circumference of the internal ring. It is com- 
pletely reduced from the canal into the abdomen beyond the 
internal ring, then thrown into a series of folds, constituting a 
pad which is placed on the peritoneal surface opposite the in- 
ternal ring. It there constitutes a boss or bulwark with its 
convexity presenting backwards toward the abdomen, while 
its base rests on the abdominal walls surrounding the circum- 
ference of the internal ring. This not only protects the inter- 
nal ring, but sheds the intestinal wave backwards away from 
the opening. 

Having thus secured the peritoneal surface, some surgeons 
would be inclined to leave the canal alone, thinking when the 
former is accomplished that the bulwark behind requires little 
strengthening. While agreeing in the primary importance of 
securing the peritoneal surface, it is considered advisable to 
bring into apposition and to unite parts which are abnormally 
wide, greater security and resisting power being thus imparted 
to the abdominal wall. This is especially the case, as the 
valve like formation of the canal is more or less obliterated in 
hernia, the internal ring being widened by the pushing inwards 
of the conjoint tendon, so that the external and the internal 
apertures are placed more directly opposite each other. 

The canal having been refreshed by the finger and the han- 
dle of the scalpel during removal of the sac therefrom, its walls 
are brought into direct contact. This may be effected by any 
of the many methods of stitching. There are, however, inmost 
of these methods, two objectionable points which ought to be 
obviated. First, the stitch through the conjoint tendon is sin- 
gle and includes the external oblique, therefore the apposition 



RADICAL CURE OF OBLIQUE INGUINAL HERNIA. 9 1 

of the internal with the outer pillar is not so extensive or so 
exact as it would be were a double suture placed in the con- 
joint tendon alone. Second, the conjoint tendon is approxi- 
mated to the outer pillar of the external ring, the abdominal 
walls being thinned thereby and the natural valve which the 
canal forms is to a great extent obliterated. Instead, one 
ought to endeavor to bring the conjoint tendon into close 
proximity with the outer wall represented below by that por- 
tion of Poupart's ligament on a level with the lowest part of 
the interna) opening, and above by Poupart's ligament, the 
transversalis and internal oblique muscles at a point corres- 
ponding to the highest level of the internal ring, the aim 
being to carry the conjoint tendon outwards toward the fixed 
unyielding ligament of Poupart and to unite it with the trans- 
versalis and internal oblique muscles. In oblique inguinal 
hernia, the transversalis muscle ought never to be included in 
the suture, as that would tend to defeat the desired object. 

The principles of this operation may be equally applied to 
other forms of abdominal hernia, though in this paper its ap- 
plication to indirect inguinal hernia is alone described. 

Preparation of the Parts Prior to Operation. — Before operating 
the hair of the pubes and neighboring parts is closely shaven, 
the skin is washed with soap and water, a nail brush being em- 
ployed for this purpose. After drying, turpentine is smeared 
over the parts to remove any grease which may remain, a little 
methylated spirit clearing away the turpentine and leaving the 
skin in a good condition for operating. The parts are then 
covered wath a portion of lint saturated with a bichloride solu- 
tion until the patient is placed under the influence of an anaes- 
thetic. 

When the patient has been anaesthetized, the limb on the 
side of the hernia is flexed at the knee by a pillow which is 
placed under the latter. An assistant stands at the opposite 
side of the surgeon whose duty it is to retract the parts. 

Hernia Needles. — The needles found to be most useful for 
the insertion of the stitch into the inguinal canal are figured 
here, one being used for passing the thread from right to left, 
the other from left to right. They are serviceable for many 
other purposes, such as for inserting sutures through broad 



92 



WILLIAM MA CE WEN. 



ovarian pedicles or through masses of omentum which are 
about to be removed. Wood's needle might, however be em- 
ployed for all the sutures, except the double one introduced 
into the conjoint tendon. 




Fig. 



Needles, Right and Left, Used in Operation for Rad- 
ical Cure of Hernia. 



The handle and blade are continuous being made from one piece of steel. 



Operation for Radical Cure of Inguinal Hernia. — After 
having reduced the bowel make an incision sufficient to ex- 
pose the external abdominal ring. An exploration of the sac 



RADICAL CURE OF OBLIQUE INGUINAL HERNIA. 



93 



and its contents is then made and the finger introduced through 
the canal examines the abdominal aspects of the internal ring 
and the relative position of the epigastric artery. The opera- 
tion may then be divided into two parts, the one relating to 
the establishment of a pad on the abdominal aspects of the 
internal ring, the other, to the closure of the inguinal canal. 
The steps of the operation are as follows : 




Fig. 2. Site of Incision. 



The dark line shows site of incision, exposing external opening of inguinal canal. 

(A). The formation of a pad on the abdominal surface of 
the circwnference of the internal ring. 

(i). Free and elevate the distal extremity of the sac, pre- 
serving along with it any adipose tissue that may be adherent 
to it. When this is done, pull down the sac, and while main- 
taining tension upon it, introduce the index finger into the in- 
guinal canal separating the sac from the cord and from the 
parietes of the canal. 



94 



WILLIAM MACE WEN. 



(2). Insert the index finger outside the sac till it reaches 
the internal ring, there separate with its tip, the peritoneum 
for about half an inch round the whole abdominal aspects of 
the circumference of the ring. (Fig. 3). 




Fig. 3. Separating the Peritoneum. 

Showing finger inserted through inguinal canal, separating the peritoneum from 
abdominal aspects of circumference of internal ring. 

(3). A Stitch is secured firmly to the distal extremity of the 
sac. The end of the thread is then passed in a proximal direc- 
tion several times through the sac, so that when pulled upon 
the sac, becomes folded upon itself like a curtain. (Fig. 4). The 
free end of this stitch, threaded on a hernial needle, is made to 
traverse the canal and to penetrate the anterior abdominal 
wall about an inch above the internal ring, the wound in the 
skin being pulled upward so as to allow the point of the needle 



RADICAL CURE OF OBLIQUE INGUINAL HERNIA. 95 




Fig. 4- ' Folding the Sac. 

The sac transfixed and drawn into a series of folds. 

to project through the abdominal muscles without penetrating 
the skin. (Fig. 5.) The thread is relieved from the extremity of 




Fig. 5. Securing the Folded Sac Above. 

The hernia needle carrying the thread from the upper portion of the sac through 
the abdominal muscles from behind forward about an inch above the internal ring. 



96 



WILLIAM MACE WEN. 



the needle, when the latter is withdrawn. The thread is pulled 
through the abdominal wall and when traction is made upon 
it, the sac wrinkling upon itself is thrown into a series of folds, 
its distal extremity being drawn furthest backwards and up- 
wards. An assistant maintains traction upon the stitch until 
the introduction of the sutures into the inguinal canal, and 
when this is completed the end of the stitch is secured by- 
introducing its free extremity several times through the super- 
ficial layers of the external oblique muscle ; or it may be se- 
cured to a minute portion ot decalcified drainage tube placed 
on the surface of th^ muscle. A pad of peritoneum is thus 
placed upon the abdominal side of the internal opening, where, 
owing to the abdominal aspect of the circumference of the 
internal ring having been refreshed, new adhesions may form. 
(Fig. 6). 




Fig. 6. Pad Covering Abdominal Aspect of Internal Ring. 



The following modifications have been practised : After se- 
curing the stitch to the distal extremity of the sac, the thread 
has been passed directly through the abdominal muscles 
without first transfixing the sac. In children this may be suf- 
ficient. On one occasion, instead of placing the stitch extra- 
peritoneally it was introduced from within, the sac being com- 
pletely invaginated so as to resemble an umbilicus, the prom- 
inence being directed backward into the abdomen. The case 
did well in every respect. This method has not been repeated 
as the extra peritoneal method answers equally well. After 
having reduced the sac into the abdominal cavity and securing 
it there, it has been fixed below by a stitch as well as above. 
This has been found to be unnecessary. 



RADICAL CURE OF OBLIQUE INGUINAL HERNIA. 



97 



(B). Closure of the higinnal Canal. — The sac having been 
returned into the abdomen and secured to the abdominal cir- 
cumference of the ring this aperture is closed outside of it in 
the following manner : The finger is introduced into the canal 
and lies between the inner and lower borders of the iitternal 
ring. It makes out the position of the epigastric artery so as 



^e 




Fig. 



The Threaded Hernia Needle Making Double Penetra- 
tion OF Conjoint Tendon. 



to avoid it. The threaded hernia needle is then introduced 
and guided by the index finger is made to penetrate the con- 
joint tendon in two places. First from without inwards near 
the lower border of the conjoint tendon; second, from within 
outwards as high as possible on the inner aspects of the canal. 
This double penetration of the conjoint tendon is accomplished 
by a single screw like turn of the instrument. (Fig. 7.) One 



98 



WILLIAM MACE WEN. 



single thread is then withdrawn from the point of the needle 
by the index finger, and when this is accomplished, the needle 
along with the other extremity of the thread is removed. The 
inner side of the conjoint tendon is therefore penetrated twice 
by this thread and a loop left on its abdominal aspect (Fig. 8). 
Second. The other hernia needle, threaded with that portion 
of the stitch which comes from the lower border of the con- 




FlG. 



Loop ON Abdominal Aspect of Conjoint Tendon. 



joint tendon, guided by the index finger in the inguinal canal, 
is introduced from within outwards through Poupart's ligament 
and the aponeurotic structures of the transversalis, internal and 
external oblique muscles. It penetrates these structures, at a 
point on a level with the lower stitch in the conjoint tendon 
(Fig. 9). The needle is then completely freed from the thread 
and withdrawn. 



RADICAL CURE OF OB U QUE INGUINAL HERNIA. 



99 



The needle is now threaded with the gut which protrudes 
from the upper border of the conjoint tendon and is introduced 
from within outwards through the transversalis, internal and ex- 
ternal oblique muscles at a level corresponding with that of 
the upper stitch in the conjoint tendon. It is then quite freed 




Fig. 9. Thread From Lower Border of Conjoint Tendon Being 
Carried Through Outer Pillar of Internal Ring. 



from the thread and withdrawn (Fig. to). There are now two 
free ends of the suture on the outer surface of the external 
oblique and these are connected with the loop on the abdom- 
inal aspect of the conjoint tendon. To complete the suture 
the two free ends are drawn tightly together and tied in a reef 
knot. 

This unites firmly the internal ring. The same stitch may 
be repeated lower down the canal if thought desirable. In 
adults it is well to do so. The pillars of the external ring are 



lOO 



WILLIAM MACE WEN. 



likewise brought together. In order to avoid compression of 
the cord, it ought to be examined before tightening each stitch. 
It ought to be freely movable. It is advisable to introduce all 
the necessary sutures before tightening any of them. When 
this is done, they may be all drawn tight and maintained so 
while the operator's finger is introduced into the canal to ascer- 
tain the result. If satisfactory, they are then tied, beginning 




Fig. io. Thread Ready for Tying. 

In Figures 3, 5, 7, 8, 9 and 10 the skin and cellular tissue is reflected in a flap and the 

external oblique is opened up in such a way as to expose the interior of 

the canal and the internal ring. 



with the one at the internal ring and taking up the others in 
order. During the operation, the skin is retracted from side to 
side, to bring the parts into view and to enable the stitches to 
be fixed subcutaneously. When the retraction is relieved the 
skin falls into its normal position, the wound being opposite 



RADICAL CURE OF OBLIQUE INGUINAL HERNIA. lOI 

the external ring. The operation is therefore partly subcu- 
taneous. 

When the canal has been brought together, a decalcified 
chicken bone drainage tube is placed with its one extremity 
next the external ring, the other projecting just beyond the 
lower border of the external wound. A few chromic gut su- 
tures are then introduced along the line of skin incision. 

Dressing the Wormd. — Iodoform is dusted over the wound, 
the interstices of the scrotum and its junction with the thigh. 
A small portion of sublimated gauze is applied and on top a 
subhmated wood-wool pad held in position by an aseptic band- 
age. As a rule a portion of elastic webbing is placed over the 
margins of the pad to secure it firmly. 

As the patient is laid in bed, a pillow is placed under his 
knees while his shoulders are slightly raised, so as to relax the 
tissues about the canal. 

After Treatment. — The rectal temperature is taken night and 
morning, and at the same time the dressings are inspected. 
The dressings are left undisturbed from fourteen to twenty-one 
days, unless they are previously stained or the temperature is 
abnormally high. On their removal at the end of that period 
the wound is found healed, the extremity of the decalcified 
drainage tube which projected beyond the margin of the skin 
is seen to lie loose on the dressings along with the external 
portion of the majority of the superficial stitches. A fresh pad 
is applied to maintain pressure over the part. From four to 
six weeks after the operation, the patient is allowed to rise 
from bed, but he is not permitted to work until the end of 
the eighth week. He is further advised not to lift heavy 
weights until the end of the third month at the very earliest. 
Adults engaged in laborious occupations are advised to wear a 
bandage and pad, as a precautionary measure. Those who 
are not so engaged are not required to wear a belt except when 
of very lax habit. All are recommended not to overstrain 
themselves. In the majority of children (six to fourteen years) 
the closure is so complete and firm that further treatment by 
pad or belt is quite unnecessary. 

Operation for Radical Cure of Coiigenital Heriiia. — In con- 
genital hernia the sac is first isolated from its connection with 



1 02 WILLIAM MA CE WEN. 

the canal. It is then opened and divided transversely into two 
parts, care being taken to preserve the cord. The lower part 
is formed into a tunica vaginalis. The upper is pulled down as 
far as possible, split behind longitudinally so as to allow the 
cord to escape, when it is closed by a stitch or two (Fig. ii). 
This portion is then dealt with quite as the sac of an acquired 
hernia, additional precautions being necessary to clear the 
cord at the internal abdominal ring. It is freed of its connec- 
tions and placed as a pad on the abdominal aspect of the cir- 
cumference of the internal ring. 

On one occasion a separate tube was formed for the cord out 
of the sac but this has not been repeated. 




Fig. II. Manner of Treating the Sac in Congenital Inguinal 
Hernia. 

Materials for Siihire. — Any of the materials usually employed 
as sutures may be used in this operation, provided the thread 
is sufficiently stout to prevent it rapidly ulcerating its way 
through the tissues. All are not equally serviceable, however. 
The substances hitherto used may be divided into three groups; 
first, those introduced with the object of being withdrawn after 
they have served their temporary purpose ; second, those in- 
serted with the view of permanently maintaining in apposition 
the parts which they have brought together, while they do not 
set up irritation in the tissues ; and third, those that are intro- 



RADICAL CURE OF OBLIQUE INGUINAL HERNIA. IO3 

duced to serve their purpose and which are afterwards absorbed. 
The first may be represented by the stout copper wire silvered 
used by Mr. Wood, of King's, which admirably answers the^ 
purpose to which he applies it. As it has to be removed after 
a definite period, the suture must be so placed that a portion of 
it presents externally. Though in the operation brought for- 
ward in this paper it is possible to arrange the sutures so as to 
permit of their ultimate withdrawal, yet in describing the man- 
ner of securing them it will be seen that this is purposely 
avoided, all of them being fixed subcutaneously. The second 
method is that of inserting a metallic suture, which, after being 
secured is cut off short, the tissues being closed over it. Some 
employ this method, merely to obviate the necessity of remov- 
ing the wire, believing that it remains in the tissues and does 
not work its way out ; while others consider that it not only 
has these advantages, but it also maintains by its presence the 
permanent apposition of the parts. That wire sutures when 
properly applied, without leaving any sharp points projecting 
from the circle into w^iich they are formed, may remain indefin- 
itely in the tissues without producing irritation or working their 
way out, is an established fact. This is especially the case 
where they are inserted into bone with their extremities turned 
in. It is not, however, a constant occurrence even in bone, less 
so in soft tissues, and much less still in tissues habitually sub- 
jected to movement. This is consistent with my own observa- 
tion, and it is admitted by many of those who practice and 
most strongly advocate the leaving of the sutures of metal in 
situ. Granting that the wire suture remains permanently in 
the tissues without producing irritation, does the mere fact of 
it doing so serve any purpose ? Some believe that its function 
is ended when it has brought the pillars of the ring closely to- 
gether and has maintained them there for some fourteen or 
twenty-one days ; after which it might as well be outside. Oth- 
ers, however, are of opinion that it maintains the pillars of the 
ring permanently in apposition. This is not the case. It serves 
a purpose in this respect while it exerts traction on the pillars. 
As long as it maintains tension on the tissues, the wire being 
itself unyielding, it causes ulceration of the parts pressed on. 
This ulcerative process will continue until the wire in relation 



1 04 WILLIAM MA CE I VEN. 

to the tissues has reached a position of rest. When this is ac- 
comphshed it is no longer an active agent but descends to the 
condition of a foreign body which at best becomes encapsuled 
in the tissues but occasionally gives rise to disturbance which 
ends in its elimination. The third variety embraces substances 
which serve their purpose and which are afterwards absorbed. 
By far the most serviceable of such substances is cat-gut pre- 
pared so as to resist the action of the tissues from fourteen to 
twenty-one days. Gut of this description has been used for se- 
curing the pad of peritoneum and also for the closure of the 
canal. Gut prepared for a shorter period and which will only 
resist the action of the tissues for a week is used for the tissues 
in the superficial wound. The use of these stitches along with 
decalcified chicken bone drainage tubes obviates the necessity 
of subsequent interference with the wound. The latter ad 
mirably serve the purpose for which they were intended, secur- 
ing drainage during the first six days and then becoming en- 
tirely absorbed. 

Results. — There have been thirty-three cases in which the 
operation has been performed for radical cure of inguinal her- 
nia, and fourteen have been subjected to it subsequently to the 
relief of strangulation ; making in all forty-seven cases of in- 
guinal hernia in which this method has been performed. In 
nine others, the principles of it were carried out in femoral 
hernia, after the relief of strangulation. In both of the latter 
classes of cases the operation was not performed where gan- 
grene of the bowel was pronounced, or even where there was 
a distinct approach to this condition. In a number of femoral 
herniae it could not be performed owing to the firm adhesions 
of the sac, especially when they were to the outer side next the 
femoral vein. 

A tabulated view of these cases is here appended, from 
which it will be seen that there have been no deaths from the 
operation. In a few cases suppuration has ensued and that to 
a very sHght extent, with the exception of a femoral hernia in 
which there was a prolonged dissection necessary. All the pa- 
tients before leaving the ward were thoroughly inspected, and 
firm occlusion was obtained in each ; so that the primary re- 
sult was highly satisfactory. But it is just in cases of this kind 



RADICAL CURE OF OBLIQUE INGUINAL HERNIA. IO5 

that the permanent result so often differs from the primary, and 
as the former is the true test of the efficiency of the operation, 
the patients have been kept under observation as long as pos- 
sible. In judging of the permanent results two must be ex- 
cluded from table No. I, as having been so recently operated 
on. The remainder in table No. I have been kept under ob- 
servation as follows : Four from four to six months after, four 
from eight to ten months, two for one year after, three for 
about one year and a half, five for two years, five for three years, 
one for four years and one for five years. So that eight have 
been kept under observation for less than a year, and seven- 
teen from one to five years. Table No. 2 gives : one for eight 
months, three for one year after, three eighteen months after, 
four two years after, two three years after, and one four years 
after. Table No. 3 gives : One not seen after dismissal, two 
seen eight months after, two one year after, one eighteen 
months after, one two and a half years after, two three years 
after. In table No. 2 one has been kept under observation for 
less than a year, and thirteen from one to four years after. In 
table No. 3 two have been kept under observation for less than 
one year, and six from one to three years after ; while one was 
not seen after dismissal from the wards. In all of them when 
last examined the rings remained firm. Out of the thirty- 
three cases in which this operation has been performed for rad- 
ical cure one only has been found subsequently to wear a pad 
and bandage. In this instance patient said that he had been 
wearing a truss so long previously to the operation that he felt 
"a want" when there was no bandage over the part. It was 
more a force of habit than a need. The parts were firm. 
Among the fourteen who had been subjected to radical cure 
after the relief of strangulated inguinal hernia, three subse- 
quently wore a pad and bandage as a precautionary measure. 
One of these was of very lax habit and was advised to continue 
the use of a support ; one was a case of direct inguinal hernia 
with a very wide opening in the abdominal muscles ; while the 
third did so as his occupation (engineer) often demanded con- 
siderable exertion. After the femoral hernias no truss has been 
worn. 



io6 



WILLIAM MACE WEN. 







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Wounds examined 
fourteen days after 
and found healed. >v. 
Seen eight months ^ 
after, ring perfectly lT 
firm. Afterwards 1:^ 
went abroad. C^ 


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Seen 9 months after; N 
Occlusion perfect. 5 
No belts. g 

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RADICAL CURE OF OBLIQUE INGUINAL HERNIA. 



109 



t end of 
day. 
Seen at 
th month 
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RADICAL CURE OF OBLIQUE INGUINAL HERNIA. Ill 



moved 
teen days, 
rm ten 
fter, ring 
belt or 


moved at 
teen days 

moved at 
■teen days 
m. Five 

th rings 
ar scars. 
>rn. 


"2^ 


days af- 
d firm— 

Eighteen 
fter parts 
russ. 


ifamined wound at 
end of twenty-one 
days. Decalcified 
chicken bone drain- 
age tube d i s a p - 
peared. Wound firm. 
Superficial stitches 
separated. S i x 
months after parts 
firm. No truss. 


ressings re 
end of tour 
Wound fi 
months a 
firm. No 
pad. 




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WILLIAM MA CE WEN. 





1 
1 


wenty-one days af- 
ter wound fo un d 
firmly united. De- 
calcified chicken 
bone drainage tube 
absorbed, all but 
minute portions 
ivhich projected from 
wound, which were 
found separated and 
lying in dressing. Su- 
perficial stitches also 
separated. Linear 
scar. Four months 
after parts firm. No 
truss. 


wenty-one days after 
wound found firm. 
Decalcified chicken 
bone drainaeje tube 
absorbed. Linear 
scar. 


nne saturated dress- 
ings, temperature in- 
creased and slight 
suppuration: in con- 
sequence dressings 
more frequent. 






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RADICAL CURE OF OBLIQUE INGUINAL HERNIA. 

nils I \°tt°l 



113 



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114 



WILLIAM MACE WEN. 



cured. Nineteen 
months after 
was seen, with 
firmring,though 
wearing belt as 
precaution. 


Occlusion firm. 
Four years after 
rings still com- 
plete. No truss 
worn. Regularly 
at heavy work. 


Occlusion com- 
plete. Three 
years after 
found regularly 
at work. Rings 
firm; no belt. 


Weak man con- 
stitution ally. 
Occlusion solid. 
Two and a half 
years after rings 
still firm. At 
work uninter- 
ruptedly, wears 
bandage. 


Firm occlusion. 
Three years af- 
ter found walls 
firm. No truss, 
follows regular- 
ly his occupa- 
tion 




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Rad. cure af- 
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of sac into 
two-one 
forming tu- 
nica vagin- 
alis, the oth- 
er abdomin- 
al pad. 


si 

3 

•d 




Relief of stric- 
ture, reduc- 
tion of her- 
nia. 


Removal of 
portion of 
omen tum , 
relief of 
stricture, re- 
duction of 
hernia. 


Reliefofstric- 
ture, reduc- 
tion of her- 
nia. 

Relief ofstric- 
ture, reduc- 
tion of her- 
hia. 




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Intes- 
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Omen tal 
and In- 
testinal. 


Intes- 
tinal. 

Intes- 
tinal. 




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3 days. 
2 years. 


3 years. 
3 years. 




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RADICAL CURE OF OBLIQUE INGUINAL HERNIA. 



115 





1 




III! 


This patient had 
pneumonia a t 
time of admis- 
mion into ward, 
and prior to op- 
eration. Recov- 
ery; occlusion 
perfect. One 
year after quite 
well Firm walls; 
no truss. 


Occlusion perfect. 
Firm walls. Seen 
eighteen months 
afte. Regularly 
at work, occlu- 
sion firm; wears 
bandage. 


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er division 
of sac into 
two, one 
forming tu- 
nica vagin- 
alis, the oth- 
er abdomin- 
al pad. 


3 


8 

1 


Relief of 
double stric- 
ture, one fi- 
brous band 
round intes- 
tine, reduc- 
tion of her- 

Relief ofstric- 
ture, reduc- 
tion of her- 
nia. 


Relief of 
double stric- 
ture, one at 
ring, t h e 
Other by fi- 
brous band 
at neck of 
sac. Reduc- 
tion of her- 
nia. 




Congeni- 
tal, in- 
fantile, 
acquired. 


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ii6 



WILLIAM MACE WEN. 



Taxis failed, child 
in agony — un- 
der chloroform 
taxis again fail- 
ed. Two years 
after child in 
good health- 
firm ring. No 
truss. 


Firm occlusion. 
One year after 
found ring firm. 
Regulfirly a t 
work. No truss. 


Firm occlusion. 
i8 months after 
ring firm. No 
truss. Regularly 
at work. 


Taxis failed under 
chloroform . 
Seen one year 
after.Ring quite 
firm. No truss. 


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Relief of stric- 
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tion of her- 
nia. Valved 
incision in 
skin to pre- 
vent urine 
passing into 
wound. 


2^ = 2 S""^E 

IlillWll 

CD 


III! 


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RADICAL CURE OF OBLIQUE INGUINAL HERNIA. I 1/ 







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ii8 



WILLIAM MA CE WEN. 





Ring firm. Seen three 
years after; parts firm. 
No pad. 


Ring firm. Two and one 
half years after parts 
found firm. No truss. 


Ring firm. Seen eighittn 
months afterwards ; 

Sarts firmly occluded. 
fo truss. 


HI 

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05 




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c 



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100. T° F. 
One 

night. 

98.8° F. 


^ 6 


bJ 
I 


n 
m 

"5 3 C 


Sac formed into pad 
and placed ab- 
dominal aspect. 
Falciform process 
united to Gimber- 
nat's ligament. 


Sac formed into pad 
and placed ab- 
dominal aspect. 
Falciform process 
united to Gimber- 
nat's ligament. 

Sac formed into pad 
and placed ab- 
dominal aspect- 
Falciform process 
united to Gimber- 
nat's ligament. 


Sac formed into pad 
and placed ab- 
dominal aspect 
Falciform process 
united to Gimber- 
nat's ligament. 




Intestine enclosed 
in omentum ; had 
to be carefully 
liberated. Remov- 
al of omentum, re- 
lief of stricture, re- 
duction of bowel. 


Dissected bowel out 
of mass of omen- 
tum, which com- 
pletely enclosed 
It. Relief of stric- 
ture, reduction of 
bowel, removal of 
omentum. 


nil 

■A 


Dissected bowel out 
of mass of omen- 
tum which en- 
closed it like a 
cyst. Relief of 
stricture. Re- 
turned bowel. 




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RADiCAL CURE OF OBLIQUE INGUINAL HERNIA. 



119 



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P3 



THE OPERATION FOR VARICOCELE, 
By ALEX. OGSTON, C. M.. 

OF ABERDEEN, 
REGIUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF ABERDEEN. 

Nowhere has the introduction of the antiseptic method into 
surgery exercised a more marked influence than in the encour- 
agement it has given to the performance of such operations of 
convenience as that for Varicocele. Formerly looked upon 
with disfavor, if not actually considered unjustifiable, this op- 
eration has since the antiseptic days been again taken up by 
surgeons everywhere, and modified or improved in accord- 
ance with antiseptic principles. Where this has happened, it is 
now part of the daily routine of practice, and is recommended 
with as much confidence, and performed with the same secur- 
ity, as tenotomies and subcutaneous operations. Improved 
varicocele operations are continually appearing in our surgical 
literature, and various plans are being advanced as claiming 
both safety and success. 

That the operative treatment is sound and justifiable sur- 
gery can scarcely be denied, for advanced cases of the disease 
are so frequently found to produce distress and disablement to 
a great degree, that a reasonably safe and certain cure is wel- 
come both to the sufferer and the surgeon. Palliative 
methods of treatment, such as Wormald's ring, trusses, suspen- 
sory bandages, are seldom of any use. 

The method of operation I have employed during the last 
eight years excels in simplicity, safety and certainty the 
various proceedings that I have seen recommended by oper- 
ators. It is indeed so simple that I have no doubt many 
others besides myself have had recourse to it, although I have 
not observed in medical periodicals any statement of its having 
been adopted or recommended. 

It consists in an aseptic subcutaneous deligation of the vein 
by means of a needle and disinfected thread. 




77/fr/u/ pnssrri /hrmry/f betweeit'Vas anr/ I'f'frfs. 



Varume liins (L^s^ 




W 



Tuc/cen/uj o/^ ski/t 
atii^edle aperii/re. 




/hnorM sedmt or'. Scort/m ut Van/:Mele. /hsltion (/TJim/dMdl4'ms before i{^i/i// 




of TJireac/ a/u/ lems bftore i/i^ second msfj-tim affJiertrnd/'. 



THE OPERATION FOR VARICOCELE. 121 

I have preserved notes of six patients so operated on, the 
earliest in January, 1878. They were all young men, the sub- 
jects of advanced varicocele on the left side, and there existed 
softening of the testicle in two of them. In all the operation 
was confined to the left side, and was done in the same manner 
save that in one of them anaesthesia was not employed. They 
suffered from no fever or constitutional disturbance after the 
operation, the local reaction was confined to the formation of 
a firm induration at the site of operation, which in the course 
of a few months slowly disappeared. The result was in every 
instance satisfactory at the time, and most of them I have seen 
or heard from long after the operation, and they have found 
the cure complete and permanent. 

The operation was carried out as follows : The patient was, 
in all cases save one, put under the influence of chloroform or 
ether in bed, and the scrotum disinfected by a 5 per cent, 
solution of carbolic acid. The patient, who was not anaesthe- 
tized, was operated while sitting on a chair. After disinfec- 
tion the left half of the scrotum was, by the usual manoeuvre 
siezed three-quarters of an inch above the testicle, between 
the forefinger and thumb of the left hand and its contents 
allowed to slip back and escape until the cord-like vas defe- 
rens had slipped out of grasp. At this point the finger and 
thumb squeezed the skin of the two sides of the scrotum 
together, to squeeze the veins away from the just escaped vas, 
and a threaded needle was thrust through the scrotum at this 
spot (Fig. II). A handled needle with a large eye at its point was 
employed, and its thread was the strongest surgeons' silk, dis- 
infected either by having been boiled in 5 per cent, carbolic 
solution, or by Kocher's method of twenty-four hours soaking 
inGerman oil of jumper,the thread being afterwards kept in abso- 
lute alcohol. The needle was disinfected by being washed, first 
with oil of turpentine, and then with carbolic lotion. Care was 
had, in thrusting the needle through the scrotum, to avoid, at 
the points both of entrance and emergence of the needle, the 
tubular sebaceous scrotal glands from which the hairs emerge, 
as they are always full of bacteria and their disinfection is an 
impossibility. The needle was then unthreaded and withdrawn 
leaving the thread in its track. The skin of the front of the 



122 ALEX. OGSTON. 

scrotum was then seized by the left forefinger and thumb and 
drawn forwards in a fold between them until the punctures 
from which the thread emerged were drawn forward over the 
dilated veins to the base of the folds (Fig. III). They were 
there squeezed together and steadied by the finger and thumb, 
and the needle, this time without any thread, was once more 
passed through the scrotum, entering and emerging by the 
same points as before. The end of the thread emerging beside 
the needle point was threaded into its eye and the needle was 
withdrawn, carrying the thread with it, so that both ends of 
the thread emerged by the same point where the needle was 
first entered (Fig. IV). The needle having been detached the 
long ends of the thread were tied by a surgical knot and 
tightened upon the veins and tissues they embraced with the 
utmost strength that could be appHed. A triple knot was 
made, the ends of the silk were cut ofif short and the knot per- 
mitted to sink into the depth of the scrotum. The pucker- 
ings inward of the needle apertures, due to the first and second 
needle tracks not quite coinciding in the subcutaneous tissues, 
(see Fig. IV.) were freed by puUing the skin outwards at these 
spots until the included fibres gave way and allowed the skin 
to fall into its natural position entirely unconnected with the 
knot. 

Another exactly similar operation was made an inch (or two 
finger breadths, as the case required) higher up the veins, and 
the operation was then complete. 

The scrotum was again disinfected, surrounded by a sheet 
of salicylic wool, and the patient laid in bed with the testes 
elevated. 

One of my patients submitted to the operation without 
anaesthesia, but as a rule, it is sufificiently painful to demand 
the administration of an anaesthetic, and the careful carrying 
out of the disinfection and necessary steps are much facilitated 
thereby. 

A knot of the size of the point of the thumb appears be- 
tween and around the ligatured points, and a slight degree of 
scrotal cedema can be detected, lasting for a few days. The 
patient suffers little pain, and as the needle punctures are ag- 
glutinated at once frequent dressing is needless. 



FRACTURES OF THE LOWER END OF THE RADIUS. 1 23 

A daily renewal of the salicylic wool during the first three 
days is desirable, after that no further dressing is required. 
The knot at the site of the operation slowly disappears, and at 
the end of three weeks the patient can safely walk about, 
using, however, a suspensory bandage, and being careful to 
avoid strain, pressure, or fatigue of the part. 

The disappearance of the last traces of the knot demands a 
month or two for its accomplishment, but eventually no trace 
remains of the operation having been performed. 



THE TRETAMENT OF FRACTURES OF THE LOWER 
END OF THE RADIUS.^ 

By RICHARD JOHN HALL, M. D., 

OF NEW YORK, 

•SURGEON TO BELLEVUE, AND TO ST. LUKE's HOSPITALS. 

AT the outdoor department of the Roosevelt Hospital, a not 
inconsiderable number of fractures of the lower end of 
the radius present themselves, which have already been seen 
by physicians in private practice, and "after the reduction of 
the deformity and the application of an apparatus, have been 
referred to us for treatment, because the patients are impecu- 
nious ; or which have received the first care at some other hos- 
pital or dispensary, and are sent to us because the patients 
reside in the neighborhood. In this way, and through conver- 
sation with various surgeons and physicians in the city, I have 
had opportunity to note the different modes of treatment 
adopted by a great number of surgeons, and in a number of 
the hospitals in the city. 

In the claim of a particular apparatus, and the treatment of 
the fracture, two ideas seem to me to have special weight with 

1 Read before the New York Surgical society March 23, 1886. 



124 RICHARD JOHN HALL. 

New York surgeons. First, that by leaving the wrist and 
hand free, and allowing it to fall into a position of adduction, 
we at once reduce the displacement of the hand toward the 
radial side, and prevent the partial ankylosis of the wrist and 
the rigidity of the tendons and small joints of the hand, so 
much dreaded in this fracture ; and, second, that to avoid this 
latter condition it is necessary and advisable to commence pas- 
sive motion at an early period, long before the consolidation of 
the fracture, and to continue this during the healing process. 

A conviction, founded on both theoretical considerations 
and on a considerable practical experience, that both these 
views are incorrect, is my only excuse for bringing so well 
worn a subject to the notice of the Society. 

It will, probably, be a relief to the minds of my hearers to 
know that I have no new apparatus to present, no new mode 
of treatment to propose, and that I do not claim to cure all 
cases without deformity or ankylosis. 

My only object is to express my conviction that certain pre- 
cautions usually considered necessary, are not generally so ; 
and that in the case where the dangers feared are real, the pre- 
cautions taken are, at best, useless, and often injurious. 

In clinging to the conviction that adduction of the hand, 
maintained either by its own weight, as in the methods of 
Cline and Brasnby Cooper, or by the pistol-shaped splint of 
Goyrand or Nelaton, our surgeons are scarcely to be excused, 
since the fact that this treatment is founded on a false view of 
the nature of the displacement, and is useless to overcome 
it, has been fully demonstrated by three, at least, of the au- 
thorities most frequently consulted, IMalgaigne (Traite des 
Fractures, etc., t. i. p. 6i6), Hamilton [A Practical Treatise on 
Fractures and Dislocations, p. 300), and Stimson [A Treatise on 
Fractures, p. 460). 

For the practice of leaving the wrist and hand free, to allow 
of active and passive motion, or of removing the apparatus at 
short intervals during the consolidation, for the same purpose, 
much more weighty authority can be cited. Indeed, almost 
all the authorities insist upon the importance of one or the 
other of these measures. As instances may be cited Mal- 
gaigne (op. cit., t. p. 617), who allowed the splints to descend 



FRACTURES OF THE LOWER END OF THE RADIUS. 125 

only as far as the first row of carpal bones, in order to be able 
to make moderate movements. V. Pitha [Handb. dej'allg. iind 
spec, chir., Billroth and Pitha, Bd. 4, Abt. 2, S. 102) advises the 
same. Hamilton (op. cit.,^p. 309) seems to advocate complete 
rest, as a rule, but states that when a fracture extends into the 
joint, early passive motions must be made to prevent ankylo- 
sis. Erichsen [Science aud Aft of Surgery, vol. i. p. 575) says: 
"After the first week it is well, especially in elderly people, to 
leave the fingers free, and to encourage movement of them, 
lest that painful stiffness result which is so common a result 
of the accident. Passive motion of the wrist-joint may, how- 
ever, often be commenced with great advantage to the patient 
before the union of the fracture, more particularly when it is 
impacted," and predicts very troublesome stiffness if the hand 
and fingers be kept fixed during the whole time. Packard 
(Ashurst's Internat. Encyclopcedia of Sin-g., vol. iv. p. 177) ad- 
vises that passive motion should be made only in exceptional 
cases " where there is a strong tendency to stiffening, such as 
sometimes occurs in old people, or where the violence producing 
the injury has been very great." Stimson (op. cit., p. 184) 
recognizes the principle that immobilization is indicated, as 
a rule, in injuries involved close to joints; but adds, "in the 
smaller joints of the hand the case is different. There the ex- 
tended position and immobility favor stiffening, even when the 
fracture involves only the forearm or arm ; and, therefore, 
should be left free, or dressed in the fixed position and moved 
every day." And again (p. 146), "the indications are of two 
kinds : to immobilize the fragments, and to allow passive and 
voluntar>^ motions of the fingers in order to prevent or dimin- 
ish their subsequent stiffness." 

Schede (Zur Behand. des typischen Bruches der unteren 
Radiusepiphyse ; Verhaiid. der Deutschen Gesell. fur Chir., 
1882, p. 68) recommends that the fingers should be left free 
and the patients encouraged to make active and passive mo- 
tions with them, and that the splints should be removed every 
eight days to allow of passive motion, removing them finally 
in three weeks. The discussion which followed turned rather 
on the relative merits of various splints, especially as com- 
pared with plaster of Paris, rather than on the question of 



126 RICHARD JOHN HALL. 

early motion ; but Schiiller, Langenbeck, and Billroth stated 
that they always used plaster as a permanent dressing, leaving 
the fingers free, and without ever seeing stiffness as a result. 
Billroth stated that the cases in which there was a tendency to 
ankylosis and much stiffness were those due to great violence, 
the fracture penetrating the joint, or with great effusion of 
blood and inflammatory products. 

It will be observed that some of the authorities quoted above 
advocate early motion only in the more severe cases, If, how- 
ever, the principle which I advocate is correct, that motion of 
an injured joint and of the parts surrounding it will only in- 
crease the inflammatory^ process, give us a greater quantity of 
provisional callus, and cause more effusion into the ligaments 
and sheaths of tendons, with consequent greater subsequent 
rigidity, it follows that the worse the case the more harm will 
be done by disturbing the parts, and the stronger indication 
we have for more perfect and prolonged immobihzation. Some, 
as Stimson, advocate fixation of the wrist, but leave the fingers 
free, and consider active and passive motion of these of great 
importance. 

Like almost all surgeons, I leave the fingers free also, but 
merely because this allows them to fall into a natural and easy 
position of flexion, and the hand being enclosed in splints and 
carried in a sling, the patient is under no temptation to attempt 
much motion. 

That fixation in the constrained and unnatural position of 
complete extension should cause rigidity and discomfort, I can 
well understand, and have often had opportunity to verify by 
observation ; but if immobilization be advisable in cases of in- 
jury to larger joints, or in their neighborhood, I know of no 
reason why it should be injurious in the case of the smaller. 

As a matter of fact, I have frequently, in the treatment of 
fractures of the metacarpal bones with sinking in of the 
knuckles, kept all the fingers flexed over the end of the padded 
splint, and completely immobilized for a month continuously, 
and have never noticed the slightest stiffening as a result. 

Verneuil {^Biill. et Mem. de la Socicte de CJiir. de Paris, t. 5, 
p. 487) combats with great ability the idea that ankylosis of an 
inflamed or injured joint is promoted by immobilization; shows 



FRACTURES OF THE LOWER END OF THE RADIUS. 12/ 

that prolonged fixation of a healthy joint has never been 
known to lead to such a result ; that the ankylosis is due to the 
inflammation of the joint and of the surrounding parts, and 
that the first requisite for preventing or subduing inflammation 
here as elsewhere is complete rest of the part. 

In giving the mode of treatment adopted by us in these 
fractures, I would not be understood to advocate the particular 
kind of splint applied as better than any others in which the 
same principles of treatment are recognized — they have been 
used merely because they are cheap, and readily and rapidly 
applied. Neither have we found one mode of treatment ap- 
plicable to all cases ; where there has been a great tendency to 
recurrence of the displacement, special means have occasion- 
ally been necessary to prevent this. The cases of which I have 
histories represent really only a small proportion of those 
at the Roosevelt Hospital during this time ; they are, how- 
ever, by no means selected cases. If there has been any se- 
lection it has been of the more severe cases which demanded 
my personal attention. 

In a large number of cases no history was taken, because 
deformity, crepitus and mobility were absent, almost the only 
sign of fracture being the great tenderness on pressure. Were 
these cases included, it would be open to any one to question 
a diagnosis made on such grounds. These cases, however, 
have always been a perfect result as regards freedom from 
ankylosis and stiffness. 

A certain number of other cases have not been recorded, 
owing to the pressure of work and to the confusion incident to 
moving from crowded quarters to a new building. 

Of seventy-one cases in w^hich histories have been kept, 
eight are useless, because no statement is made of the condi- 
tion of the parts at the time of discharge sufficiently definite 
to be of value. Twenty-eight disappeard before the splints 
were finally removed. This leaves forty-one cases in which 
the exact result has been carefully noted. 

The principles of treatment have been the following : Com- 
plete reduction of all deformity when patient is first seen. In 
only one case was it necessary to give ether to accomplish 
this. 



128 



RICHARD JOHN HALL. 



Application of antefo-posterior splints extending from the 
elbow to the metacarpo-phalangeal articulation. 

Inspection of the parts at intervals of two or three days 
during the early part of the treatment, and later at intervals of 
a week. 

In two or three cases only the simple antero-posterior splints 
have not sufficed to retain the parts in position, when we have 
applied either Roser's apparatus, a long dorsal splint, with a 
wedged-shaped pad, keeping the wrist flexed, or strong iron 
strips, bent so as to give flexion with slight adduction. 

The splints have been kept in place for from four to five 
weeks, no passive motion being made. 

When the splints have been removed, the arm has been ex- 
amined by all the surgeons present, usually at least three or 
four, often more, and the result noted as perfect only when 
all were agreed. 

The patient has usually been instructed to carry the arm 
in a sling for a week longer, and not to attempt any laborious 
work for at least three weeks more. Of these forty-one cases 
the result as regards absence of any deformity, and either 
perfectly normal movements of the wrist and fingers, or so little 
stiffness that the functions were practically normal, has been 
recorded as perfect in thirty-one. 

A similar result as regards motion, but with slight deformity, 
has been noted in five more cases. In one of these the patient 
had not presented himself from the time the splints were ap- 
plied until the day on which they were removed. 

In another case it is noted that active motion at the wrist is 
slight, but passive motion perfect, and very slight deformity. 
In another case, in which the injury was due to great violence, 
the impaction of the radius was so firm, and the displacement 
of the ulna so marked that etherization was necessary, and 
even then the deformity was reduced with great difficulty, and 
not quite perfectly. When the splints were removed, dorsal 
flexion was fair, palmar only to a slight extent, due, it is noted, 
to the severity of the original injury and the flexed condition 
in which it was necessary to keep the wrist to prevent a return 
of the displacement. Finally, we have three cases ^in which 
slight or well-marked silver-fork deformity resulted with, in 



FRACTURES OF THE LOWER END OF THE RADIUS. I 29 

two, marked displacement of the hands toward the radial side. 

In one of these, a man of 72, an active eczema was devel- 
oped under the splints immediately after their application, so 
severe that the patient woyld tolerate no apparatus whatever. 
No rigidity of the wrist or fingers occuried. 

The other two patients were discharged after the usual treat- 
ment, the result being noted as very good. Being again under 
observation some months later, slight silver-fork deformity 
was noted with well-marked displacement of the hand toward 
the radial side. In one of these there was reason to believe 
that the deformity was due to disregard of our instructions, as 
to undertaking hard work immediately after the removal of the 
splints. I had a similar experience some years ago when, 
after discharging an elderly woman at the end of four weeks 
with a very good result, in defiance of my instructions she at 
once commenced hard work at a scrubbing board, and pre- 
sented herself some three months later with one of the worst 
deformities that I have ever seen. I would call attention to 
this as being one of the ways in which blame may be unjustly 
attached to the surgeon. 

In the third case, besides deformity, there was decided 
weakness of the flexor muscles of the hand, apparently due to 
an effusion into the sheaths of the tendons. I am at a loss to 
account for the late appearance of the deformity, as the pa- 
tient really seemed to have done no work since his discharge. 
He was receiving a weekly allowance from a society, and the 
continued weakness may have been due to long-continued 
voluntary disuse of the muscles. 

I am far from maintaining that good results may not be at- 
tained in particular cases by the methods which I condemn, 
but holding, as I do, that the principle of early passive motion 
for injuries near to or involving joints is wrong, I must regard 
them as having been attained in spite of, and not in conse- 
quence of, the treatment. 

As incidental points of interest in these cases, I may men- 
tion that in three the fracture was distinctly stated to have 
been produced by forced palmar flexion. In two of these the 
deformity had been partially reduced before the patients were 
seen, so that I am unable to give the direction of the original 



130 RICHARD JOHN HALL. 

displacement. The third, a very intelligent man who gave a 
clear and positive account of how the accident occurred, pre- 
sented the silver fork deformity of a typical Colles. One case 
presenting the regular deformity was alleged to be due to 
direct violence, a heavy board having fallen on the wrist. 

Another, a man, presented himself with an unimpacted frac- 
ture of the lower end of the radius and no deformity. On 
touching the parts a violent spasm of the extensors of the 
thumb and of the radial extensors of the wrist threw the parts 
into a perfect silver-fork position, the spasm causing severe 
pain and lasting several seconds. This could be made to recur 
a number of times and be carefully observed. 

One case presented an oblique fracture running from above 
and internally downward and outward into the joint, so as to 
chip off a triangular fragment from the internal portion of the 
lower end of the radius ; the fragment, of course, did not in- 
clude the styloid process. 

DISCUSSION. 

Dr. H. B. Sadns said he did not suppose that the members of the 
Society would come to any agreement on the chief point raised by Dr. 
Hall because their experience doubtless had differed, whereas the re- 
sults had generally been good. His own attention was called to the 
point of the avoidance of passive motion by reading Verneuil's very 
able discussion of the subject in 1879. He confessed that he had 
often been disappointed in attempting to secure the results said to 
have been obtained by passive motion. His practice had been very 
much like that advocated by Dr. Hall, and he was prepared to endorse 
the views that had been advanced. He believed that mistakes were 
frequently made by resorting to passive motion early in all cases of 
fracture in the neighborhood of joints. In the case of one joint he 
thought all surgeons would agree that passive motion should not be 
resorted to, and that is fracture in the neighborhood of the hip-joint. 
The usual plan of treatment was to adjust a posterior splint and allow 
the limb to remain in a fixed position for at least six weeks ; at the end 
of that time Dr. Sands thought there was not, as a rule, any stiffness 
to be observed at the coxo-femoral articulation. He had been fre- 
quently disappointed in attempting by means of passive motion to re- 
store or preserve the mobility of the wrist- joint. He believed that in 
some cases immobility is inevitable. He had treated the fracture 



FRACTURES OF THE LOWER END OF THE RADIUS. I3I 

under consideration in both ways ; that is, by complete immobilization, 
and by resorting to early passive motion, and by each method had oc- 
casionally been disappointed in the results when the accident occurred 
in old persons. But when the comparison came to be made between 
the results obtained by the two methods, he had no hesitation in saying 
that passive motion had been resorted to much too often and much too 
early. He had frequently noticed in fracture in the neighborhood of 
the elbow-joint occurring in children, that the joint, after the fracture 
had united, was very stiff and the tissues about it more or less thick- 
ened, and the conditions such that all efforts on the part of the sur- 
geon to restore complete mobility by passive motion were futile ; but 
he had seen some of these patients at a subsequent period, and had 
been both surprised and pleased at the result, for the inflammatory 
products had disappeared, and the arm, being left to perform its 
natural movements, had become quite supple. At the same time he 
did not wish to go so far as always to condemn an early resort to pas- 
sive motion, for he had seen cases in which it had been the means of 
bringing about mobility where otherwise such motion would have been 
lost. But, as a general rule, it would be better to let nature have her 
own way rather than attempt to force it by early -resort to passive mo- 
tion, and so far as his experience went he was prepared to endorse the 
rule advised by Dr. Hall. 

Dr. Yale said that, from his own experience, prolonged rest of a 
joint is not productive of the ankylosis often attributed to it. Not only 
with diseases of joints, but with fractures in the neighborhood, it had 
been his habit to keep them in a fixed position rather a long time than 
otherwise, and he had not been troubled subsequently with ankylosis. 
Furthermore, he had seen some cases in which immobilization had not 
been the cause of ankylosis when it did occur. He recalled one case 
in particular, that of an elderly lady who fell down some steps and 
broke her humerus. The splint which was applied fixed the elbow and 
shoulder-joints, but the hand was intentionally left free so that it should 
not become ankylosed. In the results the elbow and shoulder-joints 
were free very much earlier than were the joints of the hand,which were 
never fixed in a splint nor suffered any injury. He was obliged to 
work for several weeks with passive motion before succeeding in Umb- 
ering up the joints of the hand. 

Dr. L. S. PiLCHER said that he was fully in accord with the idea of 
immobilization of joints, as a rule, either when they are themselves the seat 
of an injury, or when the parts in the immediate neighborhood have been 
injured ; for it had seemed to him that in attempts at early mobiliza- 



132 L. S. PILCHER. 

tion there is danger of increasing or prolonging irritation by the move- 
ments of the fragments, movements caused by the contraction of those 
muscles which are inserted into the immediate neighborhood of the af- 
fected parts, these contractions being both voluntary and involuntary, 
provoked by passive motion. The main reason why passive motion 
should not be used would be found in these results, and not in anything 
produced in the joint itself. 

But in this injury at the wrist-joint there is an entirely different con- 
dition of afifairs ; in fracture at the lower end of the radius we do not 
by passive movements set in motion muscles which are attached in the 
immediate neighborhood of the affected part. The only muscle which 
could be brought into motion is the pronator quadratus — all the other 
muscles terminate in tendons which pass beyond the affected parts, 
with the exception of the supinator longus, which in the ordinary move- 
ments of flexion of the joint is not brought into use at all. The great 
masses of the extensors and the flexors are not so related to the injury 
as either voluntarily or involuntarily to produce movements ot the 
parts which may increase irritation, while the movements of the ar- 
ticular surfaces upon themselves produced by passive motion are in- 
nocuous. 

It seemed to him that in these injuries the greatest difficulty with 
which we had to contend, and the evil results of which we wished to 
avoid, was the tendency to efl"usion and subsequent adhesion along 
the sheaths of the tendons, and that m the movements properly guarded 
which may be produced at a very early date the formation of these ad- 
hesions may be prevented, adhesions which, if not prevented, will pro- 
duce after-stiffness of the parts for a considerable period, and some- 
times render the joints useless. His own practice during the last 
twelve years had been based upon this theory, and during this time he 
had thrown aside entirely splints of all kinds. After the fragments 
have been properly replaced he simply encircles the part by a band of 
adhesive plaster an inch and a half wide, which pretty firmly binds 
them together. This he reinforces by a roller bandage applied to the 
hand and forearm, which gives a sense of greater security, and dimin- 
ishes the tendency to fluxion present in the earlier days of the injury. 
In this way the hand and the fingers are left to the natural movements. 
By this method he had treated patients of all ages, and the result had 
been uniformly satisfactory, certainly much more satisfactory as regards 
functional result than the results usually expected to be attained by 
surgeons. As an illustration of the method, he presented a patient, a 
woman tet. 45, who a Htde more than two weeks previously had fallen 



FRACTURES OF THE LOWER END OF THE RADIUS. 133 

upon the pavement and sustained in the usual way fracture of the low- 
er extremity of the radius, at the same time tearing off the styloid pro- 
cess of the ulna also. 

He further remarked that iu only two cases had he applied any other 
dressing after the receipt of this injury, and in both instances it was 
done simply to satisfy the fears of either the patient or the friends. In 
one case a circular starch bandage was used which completely im- 
mobilized the wrist, and in the other Levis's metaUic spHnt was used. 

Of course, he appreciated the fact that very great differences exits in 
the character of the injuries which we are in the habit of placing under 
the general head of fracture of the lower extremity of the radius, and 
that in cases of severe comminution of the lower fragments particularly 
it might be desirable to immobilize the wrist-joint. But in the ordi- 
nary cases, where the lower fragment is simply torn off, with more or 
less displacement, without such a degree of injury of the parts about 
the wrist-joint as to produce a very serious complication of the case, it 
seemed to him that in the simple retentive bandage there is given a 
sufficient apparatus for the successful management of these cases, and 
after an experience of these years, which has been reinforced by the ex- 
perience of many others who had used the same method, he was ready 
to believe that it is sufficiently efficient, and that it will give just as 
good results as the use of splints. In the application of the bandage 
he would say that it is always a matter of first importance accurately to 
reduce the fragments, and after that a simple circular bandage in the 
great majority of cases will be found sufficient to carry it to a satisfac- 
tory conclusion. 

Dr. C. K. Briddon said that for more than eight years he had a ser- 
vice in the New York Dispensary, where there were treated between 
four and five hundred fractures of the lower end of the radius, nearly 
all of which came under his supervision. In the early part of that 
period they were treated by immobilization by the ordinary pistol 
splint, and no passive motion was used until at the end of four or five 
weeks, and in a large percentage of these cases fair results were ob- 
tained, stiffness remaining only for a short period of time. In other 
cases, treated by the use of the dorsal in addition to the palmar splint, 
the results were unsatisfactory as regards subsequent mobility of the 
joint. 

His impression had always been that the stiffness which follows this 
injury does not depend so much upon the character of the treatment, 
or immobilization, or passive motion, as upon the nature of the injury 
itself. In the simple fractures very good motion is usually obtained, al- 
though in some cases there is stiffness of the fingers. 



134 J' C. HUTCHISON. 

He certainly reached one conclusion during his term of service, and 
that was, no matter whether the case was treated with plaster-of-Paris 
splint or with a short pistol splint, or otherwise, a great deal of mis- 
chief was done by the dorsal splint. In all the latter part of his ser- 
vice in the dispensary he never used the dorsal splint, but especially 
the pads, which were commonly placed upon it, and also upon the 
plantar splint, in the neighborhood of the fracture. He had found that 
they produced inflammation of the sheaths of the tendons, and that an 
undue degree of stiffness remained. For a number of years he had not 
used any posterior splint at all, but had simply employed a curtailed 
anterior splint, padding the radial aspect of the spHnt to fill up the con- 
cavity of the forearm, and leaving the ulnar portion of the splint free, 
and he had obtained fair results. 

He thought that a good deal of the deformity and of the stiffness 
which remained in these cases was due to the fact that the fracture was 
not reduced. It is sometimes exceedingly difficult to make complete 
reduction, and that difficulty does not occur in bad fractures, but in 
cases in which the lesion is moderate, involving the bone simply, and 
not tearing away the fibrous structures of the joint, which continue up- 
ward in the periosteum for a distance above the usual site of fracture. 
In the cases in which considerable damage is done the mobility of the 
parts is such that they are easily restored. If, therefore, great care is 
taken to reduce the fracture completely, the fragments will be retained 
in position with the simple treatment devised by Dr. Pilcher ; but 
where there is considerable damage done to the parts about the joint 
he beUeved that to depend upon a simple retentive bandage would be 
liable to be followed by a good deal of mischief and bad results ; at 
least that had been his personal experience, as he had treated some 
cases, not many, with the simple retentive apparatus, and the swelling 
and inflammation had gone on increasing, and he thought that the 
swelling and inflammation were consequent upon the mobility permit- 
ted by the simple retentive dressing. He could not conceive that, 
where there was much mobility of the parts, this simple retentive band- 
age would answer. He did not wish by any means to condemn the 
method advocated by Dr. Pilcher, but simply to state that such was the 
result in the few cases in which he had attempted to treat the fracture 
in that way. 

Dr. J. C. Hutchison said that tor a number of years he had treated 
fractures of the lower end of the radius in the manner shown on the 
patient introduced by Dr. Pilcher, which, it was only fair to say, was 
brought to the attention of the profession by Dr. Moore, of Rochester, 



FRACTURES OF THE LOWER END OF THE RADIUS. 135 

in a paper read before the Medical Society of the State of New York 
many years ago, in which he expressed the opinion that there was with 
this fracture dislocation of the ulna in more than half of the cases. Dr. 
Moore cited five cases which he thought established his view. They 
were all severe cases, and probably there was dislocation of the ulna. 
His method consists in applying a compress over the lower end of the 
ulna, which is retained in position by surrounding it with adhesive plas- 
ters, as seen in Dr. Pilcher's case. Since then Dr. Hutchison had 
adopted this method almost invariably, and with most satisfactory re- 
sults. There has been much less stiffness of the fingers, less ankylosis, 
and less pain than in the use of former methods, and the treatment was 
mujch less troublesome to the surgeon than any which he had em- 
ployed. He agreed entirely with the statement made with reference to 
the satisfactory results obtained by this method of treatment. Of 
course, perfect results were not to be expected in every case by any 
method of treatment. 

Dr. PiLCHER said that in previous discussions of this subject he had 
credited Dr. Moore with his suggestion concerning the pathology and 
treatment of these fractures, and it might not be out of place to state 
again that the turning of his attention to the possibility of doing away 
with the splint was due to Dr. Moore's original paper on the subject, 
pubhshed in the Transactions of the Medical Society of the State of 
New York for 1870. Soon after reading it a case of an aggravated 
character came under his observation in which a great deal of displace- 
ment presented itself. There were all the evidences of the condition 
described by Dr. Moore as present in dislocation of the extensor carpi 
ulnaris, and his method of manipulation as appHed by Dr. Pilcher was 
successful in restoring the parts to their natural condition. Dr. Moore's 
bandage, as he supposed, was then apphed. The case progressed to 
an excellent termination. When the patient was about to be discharged 
from treatment, Dr. Pilcher found that instead of placing his pad under 
the ulna, as strongly urged by Dr. Moore, he had placed it underneath 
the radius. The good result notwithstanding, led him to believe that 
the entire value of the apparatus was in the retentive bandage, and not 
in the particular mode of dressing or in the compress, and from that 
time he had thrown aside the compress and had used the retentive 
bandage, with the results already stated. 

Dr. Sands said he thought it would be inexcusable to make the state- 
ment that the results were uniformly good in the treatment of this frac- 
ture. He was sure he had seen bad results in old people, which were 
inevitable, and in a certain proportion of cases in which the fracture is 



136 A. G. GERSTER. 

severe and the patients old, more or less stiffness \\'ill be the result. 
He did not believe, as Dr. Briddon had already stated, that the treat- 
ment alone was responsible for such failures. He could hardly believe 
that any method would produce uniformly good results, and he doubted 
whether such a statement should receive the endorsement of the 
Society. 

Dr. PiLCHER said he hoped that nothing which he himself had said 
would lead to the suggestion which Dr. Sands had expressed, for he 
had simply stated that in the cases presented to him, and treated in 
this way, the results had been good. He perhaps had been fortunate 
in not having had presented to him any cases with the conditions which 
Dr. Sands had referred to, and he would dislike very much being 
understood as saying that there were no cases which would not result 
unsatisfactorily no matter what method was employed. What he had 
desired to emphasize was simply that in the ordinary fracture of the 
lower extremity of the radius the simple retentive bandage is as effective 
as any other method of treatment. 

Dr. Sands said that was the exact point ; he was unable to see how 
the Society could safely endorse the statement that the results are uni- 
formly good by any method of treatment, and he was prepared to pro- 
test against it. 

Dr. Gerster said that in his service during the last seven years at the 
German Dispensary, the number of fractures of the lower end of the 
radius was quite considerable, and he had, during the last five years, 
in a large majority of these cases, employed the simple dressing pro- 
posed by Dr. Pilcher. He had employed it where he beheved it would 
be sufficient, and, as a rule, it had been found to be efficient in these 
cases. The results were certainly just as good as those obtained by 
any other method of treatment, but especially better than those ob- 
tained where splints had been employed which included the metacarpo- 
phalangeal joints. The majority of cases of fracture of the lower end 
of the radius were such, in which, so far as replacement of fragments 
was concerned, no difficulty was experienced, and good results were 
gained. If, however, long splints, including the hand, were employed, 
as was seen in a number of cases admitted for after-treatment, a 
pseudo-ankylosis of the tendons and of the small joints of the fingers 
was produced by the prolonged inactivity, a more serious condition than 
the fracture itself, especially in old people. In the cases treated by 
Pilcher's method the patients could almost at once resume their avoca- 
tions, from the time when the bones had united. He believed the move- 
ments of the fingers, after treatment by other methods, were not as 



FRACTURES OF THE LOWER END OF THE RADIUS. 13/ 

free as they are seen to be preserved under this simple retentive 
bandage. 

He stated, on the other hand, that it is a treatment to be apphed 
only in those cases where the replacement and retention of the frag- 
ments are easy. There are cases, fortunately not very numerous, 
where this retentive bandage does not suffice. It may be said that 
these diiificult cases will give poor results under any form of treatment, 
but a large number of cases are such as admit of easy replacement and 
retention of the fragments, and m these cases Dr. Pilcher's retentive 
bandage had proved very satisfactory indeed. 

Dr. Stimson said, with reference to rigidity of the fingers following 
immobilization, that he heard with surprise the statement made by Dr. 
Hall, that immobihzation of the fingers does not end in rigidity. He was 
under the impression that it is a fact of common observation. He 
thought, also, that it is a matter of general observation that rigidity of 
the fingers occurred, as in the case mentioned by Dr. Yale, when the 
limb was immobilized in the treatment of injuries even above the 
elbow. He had a case now under observation in which almost com- 
plete rigidity of the fingers followed their immobilization for two weeks 
in the treatment of a simple uninflamed incision of the skin of the 
palm. 

He agreed fully with Dr. Hall concerning the absolute value of im- 
mobilization of the wrist. As to the objection raised by Dr. Hall, 
that passive movements of the fingers are fiable to increase the in- 
flammation within the sheaths. Dr. Stimson thought the danger a re- 
mote one, because, in the first place, the range of motion in the fin- 
gers is so slight ; and, secondly, the tendons are so well protected from 
sharing in the primary injury, in front by the pronator quadratus, be- 
hind by the usually untorn periosteum. 

The result in Dr. Hall's cases, which showed that in thirty-one 
cases no deformity was left, was by far better than the average, and he 
thought that if Dr. Gerster had heard Dr. Hall's results he would not 
have made the statement that the retentive bandage had given results 
superior to any other. 

Again, the point raised by Dr. Sands that some cases do not afford 
good results, he thought an important one. In the patient presented 
by Dr. Pilcher, it seemed to him that the deformity had not been com- 
pletely reduced, and that the fingers were not free now. In these 
cases of fracture of the lower end of the radius in which the distal 
fragment is split into several pieces, the chances are that recovery will 
take place with a Umitation of motion. Furthermore, there are cases 



138 RICHARD JOHN HALL. 

in which the intermediate spongy portion of the bone is so crushed 
that he thought the lower fragments could not be safely brought down 
without risk of failure of union ; such cases are best treated without 
making an attempt to overcome the shortening of the radius. The re- 
sulting deformity is not great, and is not accompanied by diminution 
of function. 

Dr. Hall said he expressly stated that immobiUzation in the ex- 
tended position would be followed by stiffness, accompanied by dis- 
comfort to the patient. Hence, all the cases had been treated in the 
manner described. After effusion has taken place and fibrin been de- 
posited, its place is taken by organized and vascularized tissue, so 
that in making motion blood vessels are ruptured, which gives rise to 
a fresh exudation that only increases the rigidity of the tendons. He 
should regard Dr. Pilcher's case as one in which there was marked dis- 
placement of the hand toward the radial side, with considerable limi- 
tation of motion. He had seen several fractures treated in this man- 
ner, and one in which Dr. Moore was said to have applied his own 
apparatus, and had not been pleased with the results as a rule. Dr. 
Hall failed to see how a simple band of adhesive plaster about the 
wrist could hold the fragments in position, when there was a tendency 
to recurrence of the displacement, on any mechanical theory whatever. 

Dr. Gerster said he did not wish to be understood as saying that the 
results obtained by him in the use of Dr. Pilcher's retentive bandage 
were better than any others ; simply that they were fully as good as 
those obtained by any other treatment. 

Again, he took exception to the explanation given by Dr. Hall con- 
cerning the effect produced by passive motion on the sheaths of the 
tendons in which exudation has taken place, as he did not believe that 
passive movement of a smooth tendon would increase the exudation 
or produce any additional amount of inflammation, nor did he beUeve 
from a J>riori reasoning that such a result was very probable. 



I 



EDITORIAL ARTICLES. 



ON LATERAL PHARYNGOTOMY FOR THE EXTIRPATION OF MA- 
LIGNANT TUMORS OF THE TONSILLAR REGION. 

When Cheever, of Boston, reported his first case of operation for re- 
moval of a mahgnant tumor of the tonsillar region in 1869, he was able 
to find but scant reference in literature to the subject. His case, in- 
deed, seems to have been the first in which an attempt was made to 
methodically and radically extirpate such a tumor from without by lateral 
pharyngotomy. In his first operation, Cheever did not divide the jaw 
bone, nor perform a preliminary tracheotomy, but by making an in- 
cision from a point just within the angle of the jaw downwards for 3^2 
inches parallel to the sterno-cleido mastoid muscle, followed by a 
second incision, 1^/2 inches in length, along the lower border of the 
jaw, meeting the first incision, he gained sufficient room, so that, after 
having divided the digastric, stylo-hyoid and stylo-glossus muscles, and 
having picked apart the fibres of the superior constrictor of the 
pharynx, he was able to enucleate the affected tonsil without injury to 
the pillars of the fauces. The tumor thus removed is described as the 
size of a hen's egg. That this operation was not sufficiently radical is 
evidenced, however, by the fact that speedy recurrence of the disease 
took place, infiltrating the soft palate. 

In a second case reported by the same surgeon, operated in 1878, 
the jaw was sawn through, and a preliminary tracheotomy was done, 
and the growth easily enucleated, but with no better result as regards 
the future of the patient, for at the end of two months recurrence at 
the site of the original disease had already taken place. 

Meanwhile additional contributions to the literature of the subject 
had been made, in particular a valuable memoir by Poland in the Brit, 
and For. Med. Chir. Rev., April, 1872, and byPassaquay (Paris, 1873). 
Since the pubUcation of Cheever's second case (Boston Med. and 
Surg. Jour.. August i, 1878), the noteworthy contributions upon the 

(139) 



I40 EDITORIAL ARTICLES. 

subject which have been made to literature are chiefly a statistical 
paper by Delavan, of New York, on the subject of Primary Epithe- 
liom of the Tonsil (N. Y. Med. Jour., April, 1882), an exhaustive 
memoir, involving statistical, pathological and operative features, by 
Castex, in the Revue de Chirurgie^ 1886, and a clinical report by 
MikuHcz, of Cracow, in the Deutsche Med. IVocheiischrift, Nos. 10 
and II, 1886. 

The memoir of Castex is deserving of a full review, which will be given 
in a subsequent number of this journal. The remainder of the present 
article will be devoted to the contribution of Mikulicz. 

The operative steps of M. are as follows : 

Incision in the cutis from the mastoid process obliquely downwards 
to the great cornu of the hyoid bone. The soft parts are divided care- 
fully, partially, also, the tissues of the parotid gland, and the edge of 
the ramus of the inferior maxillary bone exposed posteriorly, care 
being taken to avoid injuring the facial nerve. 

The periosteum is then removed with the raspatorium from the ex- 
ternal and internal surface of the ramus, upwards as far as possible and 
downwards as far as the insertions of the masseter and internal 
pterygoid muscles. The ramus is divided subperiosteally \/., to i cm. 
above the angle, and enucleated. Traction is now made on the jaw 
downwards and outwards, and the masseter, internal pterygoid, also 
the digastric and stylohyoid, drawn to one side. The tonsillar region 
will be found to form the base of the wound thus made. By dividing 
the lateral wall of the pharynx, direct entrance is obtained to the 
palatal arches, base of tongue and to the posterior phar3aigeal wall 
upwards into the naso-pharyngeal space. If the digastric muscle be 
furthermore divided, the entrance to the larynx will be exposed. Be- 
fore beginning this operation, it will be advisable to perform tracheot- 
omy. The author claims for this operation a great advantage over 
that of Langenbeck, inasmuch as by his method a tumor mvolving the 
lateral phar}^nx wall may be exposed trom outwards, and the whole 
operation carried out extra cavum oris et pharyngis. The author's 
method also permits of an antiseptic treatment. (Tamponade with 
iodoform-gauze). 



♦ 



MALIGNANT TUMORS OF THE TONSILLAR REGION. I4I 

Mikulicz gives the history of four cases, operated by himself in this 
manner. 

Case I. Tonsillar carcinoma involving the posterior pharynx wall, 
the base of the tonge and the soft palate. 

Patient, female, set. 65, had difiiculty in swallowing for one and a 
half years. A diagnosis of carcinoma of the left tonsil was made six 
months previous to the operation. Pharyngotomy. The inferior max- 
illary bone was not divided above the angle, but i^.^ ctm. in front of 
this ; consequently the insertions of the masseter and internal pterygoid 
muscles were severed. Removal of carcinoma. Tamponade with 
idoform gauze. Patient nourished by means of rubber tube for two 
weeks, when edges of wound were freshened up and united by sutures. 
In three weeks the external wound had healed, and that of the 
pharynx completely in six weeks. Movement of the jaw perfectly free, 
also the acts of swallowing and speaking. Patient remained in this 
condition for two years when a few suspicious looking ulcerating spots 
were observed in the cicatrix, and a few months later the relapse was 
complete. 

Case II. Sarcoma of the tonsillar region, occupying most of the phar- 
ynx. 

Patient, male, set. 28, had noticed a swelling about the angle of the 
jaw, right side, some three months before. He has had considerable 
trouble in swallowing and speaking for the past two months and diffi- 
culty in breathing for one month. At times slight haemorrhage from 
mouth. On examination a soft tumor, size of goose egg, is found on 
the right side under the angle of jaw. A soft tumor also seen in the 
right tonsillar region, involving the whole middle part of the pharynx, 
reaching downwards to the larynx and upwards to the choan^. Pre- 
ventive tracheotomy. Pharyngotomy according to author's own 
method. The extipation of the whole mass of tumor necessitated 
opening the pharynx. The defect in this reached from the choanse to 
the larynx. Patient nourished by means of a rubber tube passed into 
the oesophagus and fastened by sutures to the external skin. Dress- 
ings of iodotorm gauze. Canula removed from the trachea on the 
tenth day, the tube from the oesophagus on the twelfth. Discharged 
cured in four weeks. Breathing and swallowing entirely free, and 



142 EDITORIAL ARTICLES. 

voice clear. Patient died three months later, suddenly, but from what 
cause was not ascertained. 

The third case is that of a carcinoma of the left tonsil, involving also 
the palatal arches and extending to the hard palate. Patient, male, 
aet. 6i, badly nourished and very anaemic, died two and a half hours 
after the operation from collapse and the aspiration of blood. Tra- 
cheotomy was not performed in this case. The loss of blood during 
the operation was considerable. 

The fourth case was a carcinoma of the lateral pharyngeal wall. 
Male, set. 42, had observed a hard swelhng at the angle of the jaw, left 
side, for two months. For some time the difficulty in swallowing and 
breathing has been verj^ great. The tumor had its origin in the left 
tonsil and involved both palatal arches, the choan^, and furthermore 
the lateral pharynx wall, and reached downwards to the larynx. Phar- 
yngotomy with preventive tracheotomy. The whole lateral wall of the 
pharynx, involved by the disease, from the epiglottis to the choanae, 
was excised from without, also the palatal arches and the left half of 
the soft palate. The tissues were found infiltrated to the base of the 
skull. Dressings as in Case 3. On the sixth day, hgature of the ca- 
rotid was necessary to control haemorrhage. Canula removed from 
trachea in three weeks, and oesophagus tube in four weeks. Patient 
left clinic in six weeks, the external wound having healed. He com- 
plained much of severe headaches before lea\ang. The mass of tumor 
left in the naso-pharyngeal space was found to be rapidly increasing in 
size. Patient was not seen again. In regard to this latter case, 
MikuHcz remarks that in his opinion, malignant neoplasms in the up- 
per naso-pharynx do not offer any field for operative treatment, as a 
thorough extirpation of a diffusely extended carcinoma is not possible 
in this place. A careful examination in the narcosis should therefore 
be made before operating. If extirpation of the tumor be impossible, 
enucleation of the ramus of the jaw should be undertaken, as proposed 
by Kiister, in order to relieve the patient at least of the painful condi- 
tion of lock-jaw. If the insertions of the masseter and internal pter)'- 
goid remain intact, the acts of chewing and speaking will not be inter- 
fered with, and the position of the two rows of teeth to each other 
little, if any, changed by this latter operation. The usefulness and in 



MALIGNANT TUMORS OF THE TONSILLAR REGION. 143 

many cases the necessity of a preceding tracheotomy is specially men- 
tioned. The danger of neglecting this is seen in Case 3, where the 
collapsed and anaemic patient had not sufficient strength to expec- 
torate the blood, which had entered the larynx. 30 p. c. iodoform- 
gauze was used for dressings. Symptoms of iodoform intoxication, 
however, appearing in the first case, on the eight day, 10 p. c. iodo- 
form-gauze was substituted. As a result of his experience the author 
remarks that such symptoms of intoxication appear especially often in 
cases where the secretions from large wound surfaces, saturated with 
iodoform, enter the digestive tract. As soon as such symptoms ap- 
pear, he removes the gauze, and uses dressings of mull moistened with 
a solution of acetate of alumen. These may be continued from four 
to five days without injury to the wound. The introduction of a rubber 
tube into the oesophagus at the close of the operation, for feeding the 
patient, was altogether satisfactory, and spared the patient the pain 
which would have followed such a procedure later on, affording, also, 
the necessaiy rest to the wounded parts. 

Regarding the different methods of operating, the author has but 
httle to say. He thinks, however, the subhyoid pharyngotomy espe- 
cially adapted for tumors situated more anteriorly. Kiister's method, 
where the incision is made through the cheek, from the angle of the 
mouth to the anterior edge of the stemo-cleido-mastoid muscle, he 
recommends for tumors arising from the alveolar process and mucous 
membrane of mouth. In conclusion the author gives some interesting 
facts concerning the occurrence and course of carcinoma of the tonsils 
and lateral pharyngeal wall. He has observed seven cases in three 
years. Mackenzie has also reported seven cases. Of the latter five 
were males, aged respectively 22, 37, 47, 58 and 67 years, whilst the 
ages of the two females were 34 and 43 years, respectively. Of 
Mikulicz's seven cases, five were males, two females, with ages ranging 
from 42 to 65 years. Kiister had two cases, both males, aged 49 and 
6t years. This makes a total of sixteen cases, twelve males and four 
females. The left tonsil was the seat of the disease in six of the 
author's seven cases, and in both of those of Kiister. In these nine 
cases the palatal arches and the palate were invaded in eight, the base 
of the tongue in five, the posterior pharynx wall in four, the supra-and 



144 EDITORIAL ARTICLES. 

intramaxillary bones in three, the carcinoma extended to the larynx 
in three, and upwards beyond the choanse in two cases. 

The first symptoms of the disease appeared three to fifteen months 
before consultation, but had existed probably prior to this without 
being remarked. 

Pain in swallowing occurs relatively late, generally when the carci- 
noma has involved the palatal arches, palate, tongue and jaw bone. The 
diagnosis will not be difficult, when the tumor has reached the stage 
of ulceration, but at the commencement of the disease we are often in 
doubt as to its true nature. 

L. S. PiLCHER. 



I 



THE PARIS SOCIETY OF SURGERY AND THE QUESTION OF OP- 
ERATION FOR TUBERCULOUS JOINT DISEASE. 

At the meeting of the Paris Societe de chirurgie for the loth of Feb- 
ruary last. Dr. Chauvel reported in detail upon a paper by Dr. Mab- 
boux, of Lille, on the question of prognosis and operation in the tu- 
berculous. The paper of Mabboux was based upon two cases of tu- 
berculous joint disease, (i) the first originating in caries of the fourth 
metatarsal bone of a young soldier, with resection of the disease,which 
was followed by synovitis of the peroneal sheath and, later, by suppura- 
tion of the tibio-tarsal arriculation and concomitant pulmonarj' tuber- 
culosis ; after three months, all the symptoms continuing to be more 
unfavorable, the foot was amputated, and rapid cure followed, A\'ith 
abatement and final disappearance ot the pulmonary symptoms, the pa- 
tient being in the enjoyment of robust health at the time of the writing 
of the paper ; (2) the second case was apparently less favorable to the 
theory of operative intervention ; a corporal of the line, aet. 24, entered 
the hospital at Lille in May, 1885, for arthritis of the left knee, consec- 
utive to a fall received a month previously. He had had hsemoptysis 
in 1884 but had been well since then. In spite of immobilization and 
all other methods, the disease progressed until August 15, when the 
contents of the joint were found on aspiration to be purulent ; indura- 



OPERATION FOR TUBERCULOUS JOINT DISEASE. 145 

tion at the apex of the left lung was observed and the patient was har- 
rassed with a frequent cough. Arthrotomy was performed on the 24th, 
the pus evacuated, the fungosities removed and the denuded bone 
scraped. This was followed by redoubled suffering, probable menin- 
gitis and more pronounced pulmonary symptoms, Avith the formation 
of eschars at the sacrum and heels. In September, the pain became 
atrocious, and the emaciation extreme, the exhaustion complete, gan- 
grene imminent and early death certain. In spite of the gravity of the 
situation, and in deference to the wishes of the moribund patient, the 
thigh was amputated in the lower third. Microscopical examination of 
the knee showed the lesions of tuberculous arthritis in the highest de- 
gree of development. Immediately after the operation, sleep returned 
to the patient, pain ceased, the wound cicatrized and he seemed to be 
saved, but on the 8th of October the fever reappeared, the stump ul- 
cerated, the tuberculosis seemed to be localized in the abdominal 
viscera, and death ensued on the i8th of January following, but with no 
recurrence of the atrocious suffering for which the operation was per- 
formed. In view of the fact that there had been no therapeutic or op- 
erative success — nor indeed was one expected — was the operation jus- 
tifiable ? The author replied in the affirmative, considering the relief 
from pain and the consequent euthanasia to be abundant justification. 
That the later progress of the tuberculous disease was not due to the 
traumatism of the operation is emphatically shown by the manifest 
amelioration of the symptoms during the following twenty-five days, 
showing that, on the contrary, the disease was temporarily relieved by 
the operation, and only resumed its regular course after the beneficial 
effects of the intervention had been exhausted. 

Mabboux concludes that (i) the existence of pulmonary tuberculous 
lesions, even of an advanced type, is not a contraindication to an am- 
putation of a member affected with suppurative tuberculous synovitis, 
when the latter lesion predominates the pathological scene and men- 
aces life. (2.) The operation, by suppressing the causes of exhaus- 
tion due to the articular lesion, can stop the progress of the visceral 
lesion, to the extent of replacing the lungs in a perfectly normal state. 
(3.) Even in cases where the phthisis follows its course, amputation of 
the diseased member may improve the condition of the patient, if only 



146 EDITORIAL ARTICLES. 

by relieving the intolerable pain ; consequently the policy of non-in- 
terference in cases where a curative action can not result, should not 
be carried into the treatment of this affection. 

M. Chauvel, in commenting upon the paper, referred to the diamet- 
rically opposite views held by various surgeons with regard to the pro- 
priety and extent of operative interference and remarked that a precise, 
invariable rule with regard to action could not be laid down, but that 
each case must be treated as an individual entity. If the failure of op- 
erations and the prompt deaths attributable to surgical traumatism im- 
press us, we must also not forget the deaths, slower, perhaps, but cer- 
tainly more numerous, which result from non-intervention. These lat- 
ter are attributed to the progress of an incurable disease, but is the 
physician any more justifiable in failing to interfere than he would be 
in any other otherwise incurable affection, such as oedema of the glot- 
tis or strangulated hernia ? 

Osseous and articular tubercular affections are not generally proper 
subjects for incomplete intervention. Perhaps the day is not far dis- 
tant when osseous and articular tuberculosis, local tuberculosis, will be 
considered as a neoplasm, the more maHgnant from its tendency to 
generalization, and treated under the same rules as sarcoma and carci- 
noma. When the extirpation of the disease in place is impossible or 
when the anatomical conditions do not permit the complete and cer- 
tain ablation of all the infected tissues — conditions not rarely present 
in osteitis and synovitis — early amputation is indicated. In the cases 
of jMabboux he thought the operation was delayed too long in the 
second case, if not in the first. 

As shown by these cases, the existence of pulmonary tuberculous 
lesions should not be considered a contra-indication to operation. 
Cases of temporary cure under these conditions are common, and per- 
manent cures are not the exception. Two years previously, M. Chau- 
vel amputated the leg of an old soldier, affected with tuberculous dis- 
ease of the tarsus with pulmonary and peritoneal tubercularization,who 
had been bed-ridden for two years, and lay in a state of great exhaus- 
tion from fever and suppuration. Against the surgeon's judgment and 
in deference to the patient's wishes, the operation was performed, and, 
after repeated periodical haemorrhages from the stump, it cicatrized, 



OPERA TION FOR TUBER CULO US JOINT DISEA SE. 1 47 

and the patient, fully recovering after a tedious convalescence, was dis- 
charged completely cured. In closing, M. Chauvel emphasized the 
lesson of Mabboux's second ca^e, that one of the indications for am- 
putation in tuberculous joint-disease may be the relief of pain, even 
when the cure of the disease is hopeless. 

M. Despres, although considering it almost useless, wished to pro- 
test against the behef in the theory of the generahzation of tuberculo- 
sis by the propagation of a microbe. The question of amputation had 
long been under discussion, and, as it was still on trial, no absolute 
rules could be established for its appUcation. He had amputated the 
thigh of a patient who had an ulcerated knee-joint disease and hsemop- 
tysis. He was cured, but died two years later with tubercular ulcera- 
tions on the other leg. Tuberculous patients, affected with non-sup- 
purating joint-disease, should be treated by immobilization and com- 
pression. Amputation may be of service to young men. 

M. Lucas-Championniere considered the operation for the relief of 
intense pain, but without hope of ultimate cure, to be justifiable, in 
spite of the resulting damaging effects upon the statistics of the opera- 
tion. The true question was whether an operation for the removal of 
a tubercular lesion in a tuberculous patient was good treatment. 01- 
Her had shown in a recent work that operations, even partial ones, 
could be successfully performed on the tuberculous, and that in resec- 
tions, diseased osseous parts could be left without preventing a cure ; 
and after operations the patients grow fat and are greatly improved in 
physical condition. New trouble may supervene later, it is true, but 
even radical operations do not prevent later developments. He was 
then an advocate of surgical intervention in the tuberculous but, un- 
like M. Chauvel, he believed in the utility of partial ablation in certain 
cases. 

M. Verneuil beheved that in tuberculosis as in cancer, the surgeon 
should operate for the temporary relief of suffering, mthout necessarily 
expecting any permanent curative effect. But in tuberculous patients, 
affected with strumous synovitis, operative intervention was necessary 
only in case of the existence of sinuses and suppuration, for many cases 
were cured by compression. He did not perfonn more than two or 
three amputations a year for tuberculous articular affections and still 



148 EDITORIAL ARTICLES. 

fewer resections. Resection of the hip-joint alone has caused more at- 
tacks of meningitis or rapid generaHzation of tuberculosis than all other 
operations performed in these conditions. 

M. Berger had in a previous discussion cited some cases of rapid 
generalization of tuberculosis after amputation for chronic synovitis, but 
on the other hand, he had seen the disease clearly diminish in at least 
one case, in which he amputated the thigh of a young man in whom 
unequivocal signs of tubercularization existed, and who afterwards re- 
gained the best of health. And in an old man in whose lung cavities 
were discovered, and who was in a state of extreme debility, he saw 
radio-carpal amputation followed by an unexpected recovery. He be- 
haved that incomplete resections were bad practice m the tuberculous, 
and that primary union must be sought for, operating only in healthy 
parts. 

M. Reclus had been greatly impressed by a case in which Lisfranc's 
disarticulation had been performed for caries of the first and second 
metatarsal bones, and in which primary union was obtained, but, after 
a few days, the patient developed a large fungus in a counter-opening 
on the plantar surface. The surgeon who succeeded M. Reclus in 
charge of the case, was frightened and proposed a second amputation; 
the patient, however, recovered without further interference so com- 
pletely that a cast was made of the stump as a typical result of Lis- 
franc's operation. 

M. Pozzi did not think that it was indispensable to operate in healthy 
parts when amputating in the tuberculous; he had made an amputation 
in the middle of the leg of a young female in the midst of fistulous 
sinuses, which had to be scraped and excised to refresh the flaps, and 
he obtained a very beautiful primary union. However, he considered 
that all diseased bone should be removed. 

M. Richelot had removed only a part of the glands in a greatly ema- 
ciated young man with large suppurating glandular masses at the neck, 
in spite of which union was obtained and the glands, not removed, 
finally disappeared, while tuberculous disease of the elbow was devel- 
oped. 

M. Polaillon recalled that he had, two years previously, presented a 
patient whose wrist he had resected for tuberculous arthritis witnout 



OPERATION FOR TUBERCULOUS JOINT DISEA^iE. 149 

removing all the diseased parts, but who had recovered ; he had also 
cited several cases in which amputation had improved the condition of 
tuberculous patients. 

M. Le Fort believed that suppuration was not so much to be feared 
after amputation as might be thought ; patients who became greatly 
emaciated before operation, while losing but small quantities of pus, 
often grow fat when, after amputation, the suppuration is abundant ; a 
small amount of osseous suppuration is often sufficient to greatly ex- 
haust patients. In his work on resections of the hip, he was able to 
give the later results of the operation in a number of patients and could 
see that death by meningitis was not by any means so frequent as M. 
Verneuil asserted. After resections the bone trouble was sometimes 
cured, while the disease recurred in the soft parts ; he considered that 
incomplete resections did not give as good results in general as the 
complete. In conclusion, he remarked that he would consider tuber- 
culous disease with great debility contra-indications to operation in 
aged but not in young patients. 

M. Trelat believed that in operating upon a tuberculous patient all 
the diseased parts should be removed ; if primary union failed, the 
minimum of suppuration should be sought for. However, the tuber- 
culous patient is an individual affected with bacilli, and the operator 
can never be sure that he has removed the entire disease ; cases of os- 
teo-myehtis exist for years without becoming apparent ; there was al- 
ways then a certain amount of ignorance upon the part of the surgeon 
and a consequent amount of uncertainty as to the result ; if a patient 
had been completely examined, however, before deciding upon opera- 
tion, it would generally benefit him. He thought there were good rea- 
sons for holding that amputation was preferable to resection, but it 
could not be said that tubercularization invariably led to amputation 
rather than resection. The form and extent of the lesion should alone 
decide that question. James E. Pilcher. 



ON THE PRESENT STATE OF KNOWLEDGE IN BACTERIAL 
SCIENCE IN ITS SURGICAL RELATIONS. 

(Continued from page 57). 

G. GONORRHCEA. 

The discovery of the specific organism of gonorrhoea by A. Neisser 
in the year 1879^ is one of those scientific achievements which have 
not as yet led to the practical therapeutical results which such a dis- 
covery might well have justified us in anticipating. Perhaps this is the 
chief reason why so many surgeons of the present time hesitate to in- 
clude the gonococcus — as the organism in question has been designated, 
with more brevity than logic, by its discover — in their articles of med- 
ical faith. Our faith, however, varies with our understanding, and it is 
with the gonococcus somewhat as Bacon says, speaking of Atheism, 
" a little learning inclineth man's mind to doubt, but depth in philoso- 
phy again bringeth men's minds about to behef." 

The history of the development of the doctrine of the gonococcus is 
in point of fact somewhat singular. Discovered, as it was, compara- 
tively long ago, and repeatedly and unexceptionally found in all well- 
marked cases, there is a very conspicuous lack of successful culture 
experiments and of reUable inoculation experiments, even at the pres- 
ent day. The reason for this is to be looked for, on the one hand, in 
the fact that producing pure cultures of the gonococcus on sterilized 
soils is a very difficult matter of performance ; and, on the other hand, 
the germ is not one that easily proves infectious to animals, and there 
is a very natural reluctance on the part of experimenters to performing 
inoculations upon themselves or others, on account of the manifold 
dangerous complications so frequently attaching to the disease. 

We possess only two reports of inoculation experiments that are 

^ Ueber eine der Gonorrhre eigenthiimliche micrococcus form. Vorlauf. Mitthei- 
ung. Centralbl. f. d. Med. Wiss. 1879. ^"o- 2S. 

(150) 



BA C TERIAL S CIENCE IN ITS S UR GICAL RELA TIONS. I 5 I 

wholly satisfactory, the one by Bockhardt ,^ the other by Bumm:- 
Inoculation with cultures on the human subject, it is true, have been 
performed by others as well — ^mong whom are to be mentioned 
Bokai, Chameron, Sternberg ; but the first of these has pubhshed such 
incomplete accounts that they are not admissible for discussion, and 
the latter gentlemen, as well as Neisser himself and Oppenheim, were 
not successful in obtaining the pure culture of the true gonococcus, as 
Bumm has shown ; so that their negative results lose all their power o^ 
conviction. 

The germ itself — to begin with the author's own review of the sub- 
ject ^ — is described by Neisser as a micrococcus, always appearing in 
couples as diplococcus ; the single cocci are not perfectly spherical, but 
are flattened at one pole to such an extent that their shape resembles a 
segment of a sphere, and the whole appears not unlike a breakfast roll. 
The single cocci turn their flattened poles towards each other, but a 
narrow space separates them, and there is no contact. 

These diplococci multiply by bipartition each micrococcus becom- 
ing divided into two, so that groups of 4, 8, etc., are formed, but never 
chains. The halving process of each successive generation occurs in 
a line at right angles to that of the former generation. These groups of 
pairs are always to be found in connection with the pus-cells, and only 
when present in great numbers are single pairs found free in the serum. 

They are always present in gonorrhoea, even in those cases of six- 
teen months standing, though they are not then so readily found ; they 
are never present in other suppurations, but those of gonorrhosal origin. 
They are, moreover, usually the only ones present in gonorrhoeal dis- 
charge. 

The presence of these peculiar organisms in gonorrhoea was soon 
corroborated after Neisser's communication by numerous observers. 

1 J/, ^ocy^iarrt'/, Beitrag zur /Etiologie und Pathologie des Harnrohrentrippers. 
Vierteljahrschr. f. Dermatol, u. Syph. 1883. p. 3. Sitzungsher. d. phys. med. Ges. 
7,. Wiiizburg. Sept. 1882. 

^Der Mikro-Organismus der gonorrh. Schleimhauterkrankung. Wiesbaden. 1885. 
I F. Bergmann. 

^Die Micrococcen dcr Gonorrhce. Referirende Mittheilung. Deutsch. Med. Woch- 
enschrift. 1882. P. 279. 13. May. 



152 EDITORIAL ARTICLES. 

Bokai, Weiss, Aufrecht, Ehrlich, Brieger, Gaffky, were among the first 
to publish assenting statements, and ophthalmologists, such as Sattler; 
Leber, Haab, Hirschberg and others very soon testified to the occur- 
rence of the germ in goncrrhoeal conjunctivitis. Bockhardt found them 
present in 258 cases of gonorrhoea, in 14 cases of vaginal blennorrhoea, 
in 2 cases of suppurative cervical catarrh, etc. More recently Lund- 
strom ^ found them in all of the fifty cases he examined, one of which 
was of two years standing — and every clinical student has since been 
able to satisfy himself of their presence. 

The staining is best done with methylene blue ; the use of well-col- 
ored preparations and of Abbe's lens is indispensable in examining 
the purulent secretions, which should be dried onto cover-glasses in a 
thin layer and affixed to them by direct heat. 

It would, however, be erroneous to suppose that the shape of these 
diplococci is the main characteristic point in diagnosis. According to 
Bumm there are no less than seven different species of diplococci 
which present the same shape in appearance and grouping as the spec- 
ific gonococcus. These, however can easily be distinguished from the 
gonococcus by means of culture experiments, since none of them grow 
in the same manner on the soils. 

On the contrary the main differentiating feature of the gonococcus 
is its situation inside of its cell, the lodgment in the protoplasm, and 
its further development beneath the surface of the leucocyte. This 
abihty on the part of the micro-organism to penetrate into the sub- 
stance of the cells is no doubt the main reason why the proposed abor- 
tive methods of treatment of gonorrhoea have proved so httle suc- 
cessful. 

According to Bumm, who had the opportunity of microscopically ex- 
amining twenty-six cases of ophthalmal blennorrhoea of infants — agon- 
orrhoeal disease acquired from the mother through contagion during 
parturition- — the germs actively penetrate into the mucous membrane, 
entering between the epithelial cells, and advancing so far as the 

1 Studier ofner Gonococcus. Diss. Helsingfors. 18S5. 

''O. Haab, Der Micrococcus der Elennorrhcea Neonatorum. Festschrift. Wies- 
baden. 1881. Correspond, f. Schweizer Aertze. 1881. 3, 4. 



BACTERIAL SCIENCE IN ITS SURGICAL RELATIONS. 153 

papillary body of the mucous membrane, all the while increasing in 
numbers. 

In consequence of this invasion leucocytes appear in great quantities, 
suppuration ensues, the epitheHum becomes partly elevated and 
detached, and eventually fibrinous exudation takes place. 

The whole process in time comes to a end, partly because the mi- 
cro-organisms penetrate no deeper than the papillary body, and prob- 
ably also for the reason that the nutritive soil-substance of the parts 
becomes exhausted. The leucocytes then simply convey the micro- 
organisms to the surface, and, together with the epitheHal cells, assist 
in rebuilding the destroyed tissues. 

Bockhardt ^ has furnished a report of microscopical examinations of 
gonorrhoeal inflammation of the urethral mucous membrane. Having 
procured a pure culture of the gonococcus in the fourth generation from 
Fehleisen, he inoculated a patient suffering from general paralysis of 
the insane by urethral injection of a quantity of the pure culture, and 
observed the development of a typical gonorrhoea after three days. On 
the tenth day the patient chanced to die in a paroxysm and the autopsy 
revealed the following conditions. There was abscess of the right 
kidney, hypersemia of the mucous membrane of the bladder with ne- 
crosis of minute portions ; the mucous surface of the urethra was cov- 
ered for a distance of 6 centimetres from the cutaneous orifice with 
viscous bloody exudate ; the corpus cavemosum of the urethra was 
swollen. 

The secretions of the mucous membranes as well as the kidney 
fluid contained the specific cocci, which were also found enclosed in 
the substance of the white blood-corpuscles in the mucous and sub- 
mucous tissue of the urethra. 

The lymph-spaces and ducts furthermore contained micrococci, and 
some were observed inside of the white blood-corpuscles in the capil- 
laries. 

These anatomical data make it easily conceivable why it is that true 
gonorrhoea presents so extended a course, and the microscopical ex 
amination consequently admits of a differentiation between true gon 

M. c. 



154 EDITORIAL ARTICLES 

orrhoea and a non-specific urethritis, as well as of a prognosis as to the 
time of duration, just as, conversely, a urethritis which runs its course 
in a few days, permits the conclusion that it is not due to the gono- 
coccus. In some of the European clinics, notably at Wiirzburg, no case 
of gonorrhoea is diagnosed, until the gonococcus has been found. The 
presence of the specific germ is also of vast practical importance in the 
diagnostic estimation of gynaecological cases — nor is any great amount 
of skill or time required for such examinations, which may even be ef- 
fected before the patient leaves the examining chair. 

Inoculations of gonorrhoeal pus itself, containing diplococci, have 
frequently enough been observed to call forth the specific disease. 
Every practitioner has opportunities of witnessing inoculation experi- 
ments on the conjunctiva in his daily practice, and the earnestness 
with which surgeons warn their patients of the dangers of such inocula- 
tions is the best argument in favor of the gonococcus. 

Detailed accounts of such inoculations have been published by Wel- 
ander,' who gives three cases of successful inoculation, and so-called 
control-cases, in which inoculation with pus not containing the organ- 
isms caused no inflammation. 

Bumm has also shown that gonorrhoeal secretion which is free from 
micrococci does not produce gonorrhoeal inflammation. All of which 
tends to show that it is in point of fact the gonococcus which is the 
true cause of contagion. 

Anatomically the gonococcus has been demonstrated up to the 
present time in gonorrhoeal aff"ections of the male and female urethra, 
the bladder, the kidneys,'^ in peri-urethral abscess,^ in gonorrhoeal 
bubo,* in gonorrhoeal gonitis,^ in gonorrhoeal afi'ections of the rec- 

1 Quelques recherches sur les microbes pathogenes de la blennonhagie. Gazette 
Medicale. 1884, p. 267. Nord. Med. Arch. Vol. XVI. No. 2. 

2 Bockhardt, 1. c. 

* Welander, 1. c. 

* M. Wolff. 

* Kavivierer, Ueber gonorrh. Gelenkentzundung. Centralbl. f. Chir. 1884. No. 4. 
M. Petroiie. Sulla natuia delF artrie blennorrhagica. Rivista Chir. 1883. No, 2. 



BACTERIAL SCIENCE IN ITS SURGICAL RELATIONS. 155 

turn' of the uterus, in certain alascesses of Bartolini's glands,- and in 
gonorrhaeal conjunctivitis, although in the latter affections other micro- 
organisms are frequently present as well. 

As regards the cultivation of the germ, reliable cultures appear to 
h ave been achieved by Bumm, whose statements in this regard agree 
with Krause, Leistikow and Loffler, the cultures by other experimen- 
ters being more or less open to objection. 

The gonococcus, it appears, can only be cultivated on blood-serum 
soils, where it develops as a very fine, scarcely perceptible film of grey- 
ish-yellow color, when viewed in direct hght. The surface of the 
colony appears smooth and moist ; its margins appear gradually dif- 
fused into the surrounding parts ; the serum soil does not become 
liquefied. The gonococci appear in groups, developing in close prox- 
imity to each other. 

The cultures thrive best at a temperature of 30° to 34° C. in a moist 
atmosphere. Temperatures above 38° C. destroy the cultures. The 
growth progresses very slowly ; and to obtain good cultures it is advisa- 
ble to inoculate fresh soils after the first colony has developed for a 
period of 24 hours. 

With such a pure culture as this Bumm performed his inoculation 
experiment, which, even if it is only a single one, still commands atten- 
tion, since it answers every bacteriological requisition. 

He introduced a minimal quantity of the pure culture into the 
urethra of a healthy woman, and shortly after was able to observe the 
development of a specific gonorrhoea. 

Considering the difficulty apparently attendent upon the procuring 
of pure cultures and the scientific scruples connected with the inocula- 
tion experiments on the human body, there appears to be no reason 
for not accepting the evidence contained in the two inoculation experi- 
ments above described, nor for not according the gonococcus equal 
dignity with the tubercle-bacillus and the micro-organisms of suppura- 
tion. W. W. Van Arsdale. 

1 Bu»im, Archiv. f. Gynecol. 3, p. 339. 

''■ Bumm, 1. c. E. Arning, Ueber das Vorkommen von Gonococcen bei Bartolini- 
tis. Viertel jarschrft f. Dermat. u. Syph. 1883, p. 371. 



TREATMENT OF STRICTURE OF THE URETHRA BY 
ELECTROLYSIS. 

It is to be regretted that the discussion on Dr. Steavenson and Mr. 
Bruce-Clarke's paper on the above subject at a recent meeting of the 
Royal Medical and Chirurgical Society should have taken place so late 
in the session, and to this and to the lateness of the hour must be attri- 
buted the paucity of speakers. 

The subject is one of great interest. Six cases were brought for- 
ward which had been treated by this method, in none of which had re- 
contraction taken place, though it must be admitted that a sufficient 
interval had not elapsed to permit judgment to be passed as to the 
permanency of cure. 

In the first case rigors occurred, but this can scarcely be wondered 
at when it is remembered that both gentlemen were employing this 
method for the first time. 

We regret that more details were not given concerning the number, 
size, position and character of the strictures. We' note also that, 
a Ithough no recontraction is said to hav& taken place, it does not ap- 
pear that a thorough examination was made with a bougie a boule, 
without the aid of which slight constrictions are difficult to diagnose. 

The modus operandi employed was as follows : A gum-elastic or 
celluloid bougie with a wire running down to the centre terminating in 
a metal end, forms the electrode, this being connected with the nega- 
tive pole is held gently pressed against the stricture, and should be of 
a size larger by 2 or 3 mm. than is the stricture's calibre. To the pos- 
itive pole is attached a pad electrode which is placed over the sacrum, 
the patient lying upon it. The battery used is Stoehrer's 30 cell. A 
current strength of from 5 to 8 milliamperes is found requisite, which 
is gauged by means of a galvanometer. •. 

In cases of eccentric stricture a funnelled electrode can be used, 
|)assed over a long catgut bougie which has previously been passed 
through the stricture, or filiform guide bougie may be passed, to which 
is screwed the electrode. By this means the electrode cannot fail to 
traverse the proper course. 



TREATMENT OF STRICTURE OF THE URETHRA. 157 

Alter the passage of the electrode through the stricture, which may- 
take from two to twenty minutes, the patient goes home and the urethra is 
left untouched for fourteen da'ys. The treatment can then be repeated it 
necessary. Speaking generally, from two to three appHcations are re- 
quired. . 

In the discussion which followed the writer of this brought forward 
a case of long-standing stricture where electrolysis had succeeded after 
treatment by dilatation had failed. Although on commencing elec- 
trolysis the stricture only admitted a No. 4 bougie olivaire, after three 
applications a No. 28 passed. A month after the cessation of all 
treatment a careful examination of the urethra with a 22 bougie a boule 
failed to detect any trace of stricture. 

Mr. Berkeley Hill complained of the want of details in recorded 
cases. He had tried electrolysis by means of a needle passed into the 
neoplastic tissue, the result being that the stricture got worse in- 
stead of better. Whatever good may have resulted from this plan of 
treatment he believed was due to dilatation by means of the elec- 
trode and not to electricity, and in this Mr. Buxton Browne agreed. 

In the presence of the numerous cases now on record, we cannot but 
think that electrolysis is capable of causing strictures to disappear and 
probably of effecting a permanent cure. Much, however must depend 
upon the way of carrying out the method. It appears that Mr. Fen- 
wjck has tried it in a good many cases at St. Peter's Hospital, but 
without much success. One reason of failure being that only weak 
currents were used and, working without a galvanometer, these were 
not accurately gauged. Mr. B. Hill tried a method altogether differ- 
ent and failed ; nor can this be wondered at, when ]one considers the 
plan he pursed. 

In order to thoroughly investigate the electrical treatment of stric- 
ture it is necessary, that cases of well marked organic stricture (and for 
preference those for which dilatation has been found to be ineffectual) 
should in the first place be submitted to some well-known surgeons, 
concerning whose powers of diagnosis there can be no question. These 
same men should at the expiration of treatment, and possibly again 
after the lapse of a year, examine and report on these test cases. It 



158 EDITORIAL ARTICLES. 

seems to us that only in some such way as this can this question be 
satisfactorily settled. 

To further this object it is announced that at St. Peter's Hospital for 
Stone and Genito-Urinary diseases a special department is being in- 
stituted for the treatment of stricture by electrolysis, to the practice of 
which all medical men are invited. F. Swinfopd Edwards. 



INDEX OF SURGICAL PROGRESS. 



GENERAL SURGERY. 



I. On Tuberculosis of the Mammary Gland and Some 
Other Rare Cases of Surgical Tuberculosis. By Dr. O. Haber- 
MAAS (Tubingen). To the number of affections which are becoming 
recognized as tubercular by the microscopical demonstration of tuber- 
cle-bacilli contained therein, the author adds muscular and mammary 
tuberculosis, illustrating them with cases, and also gives two cases of 
tuberculous pre-patellar bursitis. 

After reviewing the six reliable cases already reported the author 
adds two of his own of tuberculous mammary disease, and proceeds to 
discuss the subject . 

The affection attacks only females both before and after lactation, 
and independently of traumatisms. In many cases other tuberculous 
affections existed. The course of disease is insidious, but not unex- 
ceptionally. The disease may attack the gland primarily or second- 
arily. Bacilli were found in both cases of the author's. Diagnosis is 
difficult until suppuration ensues. The treatment indicated is extirpa- 
tion of the entire gland; although circumscribed foci may be removed 
by partial excision. 

The author's two cases of tuberculous affection of the pre-patellar 
bursa were both cases of primary synovitis occurring in perfectly 
healthy individuals. 

The last case is one of multiple tuberculous foci occurring inde- 
pently in the muscles of the upper and lower extremities and of the 
body in a man 54 years of age, who was suffering from caries of the 
fifth dorsal vertebra. The tumors varied in size from that of a pea to 
a hen's egg, and were situated inside of the sheath of the muscles. 
Microscopically they contained tubercle-bacilli. The case is consid- 
ered as one of dissemination from the vertebral focus. — Beitrage zur 

(159) 



i6o jndex of surgical progress. 

klin. Chir. Miffh. aus der chir. Klinik. zu Tiibingeti. II. Bd. r. 
Heft. II. 

W. \V. Van Arsfmlf. (New York). 

II. The Treatment of Lupus. By Prof. Trendelenburg. 

In describing the aflection the author fully accepts its tubercular 
origin. It follows that treatment to be permanently successful should 
seek to destroy all the affected tissue. 

Formerly internal remedies were much in vogue. Sweat cures and 
Trittmann's decoction (sarsaparilla) appeared at times to produce 
some effect. 

Caustics he likes best in the form of pencils, and nitrate of silver is 
preferable to potash since the latter is too diffluent. Better than these, 
however, is the actual cautery in the convenient form of the pointed 
thermo-cautery, The action is then strictly localizable. In Germany 
at least the method most in favor is that introduced by Volkmann. 
viz., mechanical destruction and removal of the nodules by means of 
the sharp spoon. This plan, when followed by cauterization with a 
Paquelin, he considers specially commendable. Volkmann's puncta- 
tion treatment is only adapted to hght cases, and does not appear to 
be very certain. 

Various methods succeed if each ulceration, every nodule and sus- 
picious spot is included, and the operation — under narcosis of course — 
is repeated at the right time. In bad cases no single method protects 
against relapses. Lupus will also heal out under washings with 
solution of sublimate. 

In excision with subsequent plastic covering it is well to wait with 
the latter until solid cicatrization has taken place, and thus avoid 
taking away too much or too little. The transplanted flap is not safe 
from infection, despite Hueter's assertion. True such an operation or 
the resulting inflammation seems to have a favorable influence on the 
cure. He corroborates the old observation that an erysipelas also has 
a favorable effect. In cases where the lupus is closely localized to a 
wing of the nose and its corresponding mucous membrane he often 
splits the nose, close to the septum, up to the nasal bone. It can be 
held open and the affected parts treated wnth the sharp scoop and the 



NEKJ^OUS AND VASCULAR SYSTEMS. l6l 

thermo-cautery, when it is again sewed together. The fine scar 
is of h'ttle account, disfigurement being inevitable. — Deutsche Chir- 
urgie. Lief. n. Haelfte i. 

W. r.KOWNiNc; (Brooklyn). 

NERVOUS AND VASCULAR SYSTEMS. 

I. Secondary Suture of the Median and Ulnar Nerves. 
Recovery. By Mr. R. Harrison (Liverpool). The author narrates 
the case of a man ast. 21, who, eighteen months before admission, fell 
through a green house, severely cutting his wrist. There was a mark 
of a deep cut transversely across the wrist, just above the anterior 
annular ligament. The hand was stiff and useless, all the muscles 
were atrophied, and sensation and motion were completely absent in 
the part supplied by the median and ulnar nerves. The author 
opened up the scar by a long vertical incision, aud dissected out the 
ends of the ulnar and median nerves ; these were found clubbed and 
incorporated with the scar tissue. The ends of the nerves after dis- 
section of the part were freshened with the knife and brought together 
as accurately as possible with catgut sutures. The wound was closed 
and the limb placed on a splint, with the hand sHghtly flexed. The 
wound healed quickly. A month after the operation the patient was 
again placed under ether, when the stiffened hand was subjected to 
free movement. The amount of stiffness, especially in some of the 
phalangeal joints, was so great as to occasion considerable difficulty in 
thoroughly effecting what was desired. For 48 hours after this was 
done the patient experienced considerable pain in a part that pre- 
viously had been almost insensible. Shortly afterwards the patient 
was discharged, improving slowly but steadily. When he was seen 
after the expiration of about eighteen months, it was found that sensa- 
tion was everywhere complete where it had been destroyed, except in 
the little finger, and the recovery of muscular power had been such 
that he had been able to resume his employment. 

II. r. Dunn (London). 

II. Union of Nerves of Different Function Considered in 
its Physiological and Surgical Relations. By M. Gunx. M.l)., 
(Chicago). After an account of certain circumstances which led to 



I62 



INDEX OF SURGICAL PROGRESS. 



the conclusion that the difference between motor and sensory nerves 
is not intrinsic but dependent upon the organization at the end of the 
nerve, referring in particular to the investigations of Rawa, showing 
that {a) the central nerve apparatus is enabled to innervate organs 
which do not belong to it as soon as those organs are artificially 
brought in connection with it; {b') the central nerve apparatus is the 
chief nourishing agency for the peripheral end (of the entire correct- 
ness of which, however, there is some doubt) and (<;) for the reestab- 
lishment of function in the peripheral end of a divided nerve, which 
has been united to the central end of any other nerve, from six to six- 
teen months time is required, he details certain experiments upon dogs 
which finally went simply to show that an entire solution of continuity 
of the nerve of the fore-leg had no effect, there being so free a distal 
anastomosis, affording a retrograde route for the nervous force, and 
because of Avhich it is necessary to await the opportunity to institute 
experimental operations in man. The experiments of Rawa showed 
that the function could be established where the nerve trunks were 
laid side by side as well as end to end. showing an elective power in 
nature by which the corresponding filaments may be brought into har- 
monious conjunction. The opportunity for an experimental operation 
presented itself in December, 1885, when, having to resect between 
three and four inches of the right ulnar nerve for the removal of a 
neuroma, the author proceeded to graft the distal portion of the di- 
vided nerve upon the trunk of the median, denuding the trunk of the 
latter of its sheath and laying the broadly chamfered distal end of the 
ulnar upon the denuded side of the median, to which it was fastened 
by three fine catgut sutures. Healing was complete on the eighteenth 
day. Immediately after the operation there was complete paralysis of 
motion and sensation in the parts supplied by the ulnar nerve ; on the 
eighteenth day, examination showed a shght return of sensation along 
the ulnar side of the ring finger and, in flexing the hand upon the wrist, 
there seemed to be contraction in the flexor carpi ulnaris, but in the 
attempt to flex the fingers, there was no response in the terminal 
phalanges of the ring and little fingers ; three months after the opera- 
tion, there was marked increase of sensation on the ulnar side of the 
ring finger, but no sensation in the little finger and no increase in the 



NERVOUS AND VASCULAR SYSTEMS. 1 63 

range of motion ; a month later the patient could feel a hght touch on 
the ulnar side of the ring finger ; there was no sensation to touch in 
the litde finger, but there w^s a litde feeling of warmth in it, whereas 
heretofore it had felt and had been cold ; there was increased muscular 
power, and the patient could now adduct the hand with considerable 
vigor, but as yet has no power over the terminal phalanges. The 
author also quotes a case of Depres in which the median was engrafted 
upon the ulnar by separating the filaments of the latter and inter- 
weaving the fringed filaments of the distal median end among them, 
with the result of partially restoring the functions in the parts supplied 
by the median nerve, at the date of the report, fifty-four days after the 
operation. — Med. News. 1886. May 8. 

III. A Case of Aortic Aneurism Treated by the Insertion 
of "Wire. By J. Ransohoff, M.D., (Cincinnati). In a colored man. 
get. 35, an aneurism of the ascending aorta, resulting from over-exertion 
in rowing about two months previously, had been treated inefiectually 
by iodide of potassium and subcutaneous injections of ergotine. Fi- 
nally a straight hollow needle with thumb-screw attachment was pushed 
into the aneurism from the right side and through it was passed ninety- 
six inches of flexible silver wire. The pain experienced was very 
sHght and, during the introduction of the first forty-eight inches of wu^e 
the pulse remained unchanged, but it then suddenly became almost 
imperceptible and very rapid, the patient became very faint and death 
appeared to be imminent;stimulants, however, overcame the syncope and 
the remainder of the wire was introduced without interruption. On the 
autopsy, the syncope was found to have been due to the passage of a 
loop of wire beyond the neck of the sac and into the aorta, where it 
was probably defiected by the aortic valves. There was no bleeding 
during the operation nor immediately after the withdrawal of the 
needle. An amelioration of the symptoms continued for two weeks 
after the operation, but then a change for the worse supervened, great 
oedema of the right side of the face and the right arm being developed, 
and, in hope of consolidating this part of the sac, ninety-eight inches 
of wire were inserted into the sternal portion; some improvement su- 
pervened, but the patient died suddenly eight days later, from rupture 



T^4 INDEX OF SURGICAL PROGRESS. 

of the sac. Autopsy showed the formation of dots about the loops of 
wire. From his experience in this case and an analysis of fourteen 
others, the operator concludes that in but thirty per cent, of the cases 
can death be attributed to the operation and, except in peripheral ves- 
sels where so many safer methods are at our command, the practice is 
worthy of further trial ; practiced as a last resort, it has undoubtedly 
lengthened life, and it is far from improbable that, if often adopted, a 
permanent recovery will occasionally be obtained in cases that would 
l)e hopeless without it. — Med. Netvs. 1886. May 29. 

IV. Traumatic Aneurism of the Internal Carotid Artery. 
By T. F. Prewitt, M.D., (St. Louis, Mo.) A bullet entered the cheek 
over the malar bone, ranging backward, the injury being followed by 
immediate and profuse haemorrhage, controlled by compression from 
the wound of entrance — there being no wound exit — and from the ear, 
the latter recurring several times. A gradually increasing swelling ap- 
peared, which, three months later, projected into the pharyngeal cav- 
ity and rested against the uvula, extending externally from the anterior 
petrous portion of the tempoial to the hyoid bone, and had all the 
symptoms of an aneurism of the internal carotid artery, together with 
symptoms indicating injury of the glosso-pharyngeal and, possibly, the 
pneumogastric nerves. The common carotid artery was then liga- 
tured and the pulsation arrested for a time but soon returned. As a 
derfiier ressort, he extended the incision upward in the hope of being 
able to lay open the sac and apply a Hgature to the distal side; dis- 
section, however, revealed that the sac filled all the space between the' 
mastoid process and the condyle and ramus of the jaw, and extended 
to the skull, to which it was closely adherent, and that further attempts 
to reach it in that direction were useless, and dressings were appHed. 
Secondary haemorrhage set in some days later but was controlled by 
compression with pledgets of iodoformized lint thrust into the sac ; epi- 
leptoid convulsions, involving the facial muscles and the flexors of the 
arm and hand set in ten days later and continued at intervals until 
death on the twenty-ninth day. The diagnosis was confirmed by the 
autopsy, the ball being found in the posterior part of the sac. In con- 
nection with the case, the writer called attention to the extreme rarity 



NERVOUS AND VASCULAR SYSTEMS. 165 

of traumatic aneurism of the internal carotid and believed this case, 
resulting from a gunshot wound, to be unique in surgical literature. 

W. T. Briggs, M.D., (Nashville, Tenn.) remarked that he had re- 
ported a case of traumatic aneurism of the internal carotid, the result 
of a stab-wound, operated upon successfully in 1871. At first sight, 
he considered it to be a small aneurism of one of the branches of the 
external carotid, but an enlargement of the wound showed his error. 
Ligature of the common carotid failed to control the hemorrhage, and 
the internal carotid was dissected out until the point of injury was 
reached, the sac opened and ligatures applied above and below it, the 
patient obtaining a permanent recover}'. 

D. H. Agxew, M.D., (Philadelphia), reported a case of a woman 
with a tumor as large as an orange, just beneath and behind the angle 
of the j aw, projecting also into the pharynx ; it had grown slowly for 
eight months and was attributed by the patient to a blow on the side 
of the head. The tumor was materially reduced in size by pressure 
on the internal carotid artery, had a distinct pulsation and bruit, and 
he considered it to be an aneurism of the internal carotid ; he hgatured 
the common carotid immediately above the omo-hyoid, but, although 
the pulsation was diminished, it could still be felt, a fact attributable to 
its communication with the external carotid, and the external thyroid 
and lingual arteries were tied, stopping all pulsation. After about a 
week the pulsation reappeared and could be controlled by pressure upon 
the carotid of the opposite side, and the common carotid of that side 
was also tied. The walls of the tumor were very thin and, during a 
temporary absence of the operator, yielded to ulceration, causing haem- 
orrhage into the fauces ; this was controlled by plugging the sac, but 
the patient died of septic poisoning a few days later. He had intended, 
in case of such an accident, to divide the jaw, expose the tumor and 
apply ligatures to both ends ; this latter operation should be a primary 
one, without waiting for other methods to fail. 

A. Vax Derveer, M.D., (Albany, N. Y.), related a case of aneurism 
of the internal carotid apparently cured by compression, the patient 
dying, not long after, of seeming apoplexy. — Proceedings Am. Suro 
Ass'n. 1S86. 

J. E. PiLCHER (U. S. Army). 



1 66 INDEX OF SURGICAL PROGRESS. 

V. On the Treatment of Teleangiectasia. By Dr. Boeinc, 
(Nerdingen). The following method of treating teleangiectasia is 
recommended by the author, who has applied it in a number of cases 
with astonishing success. The tumor including the surrounding sur- 
face for about 2 mm., is painted once daily for four consecutive days 
with a 4 p. c. solution of subHmate-collodium, until a white layer about 
I mm. thick has formed. 

Case I. Angioma in the middle of the left inner edge of the scap- 
ula, 15 mm. long and 11 mm. wide, dark brown and elevated about 
i' '., mm. above the healthy skin. Two applications were made. On 
the sixth day the collodium layer had loosened itself about the peri- 
phery and was retracted, leaving a suppurating ring about 2 mm. in 
width. Two days later the scab was removed without pain. On the 
suppurating, granulating surface thus exposed, no signs of any dilated 
vessels were seen. Dressings of boramylum. Cicatrization complete 
in seven days. The patient was a delicate boy of 7 months of age, 
but showed no reaction from the treatment. 

In a similar manner the author treated an angioma 24 mm. long, 15 
mm. broad and elevated 3 mm. above the niveau of the skin, situated 
in the middle of the third spinal vertebra, in a child 9 months of age. 
Four applications were made. Result satisfactory in every way. In a 
third case but two applications were made, the angioma the size of a 
lo-cent piece about, being situated in the middle of the forehead. 
Cicatrization followed in fourteen days without reaction. The fourth 
case was an angioma on the edge of the right large labium in a girl 6 
months of age. The treatment was much comphcated here by the 
constant wetting of the parts with urine, rendering the healing process 
slow. The result, however, was entirely satisfactory, as was also that 
in the author's fifth case. 

The contraction of the cicatrix in these cases was very sHght, which 
fact should recommend this mode of treatment especially in cases of 
angioma of the face. By thoroughly covering the surrounding surface 
of skin by collodium before the solution itself is applied, little or no 
pain will oe produced, if care be taken- The solution used was the 
following: R, Hydrarg. bichlor. cor., 0.4; coUodii lo.o. For cleans- 



HEAD AND NECK. Imp- 

ing and preserving the brushes ether should be used. — Deutsch. Med. 
JVochen. No. 17. April 29, 1886. 

C. J. COLLES (New York). 
HEAD AND NECK. 

I. On Compression of the Brain, By Prof. Ernst Von 
Bergmann (Berlin). In this article the distinguished exponent of the 
subject of traumatic intracranial pressure vindicates his theories 
against certain modern authors who are endeavoring to overthrow the 
old tenets — more especially against Adamkiewicz of Cracow. 

Referring casually to the practical results recently obtained by ad- 
hering to the old doctrine, as instanced in the publication of Wies- 
mann (Annals, Vol. II. P. 502), where it is shown that twenty out of 
the twenty-two cases were saved by timely operative interference, the 
author proceeds to discuss the physical points bearing upon the ques- 
tion of brain pressure. 

Adamkiewicz had asserted that the brain was compressible and that 
compression of its substance produced the symptoms of intracranial 
pressure. To this the author makes the following reply. 

The brain substance proper possesses, physically speaking, a com- 
pressibility averaging between that of water and that of glass, which 
somewhat approximates to that of a 46-millionth part of its original 
volume. But to effect a compression, even in this degree, a far greater 
amount of force would be necessary than the cranial cavity could with- 
stand. 

It was not permissible to confound compressibility in its physical 
sense with expressibihty, as Adamkiewicz had done, which latter was 
property belonging to sponges and shared by the brain. 

When the blood contained in the capillaries of the brain is driven 
out by presssure, as the water is forced out of the pores of a saturated 
sponge by squeezing, the brain loses its nourishment and its function 
becomes impaired. The effect of such impairment of nutrition upon the 
nerve-centres is first irritation and subsequently paralysis. 

Thus the pulse, for instance, is first rendered less frequent in 
compression of the brain, by irritation of the pneumo-gastric nerve, 
and subsequently it becomes more frequent when paralysis of the vagus 
occurs. 



\ 
1 68 INDEX OF SURGICAL PROGRESS. 

The mechanical action in compression of the brain, therefore, does 
not actually differ from progressive anaemia of the brain, induced by 
other conditions. 

Adamkiewicz objecting to this theory, that the tension of the Hquor 
cerebro-spinahs could not be increased beyond its natural low tension, 
because, in the first place, it was of the nature of a transudate, and 
could not acquire a higher pressure than existed in the capillaries from 
whence it transudated, and secondly, the exits afforded to the cerebro- 
spinal Hquor were always available — the author refutes both these 
propositions at length, quoting Naunyn and Schreiber and Landerer in 
support of his assertions. 

Direct measurements of the existing pressure inside of the space oc- 
cupied by the cerebro-spinal liquor proved the tension to be greater 
than that of the capillaries. The experiments were performed upon an 
infant suffering from spina bifida. 

By continued forcible manual compression of the tumor it was, in 
fact, possible to obtain the complete series of symptoms occurring in 
traumatic compression of the brain, including Stoke's respiratory phe- 
nomenon. 

Although giving Adamkiewicz due credit for his experiments on 
localized pressure by the introduction of laminaria tents into the 
cranial cavity, the author points out that he never denied local altera- 
tions in traumatic compressions of the brain, but asserts that the gen- 
eral symptoms are produced by means of general pressure. The ex- 
periments on venous pressure performed by Adamkiewicz are criticised, 
and the opposite results, obtained by Cramer and Mosso, upheld. 

As for the assertion that the cerebro-spinal liquor has sufficient out- 
lets to prevent a high tension occurring, it is refuted by the author by 
analogy with hydrocele, ascites, etc., in which cases the internal press- 
ure is high and the lymphatic system of drainage is pathologically 
altered. 

The paper represents a valuable addition to the former well-known 
works of the author on the subject, and an especially interesting one, in 
so far as it contains references to the latest advances in closely related 



HEAD AND NECK 1 69 

subjects. — Arbeiten aus der chir. Klitiik. der Konigl. Univers. Berlin. 
I. Th. I. 

W. W. Van Arsdale (New York). 

II. Traumatic Aphasia. Followed by Hemiplegia: 
Trephining: Death. By Prof. J. R. Fraser. Patient, a publican, 
set. 44, fell into a cellar and received a severe blow on left side of fore- 
head. Stunned for ten minutes ; and was then carried home. Left 
frontal region much bruised, and an incised wound over left eyebrow. 
Speech indistinct. Walked out on the second day, but returned home 
unable to speak, and vomited. On the following day he could speak, 
but was giddy. During next seven weeks suffered from frequent pain 
in left side of forehead, and had many attacks of sudden faintness and 
giddiness. Speech often indistinct. Memory for words became greatly 
impaired. No history of syphilis. On admission to Royal Infirmary he 
complained of slight pain in left frontal region, and distinct tenderness. 
Indistinct cicatrix over left eyebrow. No paralysis. Temp. 98°. Un- 
derstands everything said to him, and answers sensibly. Cannot name 
articles presented to him, but recognizes their names. Can write, but 
spelHng is entirely at fault. Thus, he calls a knife a " nob," and then 
writes it " sotpa." When asked to write " I will come " he wrote " If 
hayh good," then stopped, shook his head, and said it was wrong. 
Can copy correctly, and understands written language. Decided im- 
pairment of right side came on. Complained of" pins and needles " 
in right hand. Memory for names quite absent. 

Hemiplegia became almost complete. Pupils unequal — evacuations 
passed involuntarily. Optic discs pale. Contracture of flexors of right 
elbow. Became semi-comatose. 

He was now trephined over left inferior convolution. On opening 
dura mater, nothing abnormal could be seen, no signs of inflammation 
of the membranes, and no accumulation of pus or other fluid. A fine 
cataract knife was introduced into brain substance in three directions, 
but no pus was found. Wound closed and dressed antiseptically. No 
improvement in condition. Temperature rose to 107° three days after 
operation, and patient died. Necropsy. Membranes of brain healthy. 
Convolutions, especially on left side, flattened. Trephine wound im- 



1 70 INDEX OF S UR GICAL PR GRESS. 

mediately over commencement of Sylvian fissure. Beneath wound 
were several small ecchymoses of recent origin, the surrounding brain 
tissue being pale and apparently abnormal. On removing the brain, 
the left hemisphere, but especially the temporo-sphenoidal lobe, was 
pale and swollen, and decidedly larger than the right. The lateral 
ventricles were dilated and contained an excess of clear serous fluid. 
On section immediately through centre of trephhie wound the whole of 
the temporo-sphenoidal lobe was seen to be occupiedby a large glioma 
and surrounding softening ; the tumors extended backwards as a uni- 
form infiltration as far as the Hmit of the posterior bone of the lateral 
ventricle. It had invaded Broca's convolution, and the adjacent parts 
of the ascending frontal and parietal convolutions. Immediately be- 
neath the superficial ecchymoses in Broca's convolution there was a 
recent haemorrhage about the size of a walnut. A small nodule of tu- 
mor, of a similar nature and as big as a cherry, Avas situated in the 
right hemisphere at the middle third of the ascending parietal convolu- 
tion. — Lancet. Feb. 27. 1886. 

III. To Remove Foreign Bodies From the Ears. By Jo- 
nathan Hutchinson, F.R.C.S. Mr. Hutchinson recommends that a 
silver wire-loop should be used instead of either forceps or scoop. He 
says he never uses either of the latter instruments, has always found 
the wire-loop most successful. It is impossible for it to injure the 
membrane or canal. After having put the patient under an anesthetic, 
the loop is introduced gently into the ear and turned about till it is be- 
lieved to be behind the foreign body. This often requires a little time 
and patience. — Brit. Med. Journ. April 10. 1886. 

IV. Alveolar Abscess With Thrombosis of Cavernous 
Sinus. By Pearce Gould, F.R.C.S. Patient, a woman aet. 57, was 
admitted into the Temperance Hospital with the mouth and teeth in a 
foul state ; a sloughy opening was seen in centre of right cheek. An 
incision was made into the tissues over the jaw from the outside, where 
fluctuation was detected over the lower part of masseter ; the swelling 
of face subsided a little after this, but the patients' general condition 

I emained very unsatisfactory. Six molar teeth were extracted, and a 



HEAD AND NECK. 1 71 

probe passed through external opening detected bare bone. Four days 
after the extraction of teeth an abscess appeared above external angu- 
lar process of orbit and another in posterior triangle of neck, but ex- 
ternal jugular was not thrombosed. Patient became drowsy ; great 
oedema of the orbit with some ptosis of right and less of left. Asthenia 
increased. Some rigors, conjunctivae yellow, and motions colorless. 
Became comatosed and died. Necropsy — several globular abscesses 
were found in lungs with dense walls, and no signs of adjacent inflam- 
mation. Liver enlarged and fatty ; kidneys healthy. Necrosis of outer 
part of right side of lower jaw; temporal muscle discolored, but not 
actually purulent. Lymph was detected along basilar process of occip- 
ital bone and sella Turcica. Right cavernous sinus greatly distended, 
and contained greyish-yellow broken down pus and clots ; right oph- 
thalmic vein similarly affected, and the circular sinus with the superior 
petrosal on the right. Inferior petrosal and lateral sinuses healthy. 
Left cavernous sinus contained a clot, of which the inner part was yel- 
low. — La7icet. March 27. 1886. 

H. H. Taylor (London). 

V. Removal of a Tumor of the Brain. By J. O. Hirsch- 
FELDER, M.D., (SanFrancisco). A man, get. 32, about eighteen months 
previously, began to suffer from pain in the head in the early morning 
hours with occasional dizziness during the day ; next, shght but pro- 
gressive loss of power in the left leg and arm ; the eyesight grew dim 
and amaurosis became nearly complete ; had occasional epileptiform 
seizures, irregular in occurrence, during which he remained conscious 
and which began about the same time as the headaches, with spasms 
and jerkings of the muscles of the left side. Physical examination 
showed the left labio-nasal fold obliterated and the left angle of the 
mouth drooping, when closed, and more, on showing the teeth ; pare- 
sis of both upper extremities, with strength of left hand shghtly dimin- 
ished, and loss of muscular sense in left upper extremity and less in 
the lower ; shght anaesthesia of the terminal branches of the trigeminal 
nerve on the left side but sensation normal in upper and lower extrem- 
ities of both sides ; tendon reflex increased on both sides, especially the 
left, striking below either patella causing contracture of the muscles on 



1/2 INDEX OF SURGICAL PROGRESS. 

the opposite side ; he tottered on standing with the eyes closed. The 
eyes present optic neuritis with atrophy, the arteries being very small 
and the right eye less affected than the left, with, however, black pig- 
ment in the center of the macula lutea. The headache, vertigo, vomit- 
ing, unilateral paralysis and atrophy of the optic nerves pointed to a 
neoplasm within the cranial cavity ; the epileptic and epileptiform seiz- 
ures occurring without loss of consciousness, pointed to a cortical seat 
for the growth ; it was evident that the motor centers about the sulcus 
of Rolando of the right side must be the seat and from the fact that the 
face, arm and leg centers apparently were affected, the middle portion 
was supposed with certainty to be involved ; it having been found that 
the seat of sensation exists in the parietal lobes of the brain, the anaes- 
thesia of the left half of the face indicated that the neoplasm was lo- 
cated in the middle of the gyrus postcentralis. Syphilis being excluded 
by history and treatment, three buttons of bone were removed with the 
trephine, and under the dura mater was found a glioma,which protruded 
about one half inch and was removed in part, it being difhcult to sep- 
arate it entirely from the healthy brain tissue. The symptoms were 
slightly amehorated by the operation, but the patient grew worse, and 
seven days later died. The author attributes the unfavorable result 
to the fact that the soft glioma was continuous with the adjoining brain 
tissue so that its complete separation was impossible without the de- 
struction of a large portion of the cerebrum. Had it been a hard tu- 
mor that could have been readily isolated, it is very probable that the 
patient would have recovered. — Pacific Med. and Surg. Jour. 1886. 
April. 

VI. Enucleation with Transplantation and Reimplanta- 
tion of Eyes. By C. H. May, M.D., (New York). After a running 
history of the operation as appHed to the human being, showing four 
out of five cases to have been failures, the writer proceeds to give a 
detailed account of twenty- four experimental operations upon rabbits, 
from which he concludes that the operation is a perfectly feasible one, 
all those cases in which a bandage could be kept on throughout the 
treatment, being successful as to size, conformity and tension, the cor- 
nea remaining hazy, however. — N. Y. Med. Rec. 1886. May 29. 

Iames E. Pii.CHF.R, (U. S. Amiy). 



HEAD AND NECK. 1/3 

VII. On the Final Results of the Operation for Cancer 
of the Lip. By Dr. A. Woerner (Tubingen). In the Tubingen 
Surgical Clinic no less than 277 operations for labial cancers have been 
performed, of all of which the author has been able to obtain recent 
histories. This subject-matter he makes use of for statistical consid- 
erations in the present paper. The total number of cases of labial 
cancer admitted to the hospital amounted to 305, but 28 of these were 
inoperable. 

The entire number of cases is condensed in tabular form, and oc- 
cupies fifty-three pages— more than half of the number covered by the 
entire article. 

Several smaller tabular synopses representing different statistical 
points of interest are distributed throughout the paper, and charts 
bear witness of the diligence with which the statistics have been com- 
piled. 

A few of the figures given may be mentioned here. 
Ninety and '-^/loo % of the number effected were males. The most 
frequent age was between 65 and 70. Ninety per cent, were exposed to 
injuries and the inclemencies of the weather. Of 69 men 51 were 
mentioned as smokers, 18 as non-smokers. Injuries were beUeved 
to cause the malady in 11 cases. 

Of the 305 cases, 289 cancers were situated on the under-lip, and 
only 16, or 5. 2'/^ on the upper one. 

The operation generally consisted in cuneiform excision of the tumor 
(224 cases). Plastic operations were performed sixty-nine times. 

Of the 277 cases operated upon in the clinic iii individuals were 
attacked by recurrences of the disease, and some repeatedly. These 
recurrences generally took place within the first year. 

As regards the results of the operation, the mortaUty amounted to 
5.77 per cent. Only three of these cases, however, belong to the an- 
tiseptic period. Most of the deaths were due to advanced age and 
severe surgical operations, such as the removal of the maxilla. 

The average length of time that the patients continued to live after 
recovery was 8.4 years ; six patients lived to be over 80. 

Taking three years as an ample period for recurrences to develop, 



174 INDEX OF SURGICAL PROGRESS. 

106 cases were completely cured, or 57.7 per cent, of the whole 
number. 

The author finally adds statistics obtained fi-om the entire number 
of operated labial cancers heretofore pubHshed, which is 866. 

The results of this comparison are very similar to those obtained 
from the Tubingen Clinic. — Beitrcige zur Klin. Chir. Mitth. aus der 
chir. KliJtik zu TuHtigen. II. Bd. i. Heft. V. 

VIII. On Intracapsular Extirpation of Thyroid Cysts. 

By Dr. Eugen Mueller (Tubingen). The author pubHshes eight 
cases in which Prof. Bruns, of Tubingen, enucleated thyroid cystic 
tumors, this method of operation being preferred since the introduction 
of the antiseptic method to injection of tincture of iodine, and to in- 
cision of the cyst. 

The operation consists in incising the capsule of the gland and then 
dissecting out the cystic tumor with its sac entire, by means of blunt 
instruments, and without injuring the sac. This operation can be per- 
formed in fifteen minutes, and frequently no vessels except those di- 
vided by the first incision have to be Hgated. 

The author compares this operation with the older ones of injection 
and incision, and points out its advantages; it is the least dangerous 
most certain, and quickest method of treating cysts of the thyroid. The 
credit of having recommended it is given to JuUiard. 

The operation is next described in detail, and a review of the results 
hitherto achieved by means of the enueleation method by Julliard, 
Buckhardt, Wolff and Bruns, given. 

In the thirty-three cases considered the tumors varied in size from 
that of a pigeon's egg to a child's head. The wounds healed mosdy 
by first intention, without any outward occurrence, and, on the aver- 
age, in thirteen days. — Beitrdge zur Klin. Chir. Mitth. aus der 
chir. Klinik. zu Tubingen. II. Bd. i Heft. IH. 

W. W. Van Arsdale (New York). 

CHEST AND ABDOMEN. 

I. Foreign Body in the CEsophagus. By A. G. Gerster, M. 
D., (New York). A child, 12 months old, presented no history of 



CHEST AND ABDOMEN. 175 

having swallowed any foreign body but suffered from increasing diffi- 
cult respiration, with occasional aggravated paroxysms of dyspnoea, 
chiefly expiratory — there being but little difficulty in inspiration — of 
six months duration. An exploratory tracheotomy failed to improve 
the respiration, and on exploration with a soft rubber catheter, the 
trachea and the bronchi seemed to be clear. It was observed that the 
introduction of a canula into the trachea increased the difficulty of 
respiration, but the breathing became easier when the mouth of the 
canula was occluded by the finger. Further exploration was post- 
poned, but the next day pneumonia set in, terminating fatally in three 
davs. On autopsy, a triangular defect of the trachea was found a lit- 
tle lower than midway between the cricoid cartilage and the bifurca- 
tion of the trachea, with a corresponding defect about i centimeter in 
diameter in the oesophagus. Through these openings, a flat brass but- 
ton, a centimeter and a half in diameter, projected into the trachea 
about 3 millimeters ; the foreign body was embedded in the tissues 
between the trachea and the oesophagus, being held in position ex- 
actly like a picture by its frame. The ulceration had evidently termi- 
nated by complete cicatrization, no active inflammation being found 
at the time of death, although the tissues were considerably thickened 
by the former inflammatory processes. The slowly progressive char- 
acter of dysphagia was due to the advancing cicatricial contraction of 
the parts. The difficult expiration, as contrasted with the comparatively 
easy inspiration, was due to the slanting position of the foreign body, 
giving it the action of a valve ; the stream of air rushing up from below 
had the effect of raising up the projecting edge of the button and thus 
rendering it more transverse to the axis of the trachea. Although the 
use of a metallic probe instead of a soft catheter, in exploring the 
trachea would have detected the foreign body, it could not have been 
extracted from the oesophagus, on account of the rim of thickened tis- 
sue which held it, and he doubted whether instant death from suffoca- 
tion would not have been produced by an attempt at removal through 
the trachea. — Proceedings N. V. Surg. Soc. 1886. April 26. 

JameS'E. Pilcher (U. S. Army). 



1 76 INDEX OF S UR GICAL PR GRESS. 

II. Primary Cancer of Lung. — Extension to the Verte- 
bral Column. — Paraplegia. By M. P. Muselier. The patient in 
this rare case was a woman, aet. 75, admitted into L'Hopital Necker 
Aug. 4, 1885. 

For eight months she suffered intense pains, apparently neuralgic, in 
the right arm and shoulder, for which various medical men had pre- 
scribed various remedies in vain. 

About eight days before she came under the care of M. Muselier she 
had herself discovered a small swelling in the posterior triangle of the 
neck. This was apparently glandular and close to the brachial 
plexus. 

A similar, but smaller, tumor existed on the other side. Slight 
pains were occasionally felt in the shoulder of that (the left) side. 

Eight days before entering hospital, she had coughed up an expec- 
toration which she herself compared to red-currant jelly. 

Auscultation revealed a zone in the middle of the right chest pos- 
teriorly, where the respiratory murmur was obscure. 

One week after admission pains were felt in the left arm and shoul- 
der almost as severe as those in the right. The same night complete 
paralysis, both motor and sensory, attacked the lower extremities. An- 
aesthesia reached as high as the second and fourth ribs. Both patellar 
reflexes soon disappeared, and, within twenty-four hours of the paraly- 
tic attack, a large sacral bed-sore formed. Three days afterwards she 
died. 

Autopsy. Cancerous nodules in the upper and posterior part of the 
right lung ; their size from that of a nut to that of an egg ; their num- 
ber, five or six. Lung substance around, intensely congested. 

No nodules in the left lung. Most careful examination of the other 
viscera revealed nothing. 

Spinal cord, etc. At the level of the junction of the seventh cervical 
vertebra with the first dorsal, slight adhesion of the dura mater to the 
intervertebral cartilage. This cartilage projected slightly into the med- 
ullary canal. The neighboring vertebrae are easily cut with the knife. 
Spinal cord hardened at the level of the cervical enlargement. One of 
the adjacent vertebral bodies was infiltrated with cancer. The supra- 
clavicular tumors were apparently cancerous, and, on the right side. 



CHES T AND ABDOMEN. 1 77 

the nerves of the brachial plexus were in immediate contact with the 
tumor. 

The author is of opinion that the cancerous gland on the right side 
excited the pains in the arm, that the paraplegia and bed-sore were due 
to pressure of the cancerous nodule developed in the vertebral body- 
acting suddenly on a spinal cord not prepared for it. 

[These views seem a litde doubtful. Great pain followed by para- 
plegia is usual when cancer attacks the vertebral column, whether the 
affected nerves are pressed on by glands or not. In this case, too, the 
right gland which was supposed to be pressing on the nerves, exercised 
no pressure on the neighboring vessels. There was no cedema of the 
arm, and the pulses were equal. It is to be remembered that the pains 
had existed eight or nine months. Moreover the left arm and shoulder 
at last became affected like the right, and this was followed iimnediately 
by the paraplegia. It will scarcely be disputed, therefore, that that 
pain was of spinal origin and due directly to the spinal cancer. If the 
left why not also the right ? The situation of the cancerous vertebra 
was also exactly in correspondence with the originof the painful nerves. 
Rep?^—Gaz. Med. de Paris. 1886. April 3. 

C. B. Keetley (London). 

Ill, On the Operative Treatment of Echinococcus of the 

Lungs. By Dr. J. Israel (EerUn). Operative treatment for echin- 
ococcus of the lungs has been rarely undertaken. The difficulty in 
making a diagnosis, the spontaneous recovery by expectoration oftimes 
observed, and finally the dread of opening a healthy pleural cavity and 
causing pneumothorax; have been the chief reasons for this therapeu- 
tic idleness. The author is in favor of more active therapeutic meas- 
ures, as so many cases, left to themselves, perish in consequence of 
perforation into the bronchi. A case of echinococcus of the convexity 
of the Hver was reported by the author in 1879, which he had success- 
fully removed by opening the pleural cavity and dividing the diaphragm. 
This and similar experiences have shown him that opening the pleural 
cavity for a short period and closing it under strict antiseptic precau- 
tions, is not necessarily followed by serious results. The entrance of 
air, of course, should be restricted as much as possible. Author gives 



178 INDEX OF SURGICAL PROGRESS. 

two methods of operating. The one consists in extended resection of 
the ribs and incision of the cyst, after uniting the lung to the costal 
pleura by sutures. This method would be indicated in such cases 
where positive pressure exists in the cavity of the thorax, as is the case 
where large echinococcus-sacs lie directly against the chest wall. Un- 
der such conditions the pleura may be incised without fear of the en- 
trance of air, the tense cyst pressing closely into the wound. When 
the cyst is not large and tense enough to change the normal intra- 
thoracic negative pressure into a positive one, then the second opera- 
tive method would be indicated. This is as follows : Above and be- 
low the proposed line of incision hooks are passed through the costal 
pleura which has been exposed by resection of the ribs. The pleura is 
then incised at intervals and only during expiration, pieces of iodo- 
form gauze being pressed into the cut, following the knife step by step, 
thus effectually closing the wound before the next inspiration takes 
place. When the incision is finished in its entire length, the gauze is 
pressed into the pleural opening as the edges are separated. The cyst 
is not incised until three days later, when the lung and chest wall have 
become adherent. Author reports the following interesting case : Pa- 
tient, woman set. 25. For past eight weeks pains in chest, and since 
two months difficulty in breathing accompanied by cough with occas- 
ional bloody sputum. There is a considerable bulging in the lower 
part of the right side of thorax, beginning at the third rib, and over 
which there is absolute dulness on percussion. No respiratory mur- 
mur or vocal fremitus. Above second rib conditions normal. During 
deep inspiration the lower boundary of the lung sound reached to the 
fourth rib, which fact dispelled all idea of the presence of a pleuritic ex- 
udation. It was decided that the presence of a tumor in the lung (as 
shown by the bloody sputum) caused the bulging mentioned above. 
Aspiration with Pravaz' syringe drew off the characteristic echinococ- 
cus liquid, also particles of compressed lung-tissue. This procedure 
was followed by violent coughing, which resulted in the expectoration 
of some 1500 ccm. of thin, frothy fluid, evidently coming from the 
echinococcus sac. Patient became worse, her temperature reaching 
40.3°. Aspiration of the echinococcus fluid caused diffuse bronchitis of 
the left side, and pleuritic pains set in on the right side, in consequence of 



CHEST AND ABDOMEN. ^79 

which the dyspnoea became alarming. Operation two days later. Re- 
section of 6 ctm. of the seventh and eighth ribs. On incising the cyst 
there escaped a very large parent-vesicle and several smaller ones with 
a quantity of aqueous transparent fluid. The lower pole of the sac 
was adherent to the diaphragm. The lung tissue composing sac- wall 
was V4 ctm. in thickness at the place of incision. Contra-incision for 
drainage behind and below. Two drainage tubes, 16 ctm. long, intro- 
duced into the lung cavity. Wound disinfected with salicylated water 
and dressed with iodoform gauze. The further progress of the patient 
was complicated by a very severe attack of broncho-pneumonia of the 
left lung, doubtless caused by the aspiration of the echinococcus-fluid. 
Dyspnoea very great and increased by the pneumothorax of the right 
side. Venesection gave much relief. Patient made then a rapid re- 
covery, a fistula, however, remaining. The latter is now closed. This 
case would demonstrate that the risk of a radical operation is really 
small compared to the dangerous consequences of an exploratory 
puncture. It was undoubtedly this latter that led to the bursting of 
the cyst into the bronchi and the dangerous state of the patient subse- 
quently. In a similar case of Schede and also in one of Comil and 
Gibier death from suffocation was caused in this manner. Puncture 
should only be undertaken when the reflex irritabiHty has been allayed 
by morphine injections or chloroform-narcosis. Author recommends 
the latter, parlicularly if one is in the position to undertake the radical 
operation at o^ce.—Deutsch. Med. Woch, No. 19. May 13. 1886. 

C. J. COLLES (New York.) 

IV. Resection of Rib for Calcareous Concretion of 
Pleura. By Dr. A. Boni (Pavia). The patient, a person «t. 60, 
had received a blow some time previously. This had been followed by 
pleuro-pneumonia, and a pulmonary cavity developed. Through a 
fistulous sinus something simulating carious bone could be made out. 
The patient becoming more and more debilitated, he removed 5 ctm. 
from the fifth and sixth ribs at about the mammary hne on the left 
side, together with a fragile concretion. 

Cleansing with disinfectant drainage ; iodoform. Complete restora- 
tion of general health. The remaining fistula shows a tendency to 



l80 INDEX OF SURGICAL PROGRESS. 

cicatrize. — Gazzt. d. Ospitali. 1885. No. 38. (Report of Medico- 
Chirg. Socty. of Pavia. 

V. On Gallstone Ileus. By P. J. Wising. The author is able, 
from an observation of his own and fifty others which he has collected, 
to give a detailed account of a trouble which has received less consid- 
eration than it seems to deserve. Amongst 1,541 cases of ileus col- 
lected by Leichtenstern 41 were of this form : 

As a rule, ileus is only caused by an exceedingly large stone ; a 
smaller one could only cause incarceration where there was previous 
contraction of the gut, or where it had become enlarged by deposition 
of faecal matter. Incarceration of gallstone in the vermiform appen- 
dix, relatively not so very rare, is not included by the author. 

Gallstones passing the natural way through the choledochic duct, 
usually not over i ctm. in diameter, do not, as a rule, play any part 
in obstructing the gut. Obturating stones usually pass through a 
fistula ; this may be caused by the stone inducing an ulceration of the 
bladder-wall, local adhesive peritonitis and finally a perforating ulcera- 
tion of the intestine, or the communication may result from a local can- 
cer. The opening may be into the stomach, colon or duodenum ; that 
into the stomach is rarest, though Cruveilheir found a stone thus in 
transit, and in other cases large stones have been vomited up. Small 
stones, after taking the natural way into the duodenum, may doubtless 
be forced into the stomach by efforts at vomiting. A stone passed di- 
rectly into the stomach has never been known to enter the intestine and 
cause ileus. 

Rarely, through more frequently than into the stomach, the stone finds 
its way into the colon. In the nine such cases — Murchison six were oc- 
casioned by cancer, and in three of these there was also a communica- 
tion between gall-bladder and duodenum. As a rule, no incarcerative 
symptoms arise in the colon, at most the stone stops above the anus 
and makes trouble in discharging . The usual way for stones too large 
for the gall duct, is by a fistula to the duodenum. Murchison gath- 
ered 34 such cases, mostly fatal. Yet recovery is not impossible. 
Amongst W's 51 cases, in 24 of which the condition of the gall-bladder 
is specified, the perforation was into the intestine in 18. In only 3 of 



CHES T AND ABD OMEN. I o I 

the 24 does a large stone appear to have traversed the choledochic 
duct. 

The point of occlusion varies in different individuals according to 
the size of the stone and the width of the intestine. Even in the duode- 
num the stone may cause a complete closure and be mistaken for 
pyloric stenosis — as has really happened. Commonly, however, the 
occlusion takes place farther down in the jejunum or ileum. The author 
found, in opposition to the statements of Frerichs that gallstones usu- 
ally lodge in the jejunum, and of Leichtenstern that they most frequent- 
ly lodge in the lower part of the ileum, amongst 33 cases the obtura- 
tion twelve times in the jejunum and twenty-one in the ileum, in 
the latter, twice in the middle, six times in the upper, twelve times in 
the lower half. However, recoveries are not included, and in them 
probably the coecal valve was the point of obturation. The gut is, as a 
rule, gready distended above the lodgment, collapsed below. It may 
be more or less altered at the spot of closure, even gangrenous. 
Above this it is sometimes hypersemic and ulcerated superficially or 
deeply. A few times circumscribed or more general peritonitis was 
present. 

As to clinical symptoms— disregarding the rare cases where the stone 
traverses the duct causing gallstone colic and icterus, or where at times 
in traversing the duodenum it compresses the divertcl. vateri — the per- 
foration of the stone from the gall-bladder into the gut is far from 
always accompanied by severe suffering. Only in a third of the cases 
does severe pain in the hepatic region with vomiting appear to have 
been present. 

Sometimes no illness preceded the ileus ; in other cases only diges- 
tive disturbances, obstipation and pain in the liver region are men- 
tioned. Icterus certainly does not belong to the regular accompani- 
ments of the perforation ; it is specified only eight times in the 51 
cases. After the stone has entered the intestine ileus very soon sets 
in ; but it presents no characteristics to distinguish it from ileus from 
other causes. All trouble disappears on the stone entering the colon. 
In solitary cases the stone distends the gut-wall to a diverticulum 
where it may be carried a long time without any difficulty. 

As regards separate symptoms, the pain may be very unequal, now 



1 8 2 INDEX OF S UR GICAL PR GRESS. 

more disseminated or again more localized. The character of the 
vomited material and the presence of meteorism depend upon the seat 
of the stone ; when this is low down, faecal vomiting does not appear 
until late. 

In only 5 of the 51 cases could a tumor be felt. 

The following matters deserve consideration in making the diagno- 
sis, (i) The sex of the patient. Of the 44 where this is stated, 11 
were males and 2)Z females. (2) The age. One was 27 years, while 
36 were 40 years old, and most of them over 50. (3) Preceding aber- 
rations in health. Since the stone does not usually traverse the natural 
way, jaundice and colic are only valuable as indicating the formation 
of stone. On the other hand, previous more or less definite symptoms 
of circumscribed peritonitis in the gall-bladder region are to be heeded, 
at the same remembering that subjective symptoms of the passage of 
the stone may be wanting. (4) The attack of ileus may afford some 
help, A'^omiting usually begins early, even when the stone is in the 
ileum. The sides of the abdomen are generally less distended. Under 
narcosis the stone may possibly be felt where the abdominal walls are 
thin; in the author's case the parietes were too thick for this. Kit is sus- 
pected that a discoverable tumor is caused by a gallstone it would be 
proper to introduce a fine needle before laparotomy. 

Regarding prognosis, 38 of the 51 died ; but presumably more fatal 
cases and especially those of autopsy would be published. All dan- 
ger is in most cases past as soon as the stone is discharged by the 
natural outlet ; still in some cases alterations in the gut — e. g. ulceration 
and cicatricial stricture — may have been induced, which later leads to 
wasting or death. Ot 25 fatal cases 14 ended between the sixth and 
eight .days, one from acute peritonitis in the first 24 hours, and one 
after three days, laparotomy having been performed. In 9, 13, 15, 26, 
and 28 days respectively, a death occurred, whilst one followed per- 
forative peritonitis at the end of two months. 

Individual cases presenting themselves, usually as intestinal oc- 
clusion of uncertain causation, have sometimes been treated a: first 
with purgatives, to which any favorable result would then be attri- 
buted. The usual treatment for ileus — high injections, opiates, etc. — 
has been repeatedly adopted, for the most part unsuccessfully. In one 



CHES T AND ABD OMEN. 1 8 3 

case the stone was passed after massage of the belly, and in two after 
thorough palpation in examining. All four cases in which laparotomy 
was done — between third and seventh day — proved fatal. In one of 
these the stone could not be found ; in the other three it was readily 
felt, the gut was opened and, after removal of the stone, was sewed 
up. Death resulted in 8 hours, 24 hours and six days respectively. 
A purgative is advised at the beginning, but should not be continued. 
Kussmaull's stomach washing he thinks will prove useful. High in- 
jections are to be tried since they are harmless, irritative clysters are to 
be avoided, however. Nutritive enemas may preserve the patient's 
strength. 

Laparotomy is certainly justifiable but should not be done too early. 

W's. case was that of a woman of 75 years. She suffered from obsti- 
pation and occasional abdominal colic, late in the summer. Septem- 
ber 5th the bowels would not move. This complete obstruction was 
followed in a few days by severe vomiting that soon took on a feculant 
character ; abdomen a httle sensitive, but slightly distended. No tumor 
could be made out either through the anterior walls or per rectum 
Slight icterus on the loth. Morphine, croton oil and high injections 
did not clear the obstruction. A council on the i6th decided against 
any operation. Death on the 19th. An egg-shaped stone, 7 ctm. 
long by ten around, blocked a loop of the upper half of the ileum just 
below the navel. Signs of beginning peritonitis. Gall-bladder 
shrunken, ulcerated and presenting a perforation into the adherent 
duodenum above the mouth of the choledochic duct. There was also 
a small opening into the colon adhering to the under surface of the 
liver. — Nord. Med. Ark. Vol. 18, No. 18 (as abstracted in Centbl. 
f. Chirg. 1886. No. 20). 

W. Browning (Brooklyn). 

VI. Cholecystotomy. By C. T. Parkes, D.D. (Chicago). Re- 
ports two unsuccessful cases, showing that obstruction of the gall-duct 
is not always amenable to surgical treatment, and illustrating the diffi- 
culties the surgeon has to deal with when the bladder is atrophied, or 
when it is not in a state of distension. The first occurred in a woman, 
who had suffered from gall-stones with frequent colic for six years and 



1 84 INDEX OF S UR GICAL PR CRESS 

whose gall-bladder, flaccid and closely adherent to the under surface 
of the liver, was found with considerable difficulty. It was finally 
loosened from its attachment to the hver and brought to view, sutured 
to the abdominal incision, opened and forty-three calculi removed. 
The patient endured the anaesthetic badly and never ralUed. The sec- 
ond occurred in a greatly emaciated man, and was explorative in 
character, since no gall-stones had ever been discovered. Close to the 
locahty where the gall-bladder should have rested lay a large cyst, 
which was too near the vessels to permit of removal. An autopsy the 
following day showed a much atrophied and empty gall-bladder, with a 
stone completely obstructing the passage through the duct, and a small 
abscess immediately by the side of the duct, accounting for the cyst 
that had been felt. 

W. H. Carmalt, M.D. (New Haven, Conn.), reported a case of a 
robust woman who came to him with a history of operation upon the 
right kidney in Berhn, claiming a recurrence of the symptoms for which 
the operation had been performed, and desiring the removal of the vis- 
cus ; there was a tumor, clearly marked on inspection and palpation, 
and no history of any biliary trouble; on laparotomy, the tumor was 
discovered to be a gall-bladder, greatly distended with inspissated mu- 
cus and calculi. These were removed, the abdomen was closed and 
the patient proceeded to rapid convalescence. — Proceedings Am. Surg. 
Assn. 1886. May 8. 

VII. Explorative Laparotomy with Consequent Cho- 
lecystotcmy. Ey J. C. Hutchison. M. D. (Brooklyn, N. Y.). A 
woman, aet. 40, had been suffering from paroxysms of abdominal pain 
for twelve years, when a tumor was obser\'ed extending from a line on 
a level with the umbilicus and an inch to the left of it, across to the 
right lumbar region and downward to within two inches of Poupart's 
ligament ; it was irregularly rounded, fluctuated distinctly, was mova- 
ble from side to side and painless. Cystic tumor of the ovary was 
diagnosed and its removal by abdominal section advised. With some 
doubt, however, resulting from a later examination, as to the correct- 
ness of the diagnosis, an incision was made extending two and a half 
inches downward from an inch below the umbilicus; a trocar drew 



EXTREMITIES. 1 85 

from the presenting tumor a pint of laudable pus, containing no choles- 
terine crystals or other elements to show that it came from the gall- 
bladder; a biliary calculus was, however, found in the sac, and, on 
further exploration, another was found, pointed on one side, the point 
fitting into the orifice of the cystic duct and completely occluding it, 
which explained the absence of jaundice, clay-colored stools or bile 
pigment in the urine. The stones were removed, the sac explored and 
cleansed and the edges of the opening into it stitched to the hps of the 
abdominal wound ; the edges of the peritoneum were closed by a con- 
tinuous catgut suture and the remainder of the abdominal tissue by in- 
terrupted carbolized silk sutures, carried down to the peritoneum but 
not through it ; a glass drainage tube was kept in the gall-bladder for 
purposes of drainage and irrigation, and the patient passed on to a sat- 
isfactory recovery. The writer considers suturing the opening in the 
gall-bladder to the abdominal walls and establishing a biliary fistula 
preferable to sewing it up and leaving it in the abdominal cavity, (i) 
because there is less danger of escape of bile into the peritoneal cavity 
and (2) if the calculi can not be found at once they may be searched 
for subsequently or be spontaneously discharged through the fistulous 
opening ; the fistula usually heals in a few weoks.— Proceedings N. Y. 
Surg. Soc. 1886. April 26. 

EXTREMITIES. 

I. Four Cases of Amputation at the Hip-Joint. By T. A. 
McGraw, M.D. (Detroit, Mich.) The first case occurred in 1872 in 
a man of low physical condition, set. 48, for a mixed sarcoma, portions 
of which were myxomatous, of the right thigh, affecting bone and soft 
parts. The wound healed kindly and the patient was discharged in 
not more than six weeks. Two operations were performed during the 
following year for recurrent trouble in the cicatrix, the last one extend- 
ing up under Poupart's ligament, the acetabulum being gouged out 
■ with a chisel. After thirteen years the patient is still living in good 
health, although with a suspicious tumor of one arm. 

The second case was in a boy set. 10, suffering from a severe burn 
involving the whole thigh, five months after the injury. The hgemor- 



1 86 



INDEX OF SURGICAL PROGRESS. 



rhage was controlled by pressure on the common iliac with a staff in 
the rectum ; the burn being extensive, but a single flap was obtained 
from the unburned tissues on the outside of the limb. The patient 
raUied well but tetanus developed, and death followed in one week. 

The third case was a large round-celled sarcoma involving nearly the 
whole thigh, originating in the cicatrix of an old gun-shot wound of the 
knee ; the femur was disarticulated through an incision on the outer 
aspect of the hip, and a long anterior flap formed by transfixion, then 
a short posterior flap, and the arteries were secured. Haemorrhage 
was controlled by means of a long piece of rubber tubing passed 
around the thigh and the body in such a manner as to cross both the 
femoral and gluteal arteries ; the flaps were seized in the hand the mo- 
ment they were cut," and the digital compression thus added to that of 
the tubing. The patient raflied well and was discharged from the hos- 
pital three months later, the wound almost healed, but died two months 
thereafter from a secondary pulmonary disease. 

The fourth case, occurring in a man aet. 37, was also for round-celled 
sarcoma of the thigh, hemorrhage being controlled by a plan similar 
to that followed in the preceding case. An external cutaneous flap 
was cut by an incision, beginning a httle below Poupart's ligament and 
just inside of the anterior inferior iliac spine, extending in a curve to a 
point on the outer aspect of the thigh, six inches below the summit of 
the trochanter, and thence to a point a little anterior to and above tha 
gluteal fold, an internal skin-flap being cut to correspond. The mus- 
cles inserted into and about the trochanters were then divided, the 
joint exposed, the bone disarticulated and the remaining structures di- 
vided by one sweep of the knife. The wound was closed with careful 
antiseptic precautions, but the patient died sixty hours later apparently 
of suppression of urine, although there was no ursemic coma. 

The writer calls attention to the rapid and extensive involvement of 
the bone by sarcoma and expresses his behef that a sarcoma, even 
though small and at the lower end the femur, demands amputation at 
the hip, believing that this plan would greatly diminish the murtahty of 
the disease. He considers that the dangers of the operation in com- 
paratively healthy subjects may be greatly overrated by the profession. 
The danger from haemorrhage is not very great, except in very fat. 



GENITO-URINARY ORGANS. 1 87 

heavy and at the same time anaemic subjects, and the bleeding can be 
readily controlled by the means described. He would, however, in- 
sist upon the disarticulation of the femur before any of the larger ves- 
sels are divided. — N. V. Afed. Rec. 1886. May 22. 

J. E. PiLCHER (U. S. Army). 

GENITO-URINARY ORGANS. 

I. On Drainage of the Bladder with Special Reference 
to a Post-Prostatic Operation. By E. H. Howlett, F. R. C. S. 
This operation is performed in the same manner as Harrison's pros- 
tatic puncture, which, indeed, it would become were the prostate hy- 
pertrophied. 

The patient being in the lithotomy position, the bladder is filled if 
empty. The forefinger of the left hand is passed into the rectum and 
kept there, whilst a trocar and canula of the size of a No. 12 catheter 
(EngHsh ?) is thrust through the skin about Y* of an inch in front of 
the anus and slowly pushed on till resistance is felt to have disap- 
peared. After maintaining the silver canula for some days an india- 
rubber catheter is substituted. 

Two cases are related in which this puncture was practised. In the 
first, a case of epispadias, for the purpose of keeping some fistulae free 
from urine, and in the second, to estabUsh a permanent drain in a case 
of atony of slight prostatic enlargement. 

For chronic cystitis, enlarged prostate, atony, paralytic retention, 
ruptured urethra, impassable stricture, and mahgnant disease of the pros- 
tate or bladder where continuous drainage of the bladder is indicated, 
the author recommends the post-prostatic puncture. — Brit. Med. Jour. 
Feb. 13,1886. 

II. A Case where Lithotomy was Twice Peformed 
Within Fourteen Months with Remarks. By Reginald Har- 
rison. T. S., get. 62, with stone in the bladder (multiple) and enlarged 
prostate was subjected to lateral Hthotomy, as Mr. Harrison hoped to 
improve the prostatic urethra by a section of the gland (vide Harrison 
"On treatment of certain cases of prostatic obstruction by a section of 



I o 5 INDEX OF SUR GICAL PR CRESS. 

the gland." Trans. International Med. Congress Copenhagen. 1884). 
A bladder drainage tube was inserted after the operation and retained 
for six weeks. The patient left the hospital shortly afterwards with a 
fistulous track unhealed. The calculi removed weighed nearly ^iij. 

Though the patient returned to work, the bladder never quite recov- 
ered itself, the wound did not close and he had frequent attacks of cys- 
titis. On sounding thirteen months after the operation a stone was de- 
tected which was removed by lithotomy in the line of the old incision 
a month subsequently. The operation was easy, access to the bladder 
being greatly improved, for on this occasion the largest staff could be 
readily passed. The calculus weighed 5], and the author concludes 
was overlooked at the first operation, even in spite of all the precau- 
tions which the state of the prostate prompted. The patient rapidly 
got well, and mention is made of the fact that there was now no pros- 
tatic bar nor residual urine. 

[Before the first operation the enlarged prostate is said to have im- 
peded the easy introduction of the instruments.] 

Mr. Harrison considers, therefore, that this operation has the advan- 
tage of supra-pubic lithotomy in cases of prostatic enlargement, for by 
the latter, although the stone may be removed, the obstructing prostate 
is left intact.— ^rzV. Med. Jour. Feb. 13, 1886. 

III. Remarks on Incontinence of Urine in Children. By 

Wm. H. Day, M.D. After mentioning the various causes of enuresis 
the following case in connection with chronic albuminuria is re- 
lated : 

S. M., get. 9, incontinence both by day and night. At 6 years of age 
had scarlet fever, followed by dropsy. A year after recovery could 
only pass urine in drops. After two months urinated every ten min- 
utes without pain. Was sounded for stone on account of pain and the 
occasional presence of blood in the urine. 

On admission urine highly albuminous, with a few casts. 

Treatment — Confinement to bed, lying for a part of the day in the 
prone position. Milk diet, and a mixture of belladonna, iron and nux 
vomica. 



GENITO-URINARY ORGANS. 1 89 

After six weeks treatment the incontinence had almost entire disap- 
peared, the boy returning home much relieved. 

Case II. A girl, set. 7. Nervous and excitable. Mitral disease. 
Never had scarlet nor rhematic fever. 

Enuresis every night. Urine pale, copious, 1020, acid, contained 
phosphates. 

Treatment — A solution of argent, nit. 9ij to ^j was appHed to the 
neck of the bladder, and a mixture of belladonna and iron was given, 
but with no good effect. Electricity by means of Stoehrer's smallest in- 
duction apparatus (interrupted current) with one cell was now used for 
ten minutes daily, one sponge being placed over the sacrum and the 
other over the pubes. After five weeks of this treatment she left the 
hospital cured. 

Case III. Y. R., jet. 7. Incontinence for eighteen months. Urine 
pale and contained a few phosphates, acid. 

Treatment — Milk diet, with meat once a day. Faradization daily 
for ten minutes. A mixture of belladonna and iron. He left the hos- 
pital cured after six weeks' treatment, having only wetted his bed five 
times since admission. 

Case IV. A pale and irritable boy, set. 8. Troubled with enuresis 
fi-om birth. Passed large quantities of high-colored offensive urine, 
containing much uric acid. Treatment as in the last case, except that 
he was ordered strychnine and phosphoric acid on account of the urine, 
and belladonna was pushed to its physiological effect. The patient 
was greatly benefited, though not quite cured, after three months' 
treatment. 

Case V. A girl, aet. 9. Suffered with enuresis of a year's duration. 

All treatment had failed to relieve her. The use of the battery and 
the iron and belladonna mixture were prescribed. After six weeks pa- 
tient was well, but the battery getting out of order enuresis to a slight 
extent returned. 

As an adjunct to the treatment employed in these cases Dr. Day 
recommends cold sponging in the morning. Indeed, he attributes one 
cure to this means alone. The cold, or even for delicate children, 
tepid sponging should be followed by vigorous friction. In this way 
it braces up the nervous system. — Brit. Med. Jour. Feb. 13. 



190 INDEX OF SURGICAL PROGRESS. 

Testicular Affections and Hernia. By M. Verneuil. When 
hydrocele is accompanied by tubercular epididymitis the author recom- 
mends the injection of iodine as in the ordinary radical cure for hydro- 
cele for it appears to exercise a beneficial influence on the diseased 
epididymis. He also points out that hydrocele may be due to the 
pressure of an epiplocele on the veins of the cord, in which case injec- 
tion is contraindicated. — Gazette des Hdpitaux. March 2, 1886. 



V. On Supra-Pubic Lithotomy. The three following con- 
tributions on this subject were reported at the Royal Med. Chir. Soc. 
on March 30, 1886. Cases I and II. By Richard Barwell, F. R. 
C. S. 

Case I. Rose A., set. 9, subject of vesical calculus of large size. To 
avoid the risk of a vesico-vaginal fistula supra-pubic lithotomy was per- 
performed, the bladder being first distended. The rectal bag was 
not used. The bladder wall was sutured after extraction of the stone, 
and the child was well in fortnight. The stone weighed 27 1 ounces. 

Case II. A man, set. 60. with a medium sized stone, prostatic en- 
largement and haemaluria. The supra-pubic operation was selected 
not only an account of the condition of the prostate, but also as it was 
thought that the haemorrhage might point to a vesical growth. 

The rectal bag was again discarded, but the bladder was distended 
with 5xvi boro-glyceride solution. 

The author concluded his paper by stating that distention of the 
rectum had a very small effect on the anterior peritoneal fold. 

Case III. A case of vesical calculus of unusually large size, removed 
by supra-pubic cystotomy. By Walter Rivixgton, M. S. Man, set. 
61. Calculous symptoms for sixteen years. 

February 24, 1885. External urethrotomy for purpose of exploration. 
A large stone was discovered, which was almost immovable when 
grasped with forceps. Supra-pubic lithotomy was now performed. The 
stone was broken up by means of a chisel and mallet and extracted 
piecemeal. 

The wound in the bladder and that in the soft parts were separately 



GENITO-URINARY ORGANS. IQI 

sutured with insertion of a drainage tube and a silver tube was placed 
in the perineal wound. 

On March 21, the patient was allowed up for one hour. 

On April 17, the patient was well with the exception of a fistula in 
perineo. 

Three months after the operation the patient succumbed to a re- 
newed attack of cystitis. Suppurative nephritis was found at the 
autopsy. 

The pieces of calculus together weighed 23 ounces avoirdupois. 

Although not absolutely the largest calculus removed during Hfe, it 
appears to be so with recovery of the patient from the immediate ef- 
fects of the operation. 

Case IV. By W. H. A. Jacobson, M. B., F. R. C. S. A lad, »t. 19, 
had symptoms of stone for five years. A lithotrite discovered more 
than one stone. 

On January 30, hypogastric lithotomy was performed, the bladder 
having been injected with 3x of water and the rectal bag introduced. 
The peritoneum was not seen. One stone only was found at the time 
of the operation, the other two escaping a fortnight after the operation 
through the wound. 

It is supposed that these were missed, owing to the mistake of keep- 
ing the bladder distended with fluid during the search. No sutures, 
drainage tube nor catheter were employed after removal of the calculus. 
The patient was well in five weeks, convalescence having been retarded 
by an attack of pneumonia. 
• The largest calculus only weighed 300 grs. so that, as the author re- 
marks, all might have been dealt with by lithotrity. Mr. Jacobson con- 
cludes his paper with these propositions: ist. That this operation 
would be found of great value by those who only had to deal with stone 
occasionally, more especially if the stones were large and in the adult 
subject. 2d. That whilst it could never contrast in briUiancy with 
lateral Hthotomy, it would, in its improved form, give better results in 
adults with stones not suited to lithotrity. 3. That at present it would 
be wiser not to attempt to close the bladder wound with suture. 4. 
That in reviewing an abandoned operation these two questions called 



192 INDEX OF SURGICAL PROGRESS. 

for an answer, a. Did we stand in a better position towards the op- 
eration than our predecessors had done ? This question could be 
answered in the affirmative after the work done by Dr. Garson, Prof 
Peterson and Sir Henry Thompson, b. On what grounds was the op- 
eration abandoned? These the author enumerated. — Brit. Med. Jour. 
April 3, 1886. 

F. SwixFORD Edwards (London). 

VI. A Case of Rupture of the Kidney. By Mr. Eales. A 
collier was brought up from a coal mine suffering from collapse, the 
result of a crush of the right side from a fall of coal. He passed some 
blood with his urine, but after a few hours this stopped. He com- 
plained of great pain in the right flank. He died 48 hours after the 
injury. 

A post-mortem revealed the fact that the right kidney was displaced 
into the iliac fossa and ruptured, whilst there was a large accumulation 
of blood behind the peritoneum. The question is raised as to whether 
any operation should have been performed. — Lancet. March 13, 
1886. 

VII. Traumatic Hydronephrosis. By John Lowe, M.D. A 
case was related in which some blood had been effused from an injured 
kidney, giving rise to a sac, part of which was formed trom the pelvis 
of the kidney and part from the surrounding tissues. 

The discussion which resulted turned principally on the question of 
treatment by incision, and also on the propriety of such a term as 
traumatic hydronephrosis, where the sac was undoubtedly not due 
solely to a dilated kidney pelvis as is the case in ordinary hydrone- 
phrosis. — Lancet. April 10, 1886. Vol. i. p. 689. 

W. B. Clarke (London). 



CESOPHAGOTOMY FOR FOREIGN BODIES LODGED 
IN THE tube: 

By THOMAS M. MARKOE, M. D., 

OF NEW YORK. 

SURGEON TO THE NEW YORK HOSPITAL. 

THE following cases, neither of which has been published, 
form the foundation of the remarks I have to offer to the 
consideration of the society on the subject of opening the oeso- 
phagus for the removal of foreign bodies lodged in the tube : 

Case I. — Harriet Jones, set. 3, while playing with some iron jacks, 
such as children now use in place of the old-fashioned jackstones, got 
one of them into her mouth and swallowed it. The alarm was imme- 
diately given by her sister, who was playing with her, and when the 
mother ran to her she seemed to be choking. The mother put her 
finger back into the fauces, and distinctly felt the foreign body, but 
only succeeded in pushing it farther down and out of her reach. A 
doctor in the neighborhood saw her within a few minutes, and passed 
a probang, which he thought had gone down to the stomach. He 
gave the child a powder, which had the effect -of making her vomit, 
and the vomiting continued during the whole night. This occurred on 
Sunday, April 25, 1875. The next day she seemed sick and pros- 
trated ; would not willingly take food, evidently on account of pain in 
the act of swallo^ving. She was able to swallow liquids, but bread, or 
other Solids, would go down for a certain distance, and then be re- 
jected. There was a Uttle cough, no dyspnoea, and no evidence that 
the child felt any local pain. This continued till Thursday, the 29th, 
when I first saw her, she in the meantime being constantly up in the 
mother's arms, very weak, and most of the time with high fever. I ex- 
amined the fauces with my finger, she being under the influence of 
ether, but could not reach any foreign body, nor could I discover any 
swelling or any abnormal condition of the parts within my reach. 
Careful exploration of the neck externally did not reveal any tumefac- 

^Read before the New York Surgical Society, April 12, 1886. 



194 THOMAS M. MARKOE. 

tion, or any other indication of the presence of the intruder. I then 
passed into the oesophagus a large leaden probe, which struck a me- 
tallic body after it had passed about five inches. I estimated its posi- 
tion to be a little below the cricoid cartilage, but renewed external pal- 
pation failed to reveal its presence. I then passed down a pair of long, 
curved forceps, with which I could easily touch the jack; but, after re- 
peated efforts with instruments of varied form and size. I could not 
succeed in getting a hold on it. Although as gentle as possible in all 
our manipulations, a small quantity of bloody mucus showed me that 
some damage was being done to the mucous membrane, and I desisted 
after trying a large bougie with which I thought I might push the 
foreign body down into the stomach. In this, however, I did not suc- 
ceed, the instrument only passing, as before, about five inches, and be- 
ing there firmly arrested. 

The next day, Friday, the 30th, having provided myself wdth other 
apphances, and having asked Dr. George A. Peters, Dr. T. T. Sabine, 
and Dr. McBurney to assist me, we all met with Dr. Ranney, in whose 
care the case originally was, and the manipulations of the day before 
were repeated, and varied in every way without any success in dis- 
lodging the piece of iron. It could easily be touched, and several 
times was fairly seized by the forceps, but they could not be made to 
keep their hold. Fearing further attempts would only increase local 
mischief, on consultation we decided to proceed at once'to oesophagot- 
omy, for which we had the consent of the parents. 

An incision was made about midway between the trachea and the 
sterno-mastoid muscle, commencing opposite the middle of the thyroid 
cartilage, and extending to within less than an inch of the top of the 
sternum. Passing down between the sterno-mastoid and sterno-hyoid 
muscles, and pushing the omo-hyoid outward, we came down to the 
level of the carotid sheath, which was also pushed outward, and from 
this point the dissection was mainly conducted by the handle of the 
scalpel. Carefully displacing the loose connective tissue, we came 
down upon the side of the oesophagus, along which could be distinctly 
seen the inferior laryngeal nerve, at this point giving off a considerable 
lateral branch to the trachea. This nerve was carefully pushed for- 
ward, and it was noticed that every time it was pressed upon by the 
finger, or the curved spatula, the child showed signs of marked laryn- 
geal distress. One of the pairs of long curved forceps we had been 
using was then passed down, closed, into the oesophagus, and by it 
the oesophagus was brought into reUef in the wound. A longitudinal 
incision of about three-quarters of an inch in length was then made, 
opening into the tube, bringing its cavity very distinctly into view. 



(ES OP HA G TOM Y FOR FO REIGN B ODIES IN THE TUBE. 1 9 5 

Drawing the lips of the oesophageal opening well apart, the position ot 
the foreign body was plainly revealed. An opening had been made, 
of course, on the left side. Opposite to the opening, therefore, on the 
right wall of the tube, was seen one limb of the jack projecting into the 
tube, while the main bcdyof the jack was entirely outside of the tube, 
which it must therefore have perforated from within outward. How 
this irregularly shaped body could have traversed the wall of the oeso- 
phagus, whether forced through by muscular contraction tending to 
close the tube upon it, or whether it was pushed through by the sponge 
probang, or by the repeated handlings of it with the forceps, could not 
now be ascertained ; the fact was plainly visible to all. That it was 
pushed through by mechanical force, and not by a process of ulcera- 
tion, seemed evident from its being surrounded and hugged by sound 
tissues so closely that I had to cut a part of the oesophageal wall in 
order to get the body back into the tube, and that there was no indica- 
tion of inflammation, ulceration, or suppuration in the nidus, from 
which it was removed. By making this incision and thereby releasing 
one of the buried iron points, the whole was easily rolled out of its bed 
and removed. It was evident that the body of the jack must have lain 
outside of the oesophageal tube, and between it and the carotid sheath, 
upon which it must already have begun to press. 

The wound was brought together in its upper three-quarters by fine 
silk sutures, the lower fourth being left open. Into this open portion 
of the wound a silk tent was inserted for drainage. No attempt was 
made to close the wounds of the 'oesophagus. No vessel had been 
wounded which required a ligature. The wound was dressed lightly, 
but, 6i course, without those antiseptic precautions which were then 
but imperfectly understood. The parents were directed not to allow 
the child to swallow anything, and an enema of beef-tea or milk was 
ordered to be given every three hours. We were informed that from 
the very first the child had been very averse to swallow anything, and 
in consequence had gro^vn very thin and feeble. 

May I. — Passed a restless night without sleep. Enemata retained 
only for about an hour. Ordered three drops of laudanum with 
each. 

May 2. — Great thirst; emaciation very evident ; very feeble ; wound 
looks well ; no trouble about throat. No swelling of neck. 

May 4. — Has been allowed to swallow water freely. It seems to 
give comfort, though it all comes out of wound, as ascertained by 
measurement. She swallows easily. Stitches all removed ; the 
wound gaps freely. Enemata are retained longer by the help of the 
laudanum. She is losing flesh rapidly. No cough, and respiration 
easy. 



196 THOMAS M. MARKOE. 

May 8. — Seems to be nourished very imperfectly by the enemata, 
though they are given faithfully. The wound does not granulate : 
all adhesions have broken up, and it seems to be incapable of repara- 
tive action. Some little milk is found, by measurement, to go do\vn 
to the stomach, but only a trifling quantity. Some bronchitis from 
constant wetting of the chest. Thirst not so great ; very restless and 
sleepless. 

May 10. — Enemata have been given by the long tube and in larger 
quantity, with a little brandy. She looks a litde better, and her pulse 
is stronger. A patch of erysipelas showed itself on the nose. Or- 
dered the patch to be painted with tinctura ferri chloridi, and to add 
one grain of quinine to each injection, which are now pretty well re- 
tained. 

May II. — Seems brighter, but erysipelas has spread on the fore- 
head. She retains the enemata, but she is poorly nourished. I have 
abstained from passing a tube through the oesophagus, on account of 
its very damaged condition. Beside the wound made in ojjening the 
tube on the left side, there is another large opening on the right side 
made for the extrication of the foreign body ; and there is also,without 
doubt, inuch laceration of the mucous membrane caused by our per- 
sistent efforts at seizing it with the forceps. I fear that the passage of 
an instrument from the mouth might do much mischief and might in. 
crease future trouble, should the patient recover. The pulse is much 
better; no reparative action in the wound. 

May 12. — A sudden change took place after my visit yesterday. 
The child seems now dying of mere inanition, though the enemata are 
given regularly and are mostly well retained. I immediately intro- 
duced a tube into the stomach and threw in four ounces of warm milk- 
punch. It was too late. The child rallied for a Httle time, and died 
about three hours after. 

Case II. — Richard Ghent, aged twenty-four, a painter by trade, was 
admitted into the New York Hospital January 22, 1886. About five 
weeks before admission, while eating supper, a plate containing four 
artificial teeth broke inhismouth,and the palate portion was swallowed. 
He made attempts immediately to vomit, and tried to dislodge the 
plate, but did not succeed. He says that several surgeons have made 
attempts to remove the plate but have not succeeded. The patient is 
a man in fair condition of health and vigor, and does not seem to have 
suffered materially from failure of nutrition. This is due to the fact 
that, though he has not been able to swallow soUd food, he has been 
able to swallow fluids with comparative comfort. He says he can feel 
distincdy the spot where the foreign body has lodged, and indicates a 



(ESOPHAGOrOMY FOR FOREIGN BODIES IN THE TUBE. 1 97 

point just below the larynx, but says it gives him no pain, nor is there 
any tenderness to be discovered in the region where he says he feels it. 
A large No. 12 resophageals-tube detects an obstruction just below the 
cricoid cartilage, about eight inches from the teeth ; a small one, No. 
4, passes easily into the stomach. 

January 29. — Attempts were made to remove the plate, and it was 
foimd not difficult to seize it with the coin-catcher, but when so seized 
it was found so immovably fixed that the force that we thought it safe 
to employ did not change its position in the least. A large stomach- 
pump tube was then passed down to the foreign body, and an attempt 
made to force it downward into the stomach, with the same result. 
From the long time which had elapsed from the time of lodgment, and 
from the fixedness of the body, I felt quite sure that it had partly ul- 
cerated its way out of the tube, and that therefore any undue force in 
extraction, would, while it was unavailing, prove disastrous to the oeso- 
phagus and to the parts around it. Reasoning thus, we recommended 
that another attempt should be made under ether, and, if not success- 
ful, that cesophagotomy should be performed. 

February 9. — The patient was placed fully under the influence of 
ether, and again the foreign body was seized with the coin-catcher, but 
the complete relaxation produced by the anaesthetic had not loosened 
in the sUghtest degree the grasp of the oesophagus, and the operation 
was proceeded with. An incision four inches and a half in length was 
made, extending from the top of the thyroid cartilage nearly to the 
clavicle, along the inner border of the sterno-mastoid muscle, passing 
obliquely so that the upper end of the incision was half an inch internal 
to the edge of the muscle, while the lower end overlapped it nearly as 
much. The omo-hyoid was divided, and then, passing down between 
the sterno-mastoid and the sterno-hyoid muscles, and pushing the thy- 
roid body inward, the side of the oesophagus was easily reached by 
separating the loose areolar textures with the finger and the handle of 
the scalpel. The recurrent laryngeal nerve was not seen, and no ves- 
sel was cut of a size requiring ligature. The oesophagus was now made 
to bulge into the wound by passing the large stomach-pump tube down 
to the point of obstruction and then pressing with the fingers deeply 
on the right side of the trachea. This brought the side of the oesopha- 
gus fully into view and enabled us very easily to make a longitudinal 
incision into it about an inch long, opening the tube just above the 
point of lodgment and bringing into view the foreign body, which was 
seen to occupy a position parallel with the axis of the oesophagus and 
about at a right angle to the median plane of the body. It was seized 
with a dressing forceps, but was found as immovable as ever. It was 



I9S THOMAS J/. MARKOE. 

not till the incision was prolonged downward, so as to cut through the 
oesophageal wall which embraced the plate so firmly, that it could be 
stirred from its bed. It was then easily removed. It would naturally 
be expected that such firm impaction during so long a period would 
have been accompanied by some ulceration of the surfaces against 
which the foreign body had so long been pressing. A careful inspec- 
tion with a good light enabled us to feel pretty sure that very slight 
abrasion of the surface had taken place, and that the reason why the 
plate was so firmly held was that the tube had contracted so firmly 
above the point of distension as to resist all our efforts at dislodgement. 
A soft-rubber tube was now introduced through the wound, and passed 
into the stomach, and left in situ. Careful antiseptic dressings were 
applied, from which the tube, which had a funnel-shaped extremity, 
was allowed to project. It was extremely easy to pass fluids through 
this tube into the stomach, usually by merely pouring them slowly into 
the funnel, though occasionally it was necessary to force them through 
with the stomach-pump . 

There was very little inflammatory reaction after the operation. The 
temperature scarcely rose above 100°, and the wound behaved in a 
most satisfactory manner. The tube gave no pain or uneasiness, and 
afforded the most comfortable possible means of alimentation. His 
general condition was well maintained, and his nutrition perfect. On 
the 19th, as the wound was granulating finely, and looking perfectly 
healthy and ready to heal, the tube was removed. Before it was taken 
out, however, a similar tube was introduced into the left nostril, and, 
as the first tube was removed, the second was slipped by the wound 
into the stomach. This again proved an easy and comfortable way of 
feeding, the tube through the nose giving rise only to a little soreness 
in the meatus through which it passed, but not enough to call for 
treatment. This second tube was used with a view of preventing any 
matters getting out of the oesophageal wound in the act of deglutition 
into the yet unhealed fistulous track left by the removal of the original 
tube. It seemed to answer its purpose perfectly, the wound closing 
promptly and healing so well that on the 26th the nasal tube was re- 
moved, and the patient was allowed to swallow soft food without re- 
striction. No further interruption to the healing occurred, and the pa- 
tient was well by the 15th of March. 

The operation of cesophagotomy for the removal of impacted 
foreign bodies is now one of universal acceptance. As a legit- 
imate surgical resource, however, it was slow in achieving 
this position, and was received with much distrust and hesita- 



(ESOPHAGOTOMY FOR FOREIGN BODIES IN THE TUBE. 1 99 

tion till within a comparatively recent period, Mr. Arnott, 
surgeon of the Middlesex Hospital, writing in 1833, says: "In- 
cision of the oesophagus for the removal of a foreign body is 
an operation which has rarely been performed. It is stated to 
have been twice executed in France about a century ago, and 
once again lately, but I can find no record of its having been 
done in England." Since the occasions for its performance 
must have been quite as frequent in former times as they are 
at present, it is not quite easy to explain the timidity of good 
and otherwise bold surgeons in regard to this operation. It 
seems likely that the depth of incision in the neck necessary to 
reach the oesophagus, and the important organs among which 
that incision must pass, deterred surgeons from attempting 
oesophagotomy in cases when we should now consider it 
clearly indicated. Perhaps also the facts that the occasions 
for its performance were so rare that no one surgeon could 
ever hope to acquire a large experience in it is a good reason 
why but few had the courage to resort to it. That this is true 
is seen by statistical tables which show that out of eighty-two 
cases, which have been collected up to date, only five men 
have had more than two cases: and, of these five, only two had 
an expe.ience embracing five cases. But probably the most 
potent reason for not doing oesophagotomy was found in the 
illusive hope that the foreign body would be spontaneously 
dislodged. This hope has been, I feel quite sure, encouraged 
by the frequency with which foreign bodies have been spon- 
taneously expelled from the air-passages after a lodgment of 
months and even years. Increasing experience has shown 
that the physical and vital conditions are not the same in the 
two sets of cases. In the air-passages we have an open tube, 
a column of air to act upon the foreign body, and all the 
power of the numerous and strong muscles engaged in the ef- 
fort of forced expiration. If it were not for the spasmodic re- 
sistance of the glottis, every foreign body, not too firmly fixed 
by size or shape, would be easily expelled through the larynx. 
No such provision exists in the oesophagus, and, if the in- 
truder can not be dislodged by forceps or probang, and can 
not be pushed into the stomach, there seem to be hardly any 
means, and, therefore, little hope of spontaneous expulsion 



200 THOMAS M. MARKOE. 

The consequences of such undisturbed lodgment are now un- 
derstood to be disastrous in every case, and fatal in a fright- 
fully large proportion. These consequences are familiar to us 
all, and are yearly illustrated by fatal cases published in the 
journals. One of these was related by Dr. W. T. Bull, at a 
recent meeting of the society, in which a horse-chestnut, lodg- 
ing near the cardiac extremity of the pylorus, had produced a 
perforation of the pleura, which was filled with a mixture of 
various ingesta in a state of decomposition, the lung itself 
being collapsed. Mr. Bryant quotes several cases, one in 
which a fish-bone caused death by perforation of the heart, an- 
other in which the aorta was eroded by a sharp spiculum of 
bone, and another in which fatal inflammation of the spinal 
cord was produced as a consequence of ulceration of the inter- 
vertebral substance following the arrest of a piece of bone in 
the oesophagus. Mr. Bryant also alludes to two cases reported 
by Mr. Erichsen, in one of which a piece of gutta-percha formed 
for itself a bed in the wall of the oesophagus for upward of six 
months, and destroyed hfe by ulceration into a large vessel,and 
consequent hjemorrhage ; and a second in which a fatal result 
was brought about by a half-crown ulcerating its way into the 
aorta. One very interesting case occurred to Mr. Bennett 
May, showing how, even at a period quite long after the origi- 
nal impaction, dangerous results may be apprehended. It oc- 
curred in a child 7 years old, from whom he removed,by oesoph- 
agotomy, a half-penny which had been swallowed three 
years and a half before. It had ulcerated through the oesoph- 
agus and opened the right bronchus, and was lying partly 
in the bronchus and partly in the oesophagus. Mr. May had 
the good fortune to save his patient by his operation. Many 
other fatal results of oesophageal impaction might be cited, 
but, from the cursory glance I have been able to take of the 
literature of the subject, I feel quite sure that it would be diffi- 
cult to find, among all the recorded cases, as many of spon- 
taneous recovery as I have here given as having a fatal issue. 
These considerations explain, at least in part, the slow prog- 
ress of this operation in public favor, and at the same time 
they point out the indications for its performance. Thus it 
may be stated that where a foreign body has lodged in the 



(ESOPHAGOTOMY FOR FOREIGN BODIES IN THE TUBE. 201 

oesophagus, and cannot be removed by forceps or snare from 
the mouth, and can not be pushed into the stomach, it should 
be removed by oesophagotomy, provided it has lodged at a 
point accessible to the surgeon's knife, and that the operation 
should not be delayed in the hope of spontaneous expulsion. 
Of course, before proceeding to so serious an operation, the 
diagnosis should be certain, and this usually presents no diffi- 
culty. The history of the accident, the sensations of the pa- 
tient, the behavior in regard to swallowing, and, above all, the 
positive evidence afforded by the bougie, usually leave no 
doubt in the mind of the surgeon both as to the fact of im- 
paction and of.the precise spot at which it has occurred. It 
should be noted here that external palpation rarely gives any 
assistance in ascertaining the presence of a foreign body 
lodged in the oesophagus. The tube lies so deep behind the 
trachea and below all the muscles of the neck, that the hardest 
and most irregular substances lodged in it can very rarely be 
appreciated by external examination. Of the operation itself, 
nothing needs to be said to this society. The plan of it is sim- 
ple and the execution easy, requiring only delicacy and care- 
fulness in its performance. It should be done on the left side, 
as the oesophagus inclines to that side, and it should be com-, 
menced by a very liberal incision of from four to five inches in 
length, in order to give a chance to conduct the deeper ma- 
nipulations, as far as possible, by the sense of sight. 

It is more particularly to the management of the case after 
operation that I wish to direct the attention of the society. 
Various plans have been suggested by various operators as to 
the two prime points which present themselves to the surgeon 
after he has completed his operation. First, the healing of the 
wound with the least risk of wound complications ; and, second, 
nutrition of the patient, not merely with the view of sustaining 
life, but also of maintaining reparative power at a point at 
which it will prove itself capable of healing a large, deep and 
difficult wound. I feel that it was a failure on my part to ap- 
preciate the importance of this latter point which caused the 
unfortunate result in my first case, and I determined, should 
another case be placed in my hands, that malnutrition should 
not cause its failure if it could be prevented. Of course, it is 



202 THOMAS M. MARKOE. 

understood that swallowing of food in the usual way can not be 
permitted, for the obvious reason that such swallowing would 
prevent the healing of the wounded gullet, would allow the es- 
cape of food in a more or less septic condition into the cavity 
of the wound outside, aud thus inflammatory complications of 
the most serious nature would almost necessarily supervene. 
To maintain the nutrition of the patient, then, either food must 
be transmitted to the stomach by tubes past the wounded 
point of the cesophagus, or else rehance must be had on rectal 
alimentation. Rectal alimentation, however, affords us only a 
limited resource in nutrition. Though it may serve us well 
during temporary interruption of gastric digestion from any 
cause, yet life can not long be sustained by it, and, when sus- 
tained, the nutritive conditions can rarely be kept up to the 
high reparative point necessary for the healing of a large op- 
eration wound. This view of the limitation of rectal alimenta- 
tion has been growing stronger in my mind ever since my at- 
tention was called to the subject by the conspicuous failure to 
secure proper nutrition in the first case I have narrated ; and 
I believe that, if I had fully appreciated just l\ow little reliance 
was to be placed on it, my little patient might have been alive 
and well at this moment. It is true that in this case the condi- 
tions were unfavorable for the passage of a tube through either 
the mouth or the wound. The extensively damaged oesophagus 
made it highly proper to avoid any further injury, if it could in 
any way be avoided, and this must be the explanation, if not 
the justification, of the course pursued. But had I at that time 
the same convictions I now entertain with reference to rectal 
alimentation, I should at all hazards have passed a tube 
through either the mouth or the wound, and thus have secured 
that full reparative nutrition without which, in my case, all re- 
pair broke up at the wound, erysipelas set in, and the patient 
sunk so rapidly that, when a tube was introduced and plentiful 
nourishment was supplied, it came too late to save the life 
which I had been for so many days blindly trusting to a most 
unreliable supporter. 

The management of the second case seems to me to present 
a much better prospect of success. Determined to secure gas- 
tric alimentation, the choice of means lay between introducing 



CESOPHAGOTOAIY FOJ^ FOREIGN BODIES IN THE TUBE. 203 

a tube through the mouth or wound whenever it was necessary 
to give nournishment, or leaving a tube, passed through the 
mouth or wound, constantly in situ, thus permitting nourish- 
ment being given whenever desired. I chose to leave the tube 
in the wound for several reasons. First, I thought that the 
tube would insure the drainage from the bottom of the deep 
wound ; secondly, that it would tend to prevent the entrance of 
any matters regurgitated from the stomach ; and, lastly, I was 
confident that the tube through wound would be much less 
distressing to the patient than a similar tube passed through 
the mouth or the nostril. I entirely rejected the idea of the 
frequent introduction of the tube, because I felt convinced that 
such a procedure would not only seriously disturb the healing 
process, but would be such a dread and a trial to the patient, 
and such a tax on the surgeon, that the result would be that 
the tube would be introduced as rarely as possible, and, when 
introduced, the stomach would be distended with as much 
food as it would hold, in order to prevent the necessity of early 
repetition of the troublesome procedure — a condition of the 
stomach by no means conducive to comfort or to good diges- 
tion. In all these respects the case answered my best expec- 
tations. The tube in the wound coming out through the dress- 
ing was always available for use, and small quantites of nour- 
ishing fluid were constantly supplied by the hands of the 
nurse without pain and without trouble, and without any over- 
taxing or distressing of the digestion ; and regurgitation, which 
rarely occurred, took place through the tube, without at any 
time appearing around or through the dressings. The wound 
was perfectly drained, and granulated healthfully from the be- 
ginning. The change to the nasal tube was made at the end 
of ten days, and this latter was kept in place for a week to al- 
low the wound to fill up solidly with granulations. The healing 
of the wound from this time was rapid and complete. The 
man is not now conscious of any impediment to the act of 
swallowing. 

The results of the operation of oesophagotomy are encour- 
aging. I am indebted to my friend, Dr. S. W. Gross, of Phil- 
adelphia for the following statement, which he very kindly 
gleaned for me from his abundant statistical resources : The 



204 THOMAS M. MARKOE. 

whole number of persons operated upon up to date is 82. Of 
these cases 63 were successful, and 19 followed by death. Of 
the 82 cases the foreign body \yas found and removed in 74, 
and of these 57 recovered and 17 died. The foreign body was 
not found in 7 cases, and in one case it was found but slipped 
into the stomach, and passed per ammi. In one of Bille's cases 
the foreign body slipped into the stomach, and was thence re- 
moved by gastrotomy, the patient dying of peritonitis. In this 
case, of course, the fatal result should not be credited to the 
oesophageal operation. Of the 16 fatal cases of oesophagotomy 
8 are stated to have died of abscess, provoked by the lodg- 
ment of the foreign body, 2 died of exhaustion, 2 of septicae- 
mia, one of pneumonia, and the rest not clearly stated. It 
would be interesting to know the relation of the death-rate to 
the time at which operation was performed alter the impaction. 
I feel certain that delay would be accountable for a very 
greatly increased death-rate. In this connection it may be 
well to call attention to the evil effects of delay, even in those 
cases where the foreign body can be dislodged without oeso- 
phagotomy. In these cases two causes contribute to make 
delay disastrous. First, the tendency of the foreign body, par- 
ticularly if it is hard and rough, to make its way out of the 
tube by ulceration, as illustrated by the first case here re- 
ported, and, secondly, by the contraction of the circular fibres 
of the oesophagus round the intruder, as described in the sec- 
ond case. Both these causes are cumulative in their action, 
and delay, therefore, must be constantly rendering both of 
them more and more efficient for mischief. A good plate 
which to-day can be removed with comparative ease has by to- 
morrow so buried its sharp points in the mucous membrane, 
or is so firmly grasped by muscular contraction, that oesopha- 
gotomy has become the only resource; and the horse-chestnut, 
as in Dr. Bull's case, which, on the day on which it was swal- 
lowed, might easily have been pushed into the stomach, gave 
infinite trouble when attempts were made several days after to 
dislodge it, and finally caused the death of the patient. 

From these considerations I would deduce the surgical rule: 
To attempt the removal of foreign bodies impacted in the 
oesophagus as soon as proper instruments can be procured, 



k 



CESOPHAGOTOMY FOR FOREIGN BODIES IN THE TUBE. 205 

and, failing after a fair and sufficient trial, to proceed at once 
to the operation of oesophagotomy. 

DISCUSSION. 

Dr. Robert Abbe thought an attempt should always be made with 
considerable hope of dislodging the foreign body under ether. The 
past winter he saw a woman twelve days after she had swallowed a 
plate with one tooth which had lodged two inches below the cricoid. 
A great many attempts had been made for a week by two or three 
surgeons to remove it, but without success. Dr. Abbe was able to get 
the coin-catcher behind the foreign body, but, with all the force which 
he dared exert, he failed to dislodge it. The patient was then put 
under the influence of ether, which so relaxed the oesophageal struc- 
tures that, with less force than he had previously exerted, he was en- 
abled to remove the plate. It seemed to him, also, that the oesopha- 
geal wound might safely be closed and the tube be introduced, pro- 
truding from the mouth, from the first. This fact was demonstrated 
in some cases recently reported in EngUsh journals, in which the pa- 
tient tolerated the tube for a number of days with comparative com- 
fort. 

Dr. Markoe said he had not seen the reports referred to by Dr. 
Abbe, but he knew of cases in which that practice had been adopted, 
and the objection to it was that the tube caused a great deal of faucial 
irritation, and it was abandoned. But in his own case the tube, 
being introduced through the wound, gave such comfort that he would 
not think of trying any other method. 

Dr. x\. G. Gerster wished to add his testimony to the advantages of 
the continuous use of the elastic tube for the purpose of alimentation 
as illustrated in three cases. Two were cases of partial extirpation of 
the larynx, in one of which the tube was left in for twelve days, and in 
the other for fourteen days. In one the tube projected through the 
wound made by removing one half of the larynx, and was borne so 
well, and enabled ahmentation to be carried to such an extent that 
the patient mcreased very rapidly in weight. In the third case, in 
which the entire tongue and floor of the mouth down to the epiglottis 
and middle portion of the inferior maxilla were removed, and degluti- 
tion was out of the question, the tube was still in (the sixteenth day 
after the operation), and alimentation was kept up with a great deal of 
comfort to the patient. In this case a strong fillet of silk was passed 
through the stump of the tongue in order that the subsequent intro- 
duction of the tube might be facilitated by pulling the stump forward ; 



206 THOMAS M. MARKOE. 

but when the tube was removed on the fifth day, and an attempt was 
made to feed the patient in the afternoon, it caused so much excite- 
ment that the tube was replaced and food was introduced as before. 
He was anxious to remove the tube, as it was of English make, hard 
and webbed, and was liable, by pressure of the calcareous tracheal 
rings, to produce a sore. But such an effect did not take place. The 
tube was removed once in three or four days for the purpose of clean- 
sing and replacing it by a new one if it had become rough. By nour- 
ishing the patient through the oesophageal tube they had been enabled 
to carry him through an attack of catarrhal pneumonia which devel- 
oped the third day after the operation. 

Dr. F. Lange performed oesophagotomy last summer at the German 
Hospital upon a man about 40 years of age who had swallowed a plate 
with several teeth some time before admission, but exactly how long 
he could not recall. Previous to admission, some surgeons had made 
ineffectual attempts to withdraw the foreign body, which was situated 
near the entrance to the stomach. Dr. Lange failed under ansethesia 
and then performed oesophagotomy, thinking he would thus be enabled 
to get a safer grasp on the foreign body. He was, however, still un- 
able to extract it, or to push it down, until finally it went down into 
the stomach under very slight pressure. The further fate of the for- 
eign body was unknown ; the man was discharged after some weeks, 
cured, and had not been heard of since. With regard to the treatment 
of the wound, he closed the walls of the oesophagus with catgut, in- 
serted only a few sutures in the external wound, leaving it partially 
open and making free drainage. The man swallowed from the begin- 
ning, the first days receiving only small quantities of water and milk 
administered cautiously. Primary union took place, the wound closing 
quickly. Dr. Lange thought such treatment would be justified in 
cases in which the tissue at the oesophageal opening was healthy ; he 
did not know that it would be proper if suppuration had taken place 
at the point of operative interference. In this case the treatment was 
quite satisfactory ; no food appeared at the external wound. 

Dr. Markoe said that success depended entirely upon closure of 
the oesophageal wound, and, if this could be secured, the method 
adopted by Dr. Lange was undoubtedly the best. But, if union failed 
to take place at any point in the line of incision, septic material would 
be likely to enter it, especially during the act of swallowing food. More 
recent writers, he believed, were almost unanimously of the opinion 
that the wound should not be closed. 

The President remarked that, in the case of the child whose history 
Dr. Markoe had related, it would have been very unwise to close the 



(ES OF HA GOTO MY FOR FOREIGN BODIES IN THE TUBE. 20/ 

oesophagus and allow the child to swallow at once, as it would have 
forced the food into the lacerated tissue on the right side of the oeso- 
phagus. 

Dr . J. C. Hutchinson thought that, when it became necessary to 
introduce the oesophageal tube to nourish a patient, it would be much 
more convenient to the surgeon, and more comfortable to the patient, 
to introduce it through the nose. Such had been his experience after 
extirpation of the tongue, and in other cases. He had observed the 
same difficulty referred to by the author of the paper when the tube 
was introduced through the mouth — namely, faucial irritation. He 
employed the tube for as long a time as fifteen days, taking it out now 
and then to cleanse it, and substituting a new one if it became rough- 
ened. 



EDITORIAL ARTICLES. 



ON TUMORS OF THE URINARY BLADDER AND THEIR 
TREATMENT. 

In one of the recent numbers of Volkmann's Collection of Clinical 
Lectures,^ this subject is treated at length by Prof. Ernst Kuster, of 
Berlin. Until comparatively recently Httle has been known of the pa- 
thology and therapy of tumors of the urinary bladder, although many 
writers, some as early as the seventeenth century, have recorded their 
observations on this malady. At the beginning of the present century, 
A. G. Richter (1802) and Sommering (1809) published treatises on 
the maUgnant diseases of the bladder. Lateral lithotomy was kno^\^l 
to them, and although seldom recommended, was conceded to afford 
the only reasonably sure, means for diagnostic and therapeutic pur- 
poses. A considerable advance was made by Civiale, in 1842, who 
distinguished two forms of tumors of the bladder, namely the fungous 
and the carcinoma, the latter of which he considered very rare. Pod- 
razki (1865), on the contrary, regards the carcinoma as the most fre- 
quent of all tumors of this organ. Civiale was opposed to both supra- 
pubic and lateral cystotomy and Podrazki did not recommend them 
either. 

The uncertainty of the diagnosis made all methods of operating ap- 
pear extremely dangerous. Progress in the right direction could only 
be made by an increase of our diagnostic resources, and the merit of 
having to a very large extent aided in this advance, belongs unques- 
tionably to G. Simon, who, in 1875, first demonstrated that the female 
urethra is capable of very great dilatation by mechanical means, thus 
rendering the whole interior of the bladder more or less accessible to 
both diagnostic and therapeutic measures. The method was after- 

• No. 269-268. (Chirurgie N. 84.) 

(208) 



TUMORS OF THE URINAR Y BLADDER. 20g 

wards adopted for operations in the male urethra and bladder by R. 
Volkmann, at first m cases of vesical calculi, a year later for the diag- 
nosis of a large myoma of the bladder. Simon's method, however, 
came into general use only after it had been perfected by Sir Henry 
Thompson in 1880-1882. 

Unfortunately the development of the pathological anatomy of these 
parts has not kept equal pace with that of our therapeutic means, and 
we are still far from possessing adequate knowledge of the pathology 
of these tumors. 

Neoplasms of the bladder develop as primary growths, they extend 
to it from other neighboring organs, or appear there through metastasis 
from neoplasms in remotely situated organs. The two latter forms of 
development belong exclusively to malignant growths, and have, con- 
sequently, but a limited interest for the surgeon. The primary tumors 
are found in the female only in the wall of the bladder, but in the male 
subject also in the prostate gland. These latter are clinically seldom 
distinguishable from the former, both producing about the same symp- 
toms, etc., and must be considered here as belonging to the subject 
before us. 

The author gives us the following classification of tumors of the 
urinary bladder : 

A. Neoplasms of the Prostate. — i. Fibt-o-adenoma (Klebs) ; 2, 
Myoma; 3, Carcinoma. 

B. Neoplasms of the Bladder-wall. — I. Neoplasms arising from 
the mucous or submucous connective tissue. 

I. Papillo7}ia (Kramer), Fibroma papillare (Virchow). This is by 
far the most frequent of all tumor-forms of the bladder, and appears 
singly or in groups. As single growths they are more often met with 
in the fundus, then in the trigonum and lastly in the lateral walls of 
the bladder near the orifices of the ureters. Oaly very rarely have 
they been found in other parts of the bladder, and then mostly in 
groups, several small ones clustering atound one large polyp. Kiister 
gives us an elaborate description of these papilloma groups, their mi- 
croscopical appearance, etc. Thompson has described a transition 
form of papilloma, i. e. to a malignant growth, and which, he says, is 
characterized by its rich vascularity and cell-infiltration in the tissues 



2IO EDITORIAL ARTICLES 

about its base. This latter is without doubt owing to inflammatory ir- 
ritation, however. The viUi are very deHcately constructed, the cur- 
rent of the urine during micturition being of sufficient strength to tear 
them off and causing, consequently, frequent haemorrhages. The deli- 
cate construction oi the inadequately supported walls of the blood-ves- 
sels in these vilU are often also the cause of haemorrhages. Every con- 
traction of the bladder-muscles must compress the blood vessels at the 
base of the villi, producing, consequently, hyperaemia of these, and lead- 
ing easily to the rupture of blood-vessels. These formations, by be- 
coming incrusted w ith the urinal salts, may deceive one as to their real 
nature, as they are often taken tor vesical calculi. Papilloma are more 
frequently met with in males than in females. Among 15 cases re- 
ported by Thompson, there were but two women, and in Sperling's 42 
cases 29 were males. This great difference is no doubt owing to the 
frequent irritation to which the mucous membrane of the bladder is ex- 
posed in males, by the extension of inflammatory processes from the 
urethra, etc., also to the greater difficulty in urinating in men of mid- 
dle age. Supporting this latter theory we find that most cases are be- 
tween the ages of 30 and 60 years, seldom earlier. 

2. Fibrous Polypi and Myxoma. — These are tongue-like or bulb- 
shaped formations and are found in the region of the neck of the blad- 
der and its base, not in groups as the papilloma, but spread out, as it 
were, over an extent of the mucous surface. These growths seldom 
cause haemorrhages, on account of their rather tough structure, and are 
found mostly in children. 

3. Sarcoma. — Very rarely seen, but five cases having been thorough- 
ly described and recorded, namely by Senftleben, Marchand, Siewert, 
Heim-Vogtlin, and Schlegtendal. Other less careful observations 
have been made by Head, Hue, Thornton and Sokolow. The greater 
number are found in female subjects, also a]l of the first mentioned 
five cases. 

11. Neoplasms arising from the muscular layer of the bladder. 

4. Myoma. — The first case recorded is one of Rob. Knox in 1862. 
Others, as A. R. Jackson, Gersuny, and Gussenbauer have observed 
this form of neoplasm, but Volkmann, in 1876, was the first who 
thoroughly described a case of undoubted myoma of the bladder. The 



TUMORS OF THE URINARY BLADDER. 211 

tumor was situated at a considerable space away from the prostate, 
which excludes the possibility of its having been in any way connected 
with the latter, a doubt evidently existing in all cases pubUshed prior 
to this. Since then a few new cases have been recorded. Belfield 
(1881) found a myoma of the bladder in two dead subjects, by acci- 
dent. The structure of these tumors resembles in most points very 
closely that ot uterine myoma. 

III. Neoplasms of the epithelium and glandular structures of the 
bladder. 

5. Adenoma. 

6. Carcinoma. — Clinically carcinomata of the bladder are not dis- 
tinguishable from those of the prostate, so that the latter will have to 
be considered in this group. Careful study only of the microscopical 
structure will reveal the real starting-point of the tumor. This latter 
is of importance not only from a pathological-anatomical standpoint, 
but also as regards the diagnosis and the therapeutic measures to be 
undertaken. As the author justly remarks, it would be of vast impor- 
tance if Klebs' assertion proved true, according to which, namely, all 
carcinomata of the bladder originate in the prostate gland, consequently 
a primary tumor found in the fundus of the bladder in a female sub- 
ject, could not possibly be a carcinoma. When these neoplasms ap- 
pear in the region of the neck of the bladder in male subjects, suspic- 
ion as to their origin would be excited. Although, doubtless, many of 
those cases described as carcinoma of the bladder, have really origi- 
nated in the prostate, it cannot be denied, on the other hand, that carci- 
noma of the bladder itself does occur, developing.in the epithehum of 
that organ. It would be, says Kuster, very remarkable if the epithe- 
Hum on a mucous surface so frequently exposed to irritations, etc., 
should differ so entirely in that respect from other mucous membranes 
of the body. Bode's treatise on the subject (1884) shows that pri- 
mary carcinomata of the bladder in women are not so very rare, as we 
find among the 30 cases collected in his report, 14 females. The form 
of carcinoma most frequently met with here is the pa|)illary, although 
the medullary form is not seldom seen, cases of the latter having been 
recorded by Marchand and others. The cancroid- form has been often 
observed by Thiersch, Paget, Winckel, and Thompson, aud the aiveo- 



212 EDITORIAL ARTICLES. 

lar carcinoma, with its singular tendency to colloid degeneration is also 
occasionally found. All these forms of carcinoma, including also the 
glandular form occuring in the prostate, develop first as flat circular 
protuberances on the mucous surface or as more deeply lying lumps 
with a smooth surface, immovable over the tumor. Various changes 
m their appearance soon occur, in consequence of the irritation to 
which they are more or less exposed. Haemorrhages soon follow, but 
in many cases precede the development of a cancer. The surface 
epitheHum becomes necrotic and falls off, allowing the urine to come 
directly into contact with the badly nourished cancer-body which is 
prone to regressive metamorphosis. Putrid decomposition of the urine 
follows, producing rapid necrosis of larger or smaller portions of the 
tumor, keeping the former, in spite of frequent micturition, in a de- 
composed state. Catarrh of the bladder is the result and the hyper- 
gemic mucous membrane is consequently prone to haemorrhages. The 
muscular layer of the bladder is soon attacked, its h5'pertrophied con- 
dition, however, generally preventing rapid perforation. Through ex- 
tension of the purulent inflammation upwards the kidneys become in- 
volved, and death soon intervenes, ending the sufterings of the pa- 
tient. 

7. Derrnoid Cysts. — They are found both as open and closed sacs. 
Martini, in 1874, pubUshed his observations on one of the latter, found 
in a newly-born male child. The bladder was closed near the urethra, 
the urine having been passed through the umbilicus. No anus ex- 
isted, a communication with the intestine, however, being found. The 
posterior half of the bladder consisted of a portion of cutis covered with 
hairs." Thompson records a case of open dermoid cyst in a woman 30 
years of age. 

Regarding the retiology of tumors of the urinary bladder, Kuster 
states nothing of much importance, beyond what is generally known. 
Foetal predisposition here as elsewhere in the body, has undoubtedly 
much to do with the development of these neoplasms, as has further- 
more pathological irritation. Gonorrhoea of long standing, hypertrophy 
of the prostate causing stagnation of part of the bladder-contents, 
hthiasis of long duration, etc., are all causative influences of this state 
0' irritation. Concerning the statistics of tumors of the urinary blad- 



Ti MORS OF THE URINAR\ BLADDER. 21 3 

we find that, from May, 1871, to January, 1885, of 8,139 cases treated 
in the surgical department of the Augusta Hospital in Berlin, 305 had 
diseases of the urinary passages = 3.74 7f- Among the latter were 
10 cases with tumors of the bladder, /. e., 0.12% of the number ad- 
mitted, or 3.25^ of those afflicted with diseases of the urinary pas- 
sages. 

Of further interest is the fact, that during the same period 1,308 
patients with tumors were admitted, the 10 with tumors of the bladder 
making, therefore, 0.76% of this whole number. Gurlt pubUshed, in 
1880, statistics of 16,637 cases of tumors, collected from the reports of 
three large Vienna Hospitals. In 66 cases of this number, the bladder 
was the seat of disease, = 0.39%. Regarding the sex of those affected 
with this trouble, we find that in Gurlt's 66 cases, 46 were males, 20 
females; in Sperling's 114 cases, 78 were males, 36 females; in 
Thompson's 20 cases, 18 were males, 2 females. Willy Meyer gives 2 
cases, both males ; Pousson 35 cases, of which 15 were males, 20 fe- 
males; and finally 11 ofKuster's 12 cases were males. This would 
make a total of 249 cases, 170 of which were males, and 79 females. 

Tumors of the urinary bladder develop in very many cases without 
marked symptoms. Their existence will be suspected, when bloody 
urine is suddenly passed by an individual, until then to all appear- 
ances perfectly healthy. These hjemorrhages, however, must be dis- 
tinguished from those caused by other lesions in the urinary tract. 

In haemorrhages from the kidneys the urine is generally evenly mixed 
with blood, but this may also be the case when shght haemorrhages 
of the bladder have taken place and the blood retained long enough 
to have become diffused in the urine. It is otherwise in cases of tu- 
mors of the bladder, at least in the earher stages of their development. 
In micturition the stream of urine is at first quite clear, becoming 
gradually bloody and consisting finally of apparently quite pure 
blood. 

A second very important symptom is the passing of particles of the 
neoplasm with the urine. This takes place at times to quite an aston- 
ishing degree, surprisingly large quantities being passed within a short 
time. From a microscopical examination of these particles a diagno- 
sis of the existence and character of a tumor may be made. Other 



2 14 EDITORIAL ARTICLES. 

symptoms consist in disturbances in urinating, and pain, in some cases, 
intense ; in others, however, very shght. The patients complain fre- 
quently of a heavy, bearing-down sensation in the perineal region, and 
of a frequent desire to stool. Catarrh of the bladder is never absent 
in the long course of the disease, adding much to the general discom- 
fort of the patient by the accompanying chills and high fever. 

The general form and consistency of a tumor of the bladder may be 
usually determined by palpation above the symphysis and through the 
rectum, in women through the vagina. The introduction of instru- 
ments should be undertaken witli care, as catarrh often results from 
this procedure. Thorough disinfection of the catheters, etc., used 
with a 5 % solution of carbohc acid is advisable ; also a careful cleans- 
ing of the glans penis and orifice of the urethra in both men and 
women, before introducing any instruments. The author employs a 
catheter of his own construction, having a long opening near its ex- 
tremity on the under side. He uses this like a scoop, pulling off por- 
tions of the neoplasm for microscopical examination. 

Haemorrhage should not be feared, from its use, as it is slight if it 
occurs at all. A further means of diagnostic value is endoscopy of 
the bladder or cystoscopy, of which there are two methods. By the 
one, the older method, the light is directed from without, through suit- 
able tubes into the bladder (Desormeaux, Griinfeld). In the other 
method, the source of light (a platinum wire kept glowing by means of 
an electric current) is carried directly into the bladder. Of all methods 
of examination, however, the most important is the digital exploration, 
for the knowledge of which we are indebted to Simon's method of dil- 
atation of the female urethra mentioned above. The introduction of 
the finger into the bladder in females, after dilatation of the urethra has 
been accompHshed, presents no great difiiculty, but in males the case 
is different. We are obUged here to oi)en the urethra in the membra- 
nous portion and dilate the prostatic portion so as to pass the finger 
into the bladder. Some operators, as Volkmann, use the finger as a 
dilator instead of the instruments constructed for that purpose. The 
author used Simon's specula, modified somewhat. Although palpa- 
tion is without doubt our best means of examination, still even this at 
times misleads us. Kiister gives the history of a case where the con- 



TUMORS OF THE URINARY BLADDER. 215 

cenlrically hypertrophied bladder-wall led him to believe in the pres- 
ence of a carcinoma, the autopsy, however, showing the case to have 
been one of purulent cystitis. The irregular fossae between the tra- 
becula gave the feeling of a deep irregular destruction of the tissues. 

If we take a retrospective view of all the diagnostic means at our 
disposal, we shall see that no single one of these is in itself sufficient to 
enlighten us completely as to the nature of the trouble, in all cases, 
but that a combination of several will be necessary for this purpose. 

Since benignant neoplasms in the bladder, with hardly an excep- 
tion, threaten the existence of the patient, their removal is therefore 
desirable. Tumors attached by means of thin pedicles are removed in 
various ways. Volkmann twisted the tumor in one case ; Kocher uses 
a scoop, passing it into the bladder along with the finger. Thompson 
advises, in cases where the pedicle is thick and large, to tear it away or 
bite it off with the forceps. For this purpose he has constructed a 
forceps with denticulated edges, similar to those used for the extrac- 
tion of stones from the bladder. The use of the instrument requires 
the greatest care, the danger of injury to other parts being considera- 
ble. At times it will be possible to draw down the tumor (especially 
in female patients), far enough to get a clear view of the point of its 
attachment to the bladder, when it can be easily removed by the knife 
and the bladder walls closed with sutures, thus effectually preventing 
haemorrhage. When the tumor is favorably situated, this procedure 
may be successfully carried out in males by dilating the urethra in the 
prostatic portion alter the incision in the median Une. 

If this manner of removal is not possible, either on account of the 
large size or position of the tumor, the bladder must be opened above 
the symphysis, in females also through the vagina. 

Colpocystotomy was first recommended and improved by Simon, 
but his method seems never to have found many followers. The au- 
thor gives but three cases where tumors were removed in this manner, 
one of Kaltenbach, a second of Lindemann, the third of Schlegtendal. 

Epicystotomy is without doubt the best of all methods of removal 
in both sexes, and gives the most complete survey of the interior of 
the bladder. Until recently the development of this operation has 
been rather retarded, owing principally to the fear of injuring the per- 



2l6 



EDITORIAL ARTICLES. 



itoneum during the operation, and to producing infiltration of urine in 
the perivesical tissues. 

To avoid the former of these dangers, the bladder should be filled 
with some antiseptic fluid before the operation, or the incision should be 
made slowly and carefully, the tissues being divided layer by layer. 
Petersen fills the bladder with 400 to 600 grammes of some antiseptic 
fluid, and introduces a colpeurynter containing some 400 grammes of 
waimtd fluid into the rectum. By this latter means the bladder is 
forced up over the edge of the symphysis, rendering injury to the per- 
itoneum almost impossible. Infiltration of the urine into the surroimd- 
ing tissues will take place only when the urine is allowed to collect in 
large quantities in the bladder and flow out through the wound. This 
is best prevented by drainage, a good manner of accomplishing which 
is to pass a rubber tube, having lateral apertures through the wound 
and out through the urethra ; at the same time plugging up the abdom- 
inal wound with pieces of iodoform mull. Guyon uses the thermo- 
cautery for removing the neoplasms of the bladder, cauterizing the 
wound-surface afterwards. The author, however, does not recommend 
this method, especially in cases of larger growths, as the wound thus 
left win be long in heaflng and a constant cause of catarrh. He prefers 
an eUiptical cut around the tumor, uniting the edges afterwards with 
catgut sutures. 

For the extirpation of deep seated tumors, in the fundus or trigonum, 
Trendelenburg's method for directing the light onto the field of op- 
eration may be employed with advantage. This consists in suspend- 
ing the patient, head downwards, by his legs over the back of an at- 
tendant and turned towards the light, so that the latter shines directly 
into the bladder when the wound-edges are separated. The bladder 
and intestines sink downwards and parts hidden behind the symphysis 
come into view._^ 

Of vast importance for the operation and after-treatnient would be 
the possibility of keeping the bladder free from urine during this whole 
period. This would only be possible by introducing catheters into the 
ureters and allowing them to remain there for a considerable space of 
time. That such a procedure may be carried out without grave re- 
sults, we ha\e seen in a case of Schede, where the catheter remained 



BA C TERIAL S CIENCE IN ITS S UR GICAL RELA TIONS. 2 1 7 

in the ureter for seven days. By properly illuminating the interior of 
the bladder, the openings of the ureters are easily seen and the intro- 
duction of instruments not difficult. The author uses for this purpose 
thin, elastic bougies, as he considers the use of Simon"s metal catheters 
too dangerous. 

The treatment of malignant tumors of the urinary bladder has con- 
sisted for the main part, until the present, in scraping away portions of 
them and cauterizing the surface in order to retard, if possible, their 
rai)id growth. 

Radical treatment has been only undertaken in cases where the car- 
cinoma was favorably situated, for example, on the anterior wall of the 
bladder. Successful operations for carcinoma in other parts of the 
bladder should not be considered impossible, if the hmits of the mu- 
cous membrane have not been passed, for which, of course, an early 
diagnosis of the disease will be necessary. 

In conclusion, Kiister thinks that the therapy of tumors of 
the bladder, far from being so hopeless as formerly thought, has 
improved so much that the larger number of those suffering from this 
terrible malady may be almost definitely cured by a timely and proper 
operation. C. J. Colles. 



ON THE PRESENT STATE OF KNOWLEDGE IN BACTERIAL 
SCIENCE IN ITS SURGICAL RELATIONS. 

(Concluded from page 150). 

Actinomycosis — Anthrax — Glanders. 

The study of those branches of bacteriology which have direct bear- 
ing upon veterinary surgery and public economy has borne more prac- 
tical fruit than any other department of the science, leading, as it has 
done, to an early and comparatively complete knowledge of certain 
zoonotics, as instanced, at least in Europe, by the successful enforce- 
ment of pubhc and private measures by legislative bodies and cattle - 
farmers for the purpose of preventing the occurrence and spread of 
such diseases. And out of these investigations, of such practical value 



21^ EDITORIAL ARTICLES. 

to veterinary surgery, a material advance in our theoretical knowledge 
of those surgical infectious diseases in man has sprung, which owe their 
origin to contagions contracted from and generally restricted to the 
lower animals. 

Although our knowledge of these diseases appears merely in the 
light of a side-issue of veterinary bacteriology (a subject which we can- 
not here enter upon), and has received but relatively little advance- 
ment by the most recent investigations, the diseases themselves still 
offer sufficient interest — an interest even enhanced by the comparative 
rarity of their occurrence — to deserve a brief consideration in these 
pages. 

Of the diseases referred to, actinomycosis is still the most obscure. 
The general impression is that it is very rare ; but it is unquestionably 
often not recognized, when present, and it is probable that it would be 
more frequently diagnosed, if the disease were better known. 

Pathologically considered the disease in its early stages, manifests 
itself by the appearance of a soft whitish tumor frequently situated 
on the lower jaw or in front of the spinal column, and connected with 
the bone. A section through the tumor shows a great number of 
softer foci of the color of sulphur,which stand well out against the more 
reddish ground. 

In the course of time the tumor breaks down and an abscess is 
formed. The pus vented by incision or spontaneous ulceration con- 
tains numbers of sulphur-yellow mihary bodies of soft consistence and 
fatty feel, which are frequently united together in clusters resembling 
mulberries. By pressure these clusters are easily separated into their 
elements, which prove, when viewed under the microscope, to consist 
of inter-twined fungus-mycelia, the single threads of which appear 
radially arranged around their centers, each one increasing in diame- 
ter towards the periphery, where they present bulbous termini. Inoc- 
ulation experiments prove these fungus masses to be the cause of the 
disease; hence the name. A proper classification of the parasite, how- 
ever, has not yet been accomphshed, the probabilities being that it be- 
longs to the class of fungi proper. 

Actinomyces in man were first described by Lebert,"' but were not 

'Traite d'anatomie pathologique I. p. 54, 1S57. Referred to by Firkeit. 1. c 



BACTERIA L SCIENCE IN ITS S UR GICAL RELA TIONS. 2 1 9 

recognized as parasites until Bollinger published his celebrated patho- 
logical treatise on the subject twenty years later. The etiology of the 
disease is still quite obscure, although the frequency of the disease in 
oxen has often suggested the possibility of infection by the consump- 
tion of raw beef — a supposition which would account for the greater 
comparative rarity of the disease in England and this country. ' 

The localization of the disease in man may be various. James 
Israel in his monograph of the disease, in which he gives an account 
of 38 cases/ divides all cases into four classes ; (i) those in which the 
parasite gains entrance through a carious tooth or a wound in the oral 
cavity, and leads to an affection of the jaw ; (2) those that present af- 
fections of the respiratory tract — which frequendy spread to the pleurae 
and spinal column ; (3) those in which the intestinal canal is primarily 
affected ; and (4) those of doubtful origin. Cases of actinomycosis of 
the Fallopian tubes spreading to the peritoneum have Hkewise been re- 
ported' suggesting an entrance through the genital tract. 

In 1884 O. Israel claimed to have cultivated actinomyces in pure 
cultures on ox-blood serum,- and stated that their growth was slow. 
This latter statement would very well correspond with the chnical as- 
pects of the disease, which shows the active suppurative processes to 
be much more sluggish even than in tuberculous disease.^ But the 
description of the cultures so lacks completeness and lucidity, that his 
statements have not been generally accepted by bacteriologists. Other 
culture experiments v.^ere commenced by Jahne,* but were never en 
tirely completed. To the knowledge of the present writer no satisfac- 
tory cultures of the fungus have been pubUshed up to the present 
time. 

Inoculations with the actinomyces-germs have been successfully per- 
formed by Ponfick,'^ Jahne," and J. Israel.' 

^Zemann. Ueber die Actinomycose des Bauchfells u. der Baucheingeweide beim 
Menschen, Wien. Med. Jahrb. 1883, p. 477. 

2 Ueber die Cultivirbarkeit des Actinomyces. Virch. Arch Vol. 95. 1884. 

3 Firkert. L' Actinomycose de I'homme et des animaux. Paris. Felix Alcan. 
1884. 

*Deutsch. Zeitschr. f. Thiermed. 1881. Vol. 7, p. 155. 
^Die Actinomycose. Berlin. Hirschwald. 1881. 
eCentralbl. f. d. med. Wiss. 1880. No. <^S 
^Berlin Med. Society. 13 June. 18S3. 



220 EDITORIAL ARTiCLES 

Staining ot the actinomyces can be effected by any aniline dye, in 
the same manner as that of ordinary fungi. The staining will, how- 
ever, again wash out in water. Pilocarmin stains them yellow. In 
sections they may be stained a different color from the surrounding 
tissues with the help of aniHne dyes, or the sections may be colored in 
Orseille for one hour, washed off in alcohol and then stained with gen- 
tian violet (Weigert).^ 

Recent cases of the disease have been published by Zemann- (5 
cases), Chiari,'* Middeldorpff^ (2 cases), Muller^ and Magnussen" (4 
cases), and, in England, by Treves" and Schattock.- 

The prognosis of the disease is generally unfavorable, if the infection 
has in any way spread. Timely surgical interference may effect a cure. 
Not less than thirteen cases of recovery have been reported. The 
treatment consists in incision of the abscess and scrapmg-out of the 
cavity. The affection is frequently taken for scrofulous disease. 

Anthrax, or malignant pustule, as the disease is clinically called in 
its surgical aspect — charbon, splenic fever, wool-sorter's disease and 
intestinal mycosis being other synonymes — has always been of great 
interest to bacteriologists for the reason that it was the first mycotic 
disease discovered in man, and one, owing to the extreme facility of 
cultivating the virus, which was especially adapted for inoculation and 
disinfection experiments. 

The bacilli of anthrax, when in contact with a suitable soil, such as 
potato-sHces, gelatine, roots o( plants, alkaline urine, or various neutral 
infusions,and at a temperature of 36^ C.,soon grow to long filaments in 
which, after a short time, small oval transparent bodies appear at reg- 



Wirchow's Archives. 1881. Vol. 84, p. 245. 

2L. c 

■'Ueber primiire Dann-actinomycose des Menschen. Prag. Med. Woch. Schr. 
1884. No. 10. 

*Ein Beitrag zwx Kenntniss der Actinomycose Deutsch. Med. Woch. schr. 1884. 
Nos. 15 and 16. 

^P. Brans. Mittheihingen a is der chir. Klinik. zu Tubingen. Tubingen 1884. 
H. Laupp. (3 Heft). 

^Beitrage zur Diagnostik u. Casuistik der Actinomycose. Dissertation. Kiel. 
1885. 

'Lancet Vol. I. 1884, p. 107. 

SLancet. Vol.1. 1885, p. 808. 



BA C TERIAL S CIEN CE IN ITS S UR GICAL RELA TIONS. 2 2 I 

ular intervals, which refract the Ught in a greater degree than the sur- 
rounding parts and survive long after the original filaments have be- 
come destroyed. These oval bodies are the spores and again develop 
under suitable circumstances into bacilU. When treated with chem- 
icals they prove very resistant ; so much so, in fact, that it is very gen- 
erally assumed that any line of treatment which suffices to destroy the 
vitality of anthrax spores, is more than sufficient to kill all other germs 
which threaten interference in the treatment of wounds. 

The manner of testing the efficacy of antiseptic solutions with 
anthrax spores is very simple. Silk threads are impregnated with an- 
thrax-bacilli in cultures, and, when the spores are formed are dried. The 
chemical substance to be tested is mixed with the culture soil in any 
given proportion, and a prepared thread is laid upon it. In this man- 
ner it was shown by Koch that corrosive subhmate-solution, of the 
strength of i in 20,000 sufficed to kill the anthrax-spores ; a solution 
containing one part in 300,000 parts of soil served to exert an inhibi- 
tory influence upon their development ; that is to say the spores could 
not develop as long as they remain in contact with this soil ; but they 
were not killed, for on being properly washed off with steriUzed water 
and transferred to other soils not disinfected, they readily developed. 
These questions have been made the subject of experiment, and papers 
by Frank 1 and Perroncito,^ the former studying the effect of antiseptics 
upon anthrax after Koch, from whose results in regard to figures he 
frequently deviates — and the latter extending his researches to the ef- 
fect of heat and disinfection upon the germs. 

Introduced into the blood of man or animals the bacilli do not form 
spores by means of long filaments, but multiply by division in such a 
manner that the bloodvessels, in the course of a few hours, become 
crowded with bacilli and death ensues. 

The discovery of the nature of the disease is connected with the 
names of PoUender,-' Branell ^ and Davaine.^ 

1 Ueber die Wirkung einiger Antiseptica auf das Milzbrand contagium. Inaug. 
Dissertat. Dorpat. 1883. 

-Ueber die Tenacitat des Milzbrand virus in seinen beiden Gestalten als Spore und 
Bacillus Anthracis. Revue fiir Thierheilk. 1883, No. n. 

•^ Vierteljahr. f. ger. Med. Vol. 8. 1885. 

* Virchow's Arch. Vol.14. 1858. 

^Compt. rend. Vol.57. 1863 ; vol. 77. 1873. 



222 EDITORIAL ARTICLES. 

More recent descriptions have been furnished by Koch, who thor- 
oughly investigated the disease in various series of experimental re- 
searches,^ and extended his experiments to the question of attenua- 
tion of the cultures. 

Following out Pasteur's discovery that certain cultures of a germ 
producing cholera in chickens, might be so treated that the virus be- 
comes attenuated, and not only fails to produce the disease when inoc- 
ulated, but acts in a manner preventive of subsequent infections, anal- 
ogous to vaccination for the prevention of small-pox, Toussaint ^ was 
able in like manner to attenuate cultures of anthrax by subjecting 
them- to heat of 55° C. for a space of ten minutes. And Pasteur him- 
self subsequently found that if the anthrax-bacilH were cultivated 
throughout at a temperature ranging from 42° to 43° C. the organisms 
became attenuated and could be employed for preventive vaccina- 
tion.^ 

Koch, in his answer * to Pasteur, afterwards proved that these state- 
ments needed to be somewhat restricted, and showed that immunity 
from the disease could be obtained in this manner only in sheep and 
oxen, and that other animals as well as man could not be benefited by 
such vaccination methods. The material used for vaccination (^'sec- 
ond vaccifie") was, moreover, by no means harmless and caused the 
death of 10 to 15 per cent, of the healthy animals ; nor did such vac- 
cination ensure immunity from spontaneous infection — the usual 
means of acquiring splenic fever through spores taken into the intes- 
tinal tract with the fodder — but only against artificial inoculation. 

These objections which banished the hope of the use of vaccination 
methods in the surgical treatment of human anthrax, Pasteur could not 
refute, his answer being restricted to vindicating his personal scientific 
position and achievements, which Koch had never intended to im- 
peach ; although he had criticised his methods of inoculating with se- 

iC^/^«'j Beitrage zur Biologic der Pfl., p. 277. Mittheil. a. d. Kais. Ges-Amt. 
Vol. I, p. 49- 

2Recherches experim. sur la maladie charbonneuse. Paris. 1879. 

» Bull, de 1' Acad. 1880. 28. Compt. rend. Vol.92. i88i,etc. 

* Ueber die Milzbrand impfung; eine entgegnung auf den von Pasteur in Genf ge- 
haltenen Vortrag. Cassel und Berlin. 1882. 



BA C TERIAL S CIENCE IN ITS S UR Gi CAL RE LA TIONS. 223 

cretions from the mouth and nose, which abound in micro-organisms, 
instead of using pure cultures. 

The correctness of Pasteur's principle in protecting sheep from 
charbon by vaccination was fully conceded by German bacteriologists.^ 
The duration of acquired immunity of the disease by inoculation is 
given by Fetz at seventeen to eighteen months for rabbits.^ An ex- 
periment of Buchner's,' who believed he could change anthrax bacilH 
into another species of innocuous germs, the so-called bacilli of hay- 
infusion, was refuted by Koch, and it was proved that he had simply 
produced an attenuated form. Other methods of attenuation were 
subsequently published by A. Chauveau * and Chamberland and Roux,^ 
but since these and further publications are only of a veterinary inter- 
est, we may, for the present, pass them over. 

A further proof of the advancement of our knowledge of anthrax 
over that of other species of bacteria is to be found in the extensive 
chemical analytical researches conducted with anthrax — a step, as has 
been before remarked, well calculated to further develop our under- 
standing of the etiology of parasitic diseases. 

Neucki '' chemically analyzed cultures of anthrax spores, and found 
that the albumen of which they are constituted differed from that of 
putrefactive germs, in that it was not soluble in acids, but only in al- 
kahes, while the other was soluble both in w^ater, alkalies and dilute 
acids. Neither contains sulphur. 

Szpilmann found that ozone killed putrefactive bacteria, but did not 
differ from oxygen in its action upon anthrax-bacilli — a fact which has 
been adduced to explain the morbific action of the germs. 



1 Koch, Gaffky and Loeffler. Experimentelle Sludien iiber die Kiinstl. Ab- 
schewachung der Milzbrandbacillen, etc. Mittheil. a. d. Kais. Ges. Amt. Vol. II, p. 
141. 1884. 

^ Acad, des sciences de Paris. Seance du 4 Aout. 1884. 

^ Ueber die experim. Erzengung des Mikbrand contag. aus den Hupilzen. Munich. 
1880. Die Umwandlung der Milzbrand bacillen in unsciidl. Bacterien, n. d. entgeg- 
nung Kadi's an Pasteur. Virchow's Arch. 18S3. Vol. 91, p. 40. 

* Compt. rend, de I'ac. des sciences. May, 1880. ibid. Vol. 96. Nos. 9, 10, 11. 

'" Compt. rend. Vol.96. No. 15. 

•* Ueber das Eiweiss der Milzbrand bacillen. Ber. der deut. Chem. Ges. 1884. H. 
.16, p. 2605. 



224 EDITORIAL ARTICLES. 

Notwithstanding the great amount of good work done on anthrax, 
the lucidity of the subject is still obscured by the appearance, even at 
the present time, of statements dissenting from the generally accepted 
facts and theories of bacteriology. 

Thus Osol ^ has lately pubhshed a contribution to the subject which 
cannot be made to agree with our present systems of mycology. Tak- 
ing the blood of horses and sheep that had died after inoculation with 
anthrax-baciUi, he sterihzed it by boiling tor from 3 to 14 hours, fil- 
tered it while hot, and repeated this process once or twice, adding a 
httle water each time, and, finally, he poured the hquid into bottles 
which he closed with cotton plugs and again brought the contents to a 
boil. This Hquid he believed to be perfectly steriHzed, as he could not 
produce anthrax in animals by inoculation of minute quantities (^2 to 
I ccm.) of it, nor could he infect suitable culture-soils with it. But on 
injecting larger quantities of this fluid into the abdomen of 17 mice, 16 
rabbits and 3 sheep he succeeded — in 7 mice, 8 rabbits and 2 sheep — 
in obtaining true anthrax, with bacilli and all the pathological symp- 
toms of the disease, which caused their death. Some further animals, 
5 rabbits and 5 mice, also died, in the blood of which no baciUi 
could be found ; but the blood of these contained small bodies, highly 
refractive to light, resembling spores, which in five cases developed on 
suitable soils to characteiistic anthrax-bacilli, and, in all cases, killed 
the animals inoculated with them. Three rabbits, five mice and one 
sheep remained healthy. But, what was more surprising, two rabbits 
and three sheep were shown to have been rendered capable of resisting 
inoculation with true anthrax, by such inoculations with the filtered 
sterihzed fluid. 

Osol beheves to have thus demonstrated the existence of a chemical 
anthrax poison, an anthrax-ptomaine. 

Even if these statements do not concur with our present knowledge 
of the subject, are in direct opposition to all experiments that have 
hitherto been so often repeated by the highest authorities, and must, 
therefore, from our present point of view, be criticised as in some man- 
ner faulty (the experiments give the impression of inoculations with in- 

lExperimentelle Untersuchungen uber das Anthraxgift. Inaug. Dissertat. Dorpat. 
1885. Vide abstract, Fortschritte der Med. Vol. IV, p. 244. 



BACTERIAL SCIENCE IN ITS SURGICAL RELATIONS. 225 

sufficiently sterilized spores), it Avould be unfair to overlook them, until 
the experiments have been repeated and tested by other reUable ex- 
perimenters ; for, being performed with an organism so well studied as 
anthrax, they may contain the first steps of an advance in our knowl- 
edge of infectious diseases, ultimately leading to some new scientific 
acquisition, which we have not dreamt of in our bacterial philoso- 
phy. 

The treatment of mahgnant pustule, that form of anthrax (the inoc- 
ulation of a wound with the germ) which the surgeon is usually called 
upon to attend, and easily recognized by the circumscribed inflamma- 
tory oedema encircling the discolored gangrenous center with its char- 
acteristic serous discharge, should be in accordance with the general 
symptoms. If fever is present, it is a sign that the virus has entered 
the circulation, and no local treatment will be of any avail. The pa- 
tient should be at once put to bed and kept at rest until the fever has 
disappeared ; the excitement incident to energetic local apphcation to 
the wound is best avoided. The present writer had opportunities for 
observing the best results after this treatment, in several cases where 
inoculations of animals with the serous discharge of the pustule re- 
vealed all the virulence of typical anthrax. If no fever symptoms have 
appeared, it has been advised by Dr. Karg, of Leipsic, to surround the 
pustule with hypodermic injections of mercuric bichloride, as much as 
half a grain of which may be given with impunity. 

Glanders. Geheimrath Struck announced^ the discovery of the 
specific bacillus of glanders by Dr. Loeffier and Prof Schuetz on the 
2oth of December, 1882, in the Deutsche Medicinische Wochenschrift. 
The bacillus, very much resembles that of tuberculosis, but does not 
possess its special staining reaction ; it may be stained with methylene 
blue in watery solution, while it loses the staining obtained in aniline- 
water, when treated with water containing a little acetic acid.^ 

Following the special methods of Koch its discoverers first micro- 
scopically examined the tubercles found in animals suffering from 



'Vorlaufige Mittheilung iiber die Entdeckung des Rotzcontagiums im kais. Ges, 
Amte. 
■^Hueppe, Methoden der Bact-Forsch. Wiesbaden. 1885, p. 67. 



226 EDITORIAL ARTICLES. 

glanders, and here found the bacilli in question always present. They 
next cultivated the germ in pure cultures on sterilized sheeps' blood 
through successive generations, and finally inoculated rabbits, field- 
mice and guinea-pigs with cultures of the fourth or fifth generation 
(representing a cultivation period of I or i'/,_, months) and thus suc- 
ceeded in producing both local and general infections. They finally 
also inoculated two horses with pure cultures, one originally obtained 
from a horse suffering from glanders, and the other from an inoculated 
guinea-pig ; the first horse died in two week's time. 

Very few days after this pubhcation, Bouchard, Capiton and Charrin' 
claimed to have found the specific organism of glanders, and in a com- 
munication in the Bulletin de I'Academie de Medicine^ Vulpian and 
Bouley claimed priority of the discovery for these gentlemen. Their 
description, however, refers to round or ovoid movable bodies, and 
not to bacilH, so that it is probable that their cultures were not pure 
ones, yet they must have contained some elements of the specific germs 
as their inoculation experiments were successful. The discovery of the 
bacilli is therefore attributed to the German scientists. 

More recent culture-experiments have been performed by Kitt ' on 
potato-soils and on blood-serum, and have served to corroborate the 
statements of Loefifier and Schiitz, besides demonstrating the property 
of the bacillus to develop at a temperature of 25° C, a degree of heat 
normally obtaining in moderated chmates, and calling attention to the 
existence of spores, more resistant to destructive agents than the 
bacilli. 

The disease in man is very rare ; recent cases have been described 
by Bucquoy,* Esser and Schiitz^ and Ballance,* in which either the 
bacilli were found or inoculations proved successful. 

W. W. Van Arsdale. 



'Sur la culture, etc. Bull, de I'Acad. de. Med. 1882. No. 51. 

^No. 41. 30 Octob. 1883. "Sur une note communiquee," etc. 

^Versuche iiber die Ziichtung des Protzpilzes. Jahresber. d. Miinch. Thierarz- 
neisch. 18S3-84, p. 56. 

♦Bulletin de I'Acad. 24 Juni, 1884. 

^Rotziibertragung auf Menschen. A. d. Mittheii. a. d. k. preuss. Veterinar-Sani- 
tats-Ber. 1882-83. Arch. f. wiss. u. priv. Thierheilk. Vol. XI, p. 92. 

"Lancet, Vol. 1. 1885, P- 200. 



INDEX OF SURGICAL PROGRESS. 



GENERAL SURGERY. 



OPERATIVE SURGERY : SURGICAL ANATOMY ; SURGICAL INSTRU- 
MENTS AND APPARATUS. 

I. Simplified Technique for Extirpation of Atheroma. 

By Dr. C. Lauenstein (Hamburg). The attenuated skin over wens 
in the scalp makes it difficult to peel out the cyst, after the usual cross- 
incision, without rupture. The cut skin also becomes relaxed and so 
retards its separation. 

L. makes a i to i^'.^ ctm. long radial incision through the skin at 
the lowest point of the little tumor, pushes in the small handle of the 
scalpel on the flat, and by lateral strokes quickly separates off the skin. 
A clip with the scissors then sufficiently lengthens the incision to fin- 
ish removal. Centralb. Chirg. 1886. No. 26. 

W. Browning (Brooklyn). 

II. A New Operation for Fracture of the Patella. Sub- 
cutaneous Patellar Suture with Silver Wire. By Prof. Anton 
Ceci (Genua). After pointing out the main disturbances incident to 
fracture of the patella, the author first concisely reviews the different 
methods of treatment heretofore recommended and practised for the 
injury. Suture he believes hardly encouraging, in the face of the ex- 
isting statistics; yet appHances and bandaging frequendy in his opinion 
cause anchylosis, and hardly ever effect good consoHdation. The au- 
thor therefore proposes the following method of treatment, which he 
believes equally serviceable in recent cases and in those of long standing, 
as well as in cases where a lengthy fibrous callus has been formed 
without any fear of anchylosis obtaining ; he also recommends it as a 
prophylactic measure in recurrent fractures. 

Before operating, the effusion into the joint should be removed by 
(227) 



228 INDEX OF SURGICAL PROGRESS. 

aspiration, especially if it be large, and the joint washed out afterward; 
or a splint may be applied and the operation deferred for about three 
days, until absorption have been completed. 

The operation is performed with the help of a drill ; this is described 
as a small cyhndrical rod of pliable steel, 2 mm. in diameter and about 
8 ctm. in length, the end of which resembles a fine raspatory and is 
perforated with an eye. This end should be broader than the rod. 
An assistant holding the Umb of the completely narcotized patient in 
hyperextension, approximating the two fragments of the patella and 
moving the skin in folds towards the centre of the patella ; the ope- 
rator pierces the skin with the drill under the patella and forces it with 
sUght rotatory movements diagonally through the substance of the pa- 
tella, keeping it parallel to the larger surfaces of the bone, and trans- 
fixing it in an oblique direction from the inner part below, upwards and 
outwards. The point passes out through the skin above. He now 
threads the eye with a silver wire and, retracting it, pulls the mre 
through the patella and out at the first point of insertion. He then re- 
peats the operation in the other diagonal line of the patella, in like 
manner, but at right angles to the first perforation, having previously 
Dassed the wire under the skin around the Icwer margin of the patella 
to the lateral aspect of the bone. He then again passes the end of 
the wire under the skin above the upper margin of the patella, and fin- 
ally twists the two ends thus approximated tightly together, and buries 
the twisted part. The assistant must hold the fragments in apposition 
unmoved throughout the operation, and care must be taken not to get 
the wire tangled or twisted into loops. The skin having been moved 
out of place during the drilHng, the perforations are removed from the 
wire when the tension is relaxed. 

The wire lies to a great extent embedded in the substance of the pa- 
tella in the shape of a figure 8. The whole procedure is to be carried 
out under strict antiseptic precautions, and may be speedily per- 
tormed. 

The indications for the operation are given as follows : (i) Patellar 
iracture of recent occurrence (perfect adaptation being always possible 
m narcosis). (2) Fractures of longer standing ; freshening up of the 
edges is unnecessary since the irritation caused by the wire alone suffices 



GENERAL SURGERY. 229 

to produce the required callus. (3) Recurrent fractures, for which 
the operation is a prophylactic measure. 

The author has twice performed the operation with excellent results. 
— Deutsch. Zeitsch. f. Chir. Bd. 23. Nos. 3 and 4. March 10. 
1886. 



III. On the Fasciae and Interfascial Spaces of the Neck. 

By Dr. Kr. Poulsen (Kopenhagen). Various authors very widely 
differ in their opinions as to the descriptive anatomy of the cervical 
fasciae. The reason for this lies in the fact that the fasciae of the neck 
do not correspond to those of the extremities. A connective tissue 
only more or less sparingly interspersed with fibrous elements, takes 
the place of fascia in the neck. The results of dissections, therefore, 
may vary, one anatomist finding two laminae where another finds none 
at all, according to the development or the leanness of the subject and 
the technical skill of the dissector. 

Henke, indeed, who examined the anatomy of the neck with the 
help of artificial local injections, came to the conclusion that in reahty 
no continuous fascia of the neck existed. 

Viewing this conclusion somewhat skeptically, the author followed a 
different mode of investigation. He first froze his subject by means of 
salt and ice, and then made a series of sections through the neck with 
a saw. After hardening the sections in alcohol for one month, he 
could easily perceive and trace out the connective tissue and thus ob- 
tain suitable specimens for demonstration to aid him in his subsequent 
experiments. 

For wherever he discovered interfascial spaces, he injected colored 
masses and thus endeavored to show their configuration and inter-rela- 
tion, and to demonstrate, upon a basis of surgical anatomy, the true 
conditions favoring the descent of abscess-pus along the fasciae. 

These experiments were performed on 64 cadavers, about 100 sep- 
arate injections being made, which are given in detail. Upon the re- 
sults obtained the author bases his description of the fascia of the neck 
and the spaces between them ; he points out, however, that the course 
which abscesses follow in their descent may vary from the course taken 



230 



INDEX OF SURGICAL PROGRESS. 



by his injections, owing to the readiness with which pus destroys tis- 
sue. 

Among the spaces minutely described are the following: (a) supra- 
sternal space ; (b) inferior cervical triangle ; (c) retrovisceral, and (d) 
previsceral space ; (e) the spaces inclosing the artery and the vein; (f) 
the submaxillary region ; (g) the parotid ; (h) the sterno-cleido-mas- 
toid region, and (i) the lateral region of the neck. 

Two handsome colored hthographic plates accompany the article. — 
Deufsch. Zeitschf. CJiirg. Bd. 23. Hft. 3, 4. March. 1886. 

W. W. Van Arsdale (New York). 

IV. Antiseptic Surgical Instruments. By Dr. Th. Heid- 
ENREiCH (Moscow, Russia). In the surgical section of the Congress 




Fig. 



Ligature |ar. Showing construction. 



of Russian physicians, held last January in St. Petersburg, Dr. Heid- 
enreich read a paper on "Antiseptic Surgical instruments," using for 
demonstration the instruments manufactured by the firm Shvabe, of 
Moscow. Dr. H. holds that in order to be antiseptic the instruments 
must be made of a hard material which could not be scratched and in 
which no crevices could be formed. The material must resist chem- 



GENERAL SURGERY. 



231 



ical or thermic influences, and must not rust after having been treated 
with an antiseptic fluid. The instruments must be made of a single 
solid piece of metal, or at least they must be easily taken apart without 
help of any tools. All parts of the instruments must be smooth and round, 
admitting no sharp edges, corners or blind holes. Steel and glass are 
the only material which can be kept aseptic, the former being nickel- 
plated or galvanized. 

In 1879 Shvabe for the first time prepared the antiseptic cases of in- 
struments for the physicians who were to battle against the plague in 




Fig. 2. Li(. virki: Jar. i -e. 

south Russia. The cases proper were made of poHshed wood, capa- 
ble of a thorough disinfection; no silk or velvet was used in them. Since 
then Shvabe has tried to observe the principles laid down above, and 
with success. In his factory he has discarded completely wood, bone 
and even vulcanized rubber, making his instruments of solid steel. 
This example is now followed by many manufacturers in Germany 
and Austria. 

It is of great importance for surgeons to have disinfected silk at 
hand. Shvabe makes a special jar for that, holding five numbers of 
silk, hermetically closed and yet easily accessible (Fig. i). This jar 



232 INDEX OF SURGICAL PROGRESS. 

consists of the following parts shown in the illustration : a round jar 
{c) contains an axis with five grooves, to which correspond as many 
grooves in the jar itself In these grooves are placed spools {d) made 
of a dull glass ; silk is wound on these spools. A flat Hd of glass (Jj) 
covers the jar ; it has a large hole in the centre, corresponding to its 
axis, and five small holes, marked by figures from i to 5, and designed 
for passing the ends of silk from the spools. The Hd can be 
lifted by means of two button-shaped handles. The exterior lid her- 
metically covers the jar; it is provided with a handle. As all the 
parts of the jar are made of glass, they can be thoroughly disinfected. 
The same jars are made for wire. — Chirurgitchesky Vesttiik. (St. 
Petersburg). March, 1886. 

P. J. POPOFF (Brooklyn). 

HEAD AND NECK. 

I. On Trephining for Haemorrhage from the Middle Me- 
ningeal Artery into the Closed Cranial Cavity. By Prof 
Kroenlein (Ziirich). The substance of this paper, read before the 
58th convention of German Scientists and Physicians at Strassbourg 
in September last, forms a complement to Wiesmann's article on the 
same subject,' the author extending the conclusions drawn from the 
observation of cases at the Zurich clinic, up to the present time. 

Within the last three years, it appears, the author had occasion to 
trephine four times for rupture of the middle meningeal artery ; the op- 
eration, however, only proved successful in two of the cases, and the 
fatal termination of the other two, with |their post-mortem evidence, 
first suggested the plan of operative procedure set forth in the present 
paper. 

Two of these cases have already been given by Wiesmann, to which 
the author adds two new ones, and, referring to W. in all points of 
symptomatology and diagnosis — so fully does he endorse his assistant 
— ^proceeds to ask in what manner we shall act, when the diagnosis of 
brain-pressure resulting from rupture of the meningeal artery has been 
arrived at by means of cerebral symptoms alone, and when no marks 

^ Vide Annals of Surgery. Vol. 2, p. 502. Dec. 18S5. 



HEAD AND NECK. 233 

of external violence indicate the point of lesion. In these cases W. 
had proposed to apply the trepan at different points at random, being 
led by attempts at localization of the cerebral symptoms. But the 
present author proposes to advance methodically in all cases accord- 
ing to a fixed plan of action, deducible from the following considera- 
tions. 

All haematomata resulting from rupture of the arter. mening. med. 
or its branches,though individually varying within certain limits in form, 
may be reduced to certain types — at least when grouped according to 
the symptoms of diagnostic importance. One group, the diffuse haem- 
atomata, may extend 6ver the inner surface of an entire half of the 
skull, extending from the internal occipital protuberance to the frontal 
tuberosity and from the falx cerebri down to the planum orbitale, the 
floor of the temporal cavity and the tentorium cerebelli respectively. 

Another group, the circumscribed haematomata, being more sharply 
defined than the diffuse ones, and representing a circle or an oval in 
outline, and a lens in shape (as being of greater thickness in the cen- 
tre than at the margin) may be subdivided according to location. 

The most frequent forms are those situated over the middle cerebral 
cavity, and bounded in front by the margin of the lesser wing of the 
pterygoid, at the back by the edge of the petrous pyramid (on account 
of the firmer adherence of the dura mater to the bone at this point), 
below, by the region of the foramen spinosum, and above, by points 
beyond the squamous suture, or situated as far up as the margin of the 
semicircular plane. 

Less frequent forms of circumscribed haematomata occupy only the 
region below the parietal tuberosity and do not encroach upon the mid- 
dle cerebral cavity. They extend upwards to the falx, posteriorly to 
the internal occipital protuberance and downwards as far as the 
cerebellar tentorium. 

This form the author calls hasmatoma posterius s. parieto-occipitale. 
The least frequent are the haematomata anteriora s. fronto-temporalia ; 
these are situated beneath the frontal tuber and extend downwards to 
the planum orbitale, from part of which the dura may be torn away, 
and backwards to the suture cruciata. 



234 INDEX OF SURGICAL PROGRESS. 

The variation in the sites of these tumors is due to variations in the 
point of rupture, which again depends upon the location and descrip- 
tion of the traumatism. The trunk or the larger or smaller branches 
of the artery may rupture. Generally speaking, rupture of the anterior 
branch of the anterior division of the artery causes the anterior haem- 
atoma, while the posterior one is caused by rupture of the posterior 
branch beyond the point where it passes the pyramid. 

The temporo-parietal form, the first one mentioned, ensues after 
rupture of one of the vessels situated in the temporal cavity. In case 
the haemorrhage is slight the circumscript variety results, otherwise a 
diffuse hematoma is formed. These forms are inost frequent for the 
reasons that the temporal region is very vulnerable, and that the lar- 
gest vessels are here met with. 

Var}ang location of these hfematomata unquestionably produces a 
difference in the symptoms, according to the seat and extent of the 
lesion and its local effect upon the psychomotor cortical provinces — in 
some cases contralateral paralysis of the upper extremity alone, in 
others of the facialis alone ; again in others paralysis of the upper and 
lower extremity combined, resulting. But frequently the cases are not 
such simple ones, and complications such as concussion, contusion of 
the brain and apoplectic foci exist, and the patient may be intoxicated, 
so that the surgeon is satisfied, if at all he can diagnose rupture of the 
artery and decide upon which side it is situated. 

The question, then as to the point where the trephine is to be ap- 
phed, is to be answered in the following manner : By perforating the 
skull in the temporal region, we gain access to the area of both the 
diffuse, the temporo-parietal and the fronto-temporal hematoma, and 
can thus remove the extravasated blood, although we here do not 
meet the trunk, but only the main anterior branch of the middle me- 
ningeal artery. But since the circumscribed parieto-occipital haematoma 
is not accessible at this point, if the first perforation prove of no avail, 
a second opening should be made in the occipital region to meet the 
vital indication. 

A second opening of this sort is, in fact, advisable in cases of diffuse 
haematoma to permit the more thorough removal of the coagula and 
ensure complete drainage. 



HEAD AND NECK. 235 

As to the exact localization of the points at which to apply the 
trephine, the author gives the following directions : Draw a hne par- 
allel to the horizontal Hne of the skull (which runs through the inferior 
orbital margin to the entrance of the auditory meatus) through the 
superior orbital margin. Both points are situated upon this line, the 
anterior one 3 to 4 ctm. behind the zygomatic process of the frontal 
bone ; the posterior one at the point of intersection of this line with a 
vertical one carried upwards directly behind the mastoid process. 

The localization of the various forms of hamatomata and of the 
points selected for trephining is illustrated by diagrams. — Deutsch. 
Zeitschr.f. Chir. Bd. 23. Nos. 3 and 4. March. 1886. 

W. W, Van Arsdale (New York). 

II. A Case of Tracheocele. By G. Daremberg, M.D. (Men- 
ton) and A. Verneuil, M.D. (Paris). A man, aet. 73, who had long 
had a dry, wheezing cough, aside from which his health had always 
been excellent, presented, in 1884, a small tumor on the left of the 
trachea, which it seemed to compress, with a prolongation behind the 
clavicle the tumor being apparently localized in the corresponding lobe 
of the thyroid gland. There was sUght cough, wheezing and suffoca- 
tion on attempting to ascend stairs ; with some variations under various 
methods of treatment, this tumor continued to develop until in Novem- 
ber, 1885, the neck had undergone a great increase in its total vol- 
ume, without any cutaneous cedema, inflammatory redness nor any 
vascular dilatation except in the supra-clavicular triangle where the 
veins were swollen ; the movements of the larynx in deglutition and 
respiration were normal ; the trachea was deviated slightly to the right; 
deglutition has been difficult but not painful for a year, although the 
ingestion of certain matters has caused paroxysms of suffocation. On 
the left side of the neck was the tumor, which would appear suddenly 
and disappear as quickly ; at first of small size, it now filled the entire 
space included between the lower jaw and the clavicle, and between 
the median line and the posterior border of the sterno-mastoid muscle ; 
its appearance is provoked only by coughing, although cough does not 
necessarily produce the tumor ; it may appear from five to fifty times 
a day ; its persistence is no less variable ; sometimes the protrusion 



236 INDEX OF SURGICAL PROGRESS. 

appears and disappears with the paroxysm of coughing, hke a balloon, 
to be inflated and collapsed by expiration and inspiration ; at other 
times, the distension lasts from ten seconds to a minute and a half; it 
may diminish in part, then stop for a few seconds, and then collapse in 
an instant ; during distension, it is elastic tympanitic and constituted 
evidently by retained air, for the stethoscope reveals no respiratory 
murmur ; pressure with the hand has no effect upon reduction, which 
is assisted by movements of deglutition or by inclining the head sud- 
denly to the left shoulder. Beside the tumor on the left side, a similar 
smaller prominence, which never became larger than a walnut, was de- 
veloped later in the right supra-clavicular triangle, behind the border of 
the stemo-mastoid muscle. The theory that the original tumor was a 
goitre of the left lobe of the thyroid gland was evidently untenable as 
well as that of a vascular tumor, although there existed a notable tur- 
gescence of the veins of the neck ; and the diagnosis finally settled 
upon an aerial tumor, called aerial goitre or tracheocele, and character- 
ized by sudden appearance and disappearance, indolence, the absence 
of inflammatory symptoms, sonorous resonance, the relation to cougli 
and coexistence of troubles of respiration, phonation and deglutition. 
The most probable theory of the causation of the tumor is that, there 
being a constriction of the trachea (as shown by the wheezing, etc.), 
the membranous wall of the passage became dilated at a circumscribed 
point in the form of a sac, as occurs in certain aneurisms and synovial 
cysts ; or the softened, inflamed and thinned wall, yielded during 
the pressure of expiration, the passage being impeded by a mass of 
mucus, and a sac was gradually developed in the loose inter-tracheo- 
cesophageal and deep cervical connective tissue, by the same mechan- 
ism as is observed in the formation of pneumoceles of the cranium. 
The danger is evidently in secondary laryngeal troubles, manifested by 
the paroxysms of suffocation. It was thought best to postpone surgi- 
cal interference, and the patient finally died in April, 1886, supposably 
from a rapidly developing adeno-sarcoma of the peritracheal glands, 
there being a family history of cancer. — Revue de Chirurgie. 1886. 
May. 

T. E. Pil.CHER (U. S. Army). 



CHEST AND ABDOMEN. 237 

CHEST AND ABDOMEN. 

I. Gastrostomy for Cancer of the CEsophagus. By A. D. 
Knee, M.D. (Moscow, Russia). In 1880, in Moscow, Dr. Knee 
founded a private clinic of his own, specially for surgical cases. He 
has now 16 beds. For the last four years Dr. Knee has treated 27 
cases of cancer of the oesophagus. The patients were 25 males and 
only two females. In the clinic were treated 17 patients, of whom 6 
were lost sight of Gastrostomy has been performed in 13 cases, of 
which in 10 the result was favorable and in 3 unfavorable. 

The cases with favorable result were as follows : 

No. I. Male, set. 49, sick 15 months; gastrostomy performed Jan. 
2, 1882 ; lived after operation 9 months ; cause of death, cancerous 
metastasis. 

No. 2. Male, aet. 48, sick four months; gastrostomy Sept, 6, 1882 ; 
was alive 2 months since, but was lost sight of 

No. 3. Male, aet. 62, sick 5 months; gastrostomy Jan. 21, 1883; 
lived after operation 5 months and 28 days ; cause of death, pleurisy. 

No. 4. Male, aet. 40, sick 6 months; gastrostomy Aug. 30, 1883; 
was seen alive in December, 1883, but was lost sight of afterwards. 

No. 5. Male, set. 50, sick 8 months ; gastrostomy Oct. 2, 1883 5 lived 
5 months ; cause of death pneumonia. 

No. 6. Male, aet. 50, sick S months ; gastrostomy Oct. 2, 1883 ; 
lived after operation 8 months and 17 days; cause of death, pneu- 
monia. 

No. 7. Male, aet. 62, sick 5 months; gastrostomy Jan. 13, 1884; 
lived 9 months ; cause of death, cancerous diathesis. 

No. 8. Male, aet. 41, sick 7 months; gastrostomy Feb. 7, 1884; 
Hved 9 months and 6 days ; cause of death, pneumonia. 

No. 9. Male, set. 59, sick 4 months; gastrostomy, April 14, 1884; 
was seen alive July 11, 1884, but afterwards was lost sight of. 

No. lo- Male, aet. 56, sick 5 months ; gastrostomy July 3, 1884 ; 
was seen alive November 6, 1884, but afterwards was lost sight of 

Cases with unfavorable result : 

No. I. Male, aet. 62, sick 12 months ; gastrostomy Nov. 11, 1881 ; 
died within 36 hours ; cause, perforation into the left bronchial tube. 



238 INDEX OF S UR GICAL PR GRESS 

No. 2. Male, set. 39, sick 6 months; gastrostomy Dec. 28, 1883; 
died on 8th day, from bleeding. 

No. 3. Male, aet. 61, sick 8 months; gastrostomy Nov. 15, 1884; 
died on 12th day. from exhaustion. 

In Europe there are known 56 cases of gastrostomy (except those 
of Dr. Knee) with favorable result. 

Dr. Knee protests emphatically against treatment with bougies or 
probes in cases of cancer of the oesophagus, for fear of perforation into 
trachea or bronchi, and also of premature opening of the cancerous 
tumor. No cicatrization can be hoped for in such cases. Out of 13 
patients of Dr. Knee, 6 had a complete stricture of the oesophagus, and 
7 could pass only small quantities of fluid. The operative technique 
adopted by Dr. K. is as follows : A primary incision in the abdominal 
wall, from 6 to 8 cm. long, from the 8th rib, along the margin of ribs. 
The peritoneum having been incised, he attached the peritoneal coat 
to the edges of wound. Then he extracted a portion of the stomach 
and attached it to edges of wound by from 15 to 20 Lembert sutures, 
taking care that sutures should pass only through the serous coat of 
the stomach. On having finished this first part of operation (lapar- 
otomy), the wound is dressed and the patient is ordered to take ice and 
opium. Four nutritious clysters per day. The wound was dressed 
again on 6th day. The stomach was opened on 8th or 9th day, and a 
tube from 5 to 6 mm. introduced. At first only Uquid food (milk,wine, 
egg) was introduced through the fistula, and afterwards scraped raw 
meat and even roasted meat. Some patients took by fistula about six 
pounds of food per day. In one case there was an obstinate vomiting, 
which disappeared only gradually. Complete cicatrization took place 
on from 18 to 20 days after laparotomy; therefore Dr. Knee removed 
sutures only at the end of a fortnight. — Chirurgitchcskiy Vestnik 
(St. Petersburg) January. 1886. 

P. POPOFF (Brooklyn). 

II. On Sublimate Intoxication after Laparotomy. By Dr. 
H. KuEMMELL (Hamburg). K., who was so instrumental in intro- 
ducing bichloride as an antiseptic, now reports his unpleasant expe- 



CHEST AND ABDOMEN. 239 

rience with it. By limiting the use of this solution and employing prin- 
cipally strengths of i to 5-10,000 his first 170 major operations with it 
showed but one case of poisoning lasting a few days ; this occurred in 
a very fat subject after amputation of the mamma. 

Within a few months, however, he has had two cases of poisoning 
after peritoneal operations. His first nine laparotomies with it passed 
off well. Then came a fatal case of poisoning in a woman of 30 years. 
She was of slender build, and very anaemic ft-om profuse uterine 
haemorrhages. Interstitial myoma of uterus: laparotomy (operation 
lasting i^i hours). Cuneiform excision of tumor ; sUght loss of blood ; 
warm sublimate solution, not stronger than i to 5-6000 was used; vom- 
iting repeated during the night ; diarrhoea set in next day, the passages 
soon containing blood ; no fever. She became progressively weaker, 
and died four days after the operation. 

Neither intra vitam nor at the autopsy was there any indication of 
inflammation about the uterine wound. In the mucous membrane of 
the ascending and transverse colon were several defects with sharp 
edges. 

The second case was that of a rather anaemic but fairly nourished 
woman of 25. Papilloma (size of a baby's head) of right ovary, with 
a large encapsulated ascites. The left ovary, also diseased, was re- 
moved at the same time ; operation at first well borne ; vomiting dur- 
ing the day and severe collapse in the evening ; stimulants hypoder- 
mically ; extreme exhaustion the following day ; vomiting had stopped, 
but the passages became bloody. Injection of 1500. grm. '^/io% salt 
solution into the left basilic vein, with great improvement in the pulse; 
it, however, caused a subjective feeling of great fear, lasting all day. 
Threatening symptoms had subsided by the next day, though bloody 
passages continued a few days and gums and oral mucous membrane 
were ulcerated at many points. Final recovery. No relapse up to 
seven months /. ^. " From former publications and the two histories 
just given, I believe we can draw the conclusion that in laparotomy on 
patients not too much reduced, sublimate solutions of i to 5-6000 may 
be used ; that, however, in highly anaemic weakened individuals and 



240 INDEX OF SURGICAL PROGRESS. 

those with kidney affections it is safest to avoid sublimate altogethei." 
Centbl. f. Chirg. 1886. No. 22. 

Wm. Browning (Brooklyn.) 

III. Treatment of Recent Abdominal ^A/ounds with Her- 
nia of the Omentum. By H. Hartmaxx, M.D., (Paris). The 
writer calls attention to the fact that, although French surgeons have 
adopted advanced views with regard to abdominal surgery in general, 
they still hold the method of allowing omentum, protruding from an 
abdominal wound, to cure itself by sloughing off, and then proceeds 
to give a detailed criticism of the authorities for this method, showing 
the crudeness of their reasoning, and that the failures of the method of 
ligature and return to the abdominal cavity, which caused its former 
repudiation, were due not to any defect in the method itself but to 
faults of its application, and recites three successful cases to show the 
perfect safety of ligaturing the protruding part and dropping it back 
into the abdominal cavity, all under careful antiseptic precautions, by 
which a surer, more rapid and more generally satisfactory cure was 
obtained than was possible by the expectant plan. — Revue de Chirur- 
gie. 1886. May. 

IV. The Significance of Collapsed Intestine in Lapa- 
rotomy for Intestinal Obstruction. By J- E. Michael, M.D. 
(Baltimore). Referring to a statement that a dilated intestine would 
indicate that the cause of the obstruction is lower down, while a col- 
lapsed intestine can only be expected on the peripheral side of the ob- 
struction, the writer quotes two cases, which had come under his ob- 
servation, in which the small intestine was collapsed while there was an 
obstruction at the sigmoid flexure, to show that the proposition is not 
strictly correct or invariably true. — Med. Ne^vs. 1886. May 29. 

V. Diagnostitial Laparotomy. By C. Johnson, M.D. (Bal- 
more). This paper discusses the subject in a general way and is in 
accordance with prevalent views on the subject, calling attention to 
the fact that all intra-abdominal operations are to a certain extent ex- 



CHEST AND ABDOMEN. 24I 

plorative. Aside from this, he divides cases demanding laparotomy 
into two classes, (i) cases in which a diagnosis can not be made with- 
out its aid, and (2) cases in which, a diagnosis having been made, no 
definite line of operation can be marked out and no abandonment of 
active measures entertained or justified. The diagnosis ought to be 
established in every case, and the opportunity offered by laparotomy 
should not be delayed too long. 

A. Van Derveer, M.D. (Albany, N. Y.), speaking approvingly of 
laparotomy as a diagnostitial method, reviewed the points upon which 
surgeons are at variance, expressing his approval of early operations 
among the best surroundings and with all antiseptic precautions. The 
incision should be in the median line ; when the intestines are inflated , 
and roll out of the opening, he advises pricking the most prominent 
loop to permit the escape of gas and secure the collapse of the gut. 
He would close the abdomen by the deep through and through su- 
ture in preference to the method of suturing each layer separately. 

J. E. Mears, M.D. (Philadelphia), would adopt the following order of 
treatment, (i) external manipulation, (2) internal examination, where 
it is possible to be made through exploration of the pelvic cavity, (3) 
aspiration and (4) laparotomy, the most serious of all and to be re- 
sorted to after the failure of all other methods. He deprecated rash- 
ness but approved of abdominal section in intestinal obstruction, and 
in gunshot wounds of the abdomen he thought there could be no ques- 
tion of its propriety. He believed that the condition of the peritoneum 
had much to do with the immunity of operative procedures, and that 
one which had been accustomed to the presence of a tumor would 
endure operation much better than a perfectly healthy one. 

C. T. Parkes, M.D. (Chicago), believed that the length of the in- 
cision had but little influence on the result of the operation, although 
he had observed that, in the cases in which it became necessary to ex- 
tend the inr'sion above the umbilicus, convalescence was somewhat 
more prolonged. He also was opposed to the suturing the different 
abdominal layers, and closed the incision by suturing the lips of the 
wound en masse. A case which had been very instructive to him in 
connection with the danger of opening the abdomen was that of a wo- 



242 INDEX OF SURGICAL PROGRESS. 

man who had been hooked by a cow, the abdomen ripped open and 
the bowels caused to protrude ; these were cleansed and returned, and 
recovery followed promptly, without even a localized peritonitis. He 
thought delay in cases of intestinal obstruction wrong and quoted cases 
in support of this view. 

J. F. Thompson, M.D. (Washington, D. C), reported two cases in 
which laparotomy had been performed for diagnostitial purposes. In 
the first, the patient had been suffering for several years from a tumor, 
resembling an ovarian tumor in many respects, except that it had two 
sinuses leading from it and opening in the groins ; the abdominal en- 
largement was as great as at the fifth or sixth month of gestation ; fol- 
• lowing up one of the sinuses into the cavity of the abdomen, a large 
tumor presented, but the flow of pus could not be explained; the tu- 
mor being apparently embedded in the abdominal wall, it was thought 
best to close the wound without further operation ; at the autopsy, five 
months later, the tumor was found to be an enlarged and dislocated 
spleen. The second case was for a tumor which, being found on open- 
ing the abdomen to be an extensive carcinoma, involving the mesen- 
tery, transverse colon and hver, was left undisturbed and the patient 
recovered readily irom the operation. He disapproved of the simple 
continuous suture in closing the abdomen, believing that each layer 
should be sutured separately so that the internal peritoneal layer may 
have united sufficiently to prevent the entrance of pus before suppura- 
tion shall have been established. 

Further remarks were made by other speakers, cases being quoted in 
which an exploratory operation would have probably saved life, the 
trend of opinion being in favor of the more frequent application of the 
operation. — Froc. Am. Surg. Assn. 1886. 

VI. A Successful Case of Laparotomy for Perityphlitic 
Abscess. By J. L. Homans, M.D., (Boston, Mass.) A boy, aet. 11, 
had suffered from pain and tenderness in the right iliac region for five 
days ; dulness was found on percussion, and the temperature and pulse 
rate were high and increasing. In pursuance of the policy of early 
interference an incision was made, about 272 inches long, without 
previous aspiration over the most ^tender point, and the peritoneum 



CHEST AND ABDOMEN. 243 

opened ; healthy intestine presenting was pushed aside, and beneath it 
were found loops of intestine bound together by a recent plastic pro- 
cess, and by poking about with the finger an abscess was torn open, 
evacuating two ounces or more of foul pus. A double drainage tube 
was inserted and the wound closed, the patient making a prompt re- 
covery. 

Especial attention was called to the early period at which the opera- 
tion was performed on the fifth day of the sickness and the second after 
being seen by a medical man. — Boston Med. and Surg. Jour. 1886. 
April 29. 

VII. Perityphlitis. By H. B. Sands, M.D., (New York). Quotes 
six cases of perityphlitis, wishing to emphasize the necessity of abso- 
lute rest in the treatment of this affection. The first was the case of a 
physician who was doing fairly well, but who, while the disease was in 
progress, was allowed to take several cathartic medicines, each of 
which only aggravated the trouble, and finally, after a copious passage 
produced by an enema, he fell into collapse and died, with no cause 
for the existing perforation of the appendix visible on autopsy. It was 
evident in this case that the difficulty had been confined within nar- 
row limits for a while, and undoubtedly a better chance for recovery 
would have been afforded if the patient had been kept absolutely quiet 
and opium given instead of cathartics. 

The second case was that of an old man who had been supposed to 
be suffering from strangulated hernia, but although a hernia existed, 
the sac was so flaccid that there could be no strangulation, and the 
case was in reahty one of perityphhtis ; the patient was allowed to get 
up and go do^vn town, with the result of precipitating a peritonitis and 
death. Autopsy revealed perityphlitis with perforation of the vermi- 
form appendix and an empty hernial sac on the right side. This 
case also emphasized the importance of rest and opium. 

The third case was also of a physician, who had signs of intestinal 
obstruction during the progress of peritonitis; and the only reason for 
supposing the trouble to have begun in the appendix vermiformis was 
the existence of slight pain in the right inguinal region. Later, dis- 
tension of the abdomen and elevation of temperature to 104° F. oc- 



244 INDEX OF SURGICAL PROGRESS. 

curred ; rest, hot fomentations and opium brought the temperature 
down to 102° F., although the pulse still continued rapid ; the speaker 
was called in at this time, but did not urge an operation, thinking it 
would offer but httle chance of recovery. Death ensued and the au- 
topsy showed the fatal result to have been due to universal peritonitis, 
originally caused by perforation of the vermiform appendix, the pus not 
being enclosed as is usual in abscesses of this kind. The only possible 
surgical success in this case would have been early laparotomy, if an 
early diagnosis had been possible. 

The fourth case was a very stout young man, ^t. 21, upon whom he 
operated on the fourteenth day. In this operation, for the first time in 
his experience, he accidentally cut the intestine, although pus had been 
withdrawn by the hypodermic syringe, before the incision was made. 
When he arrived at the tumor, all those present had the impression 
that a piece of intestine was being dealt with, and it seemed to the 
operator that there was a portion of the caecum in the wound instead of 
the usual abscess cavity ; he made a cut with the scissors, and the im- 
pression conveyed to his mind was that he was cutting intestine ; from 
the opening came pus and air, but no faces ; faeces appeared, however, 
the next day, and on the second day in large quantities, continuing for 
about ten days, having ceased altogether at the end of two weeks. The 
patient recovered entirely in three weeks ; the operator thought the hy- 
podermic needle must have passed through both walls of the mtestine 
before penetrating the abscess. 

A fifth case \vas of a young lad, there being symptoms of peritonitis 
in connection with perityphlitis ; the case progressed well for a week, 
when subnormal temperature, abdominal distension and other alarm- 
ing symptoms appeared ; an operation was performed and the abscess 
cavity found to contain pus and faeces ; the patient was convalescent 
when last seen. 

The sixth case was a lad of 14, in whom the symptoms had existed 
lor a week and where there seemed to be signs of perforation on the 
side of the peritoneum ; there was marked tympanites and he could 
make out no circumscribed tumor ; after debating whether to cut in 
the median line or at the side, he decided to make the incision in the 
latter locality. When the layers of the abdomen were cut down upon, 



CHEST AND ABDOMEN. 245 

about a half an ounce of pus was seen to flow from a small opening 
and the abscess cavity was found to be very smooth ; the abscess was 
doubtless in the cavity of the peritoneum and, as had been suspected, 
the case was one in which perforation had occurred toward the serous 
membrane and not amenable to the usual operation. 

It having been "remarked that the early recovery of the fourth case 
rendered it doubtful whether the intestine had really been wounded. 
Dr. Sands said it that was quite possible to have a simple wound of the 
intestine and also rapid recovery. A remarkable example of this was 
the case of a young man accidentally shot in the abdomen with a 38- 
calibre ball, entering the body on the right side of the median line close 
to the pubes. No faeces appeared on probing for the ball, which could 
not be found on an incision, extending as far as the spine of the ilium. 
It was noticed that there was some deep emphysema, which has re- 
cently been noted as a sign of perforation of the intestine; the external 
abdominal ring was somewhat patulous, but no more so than is often 
the case. On the third day a flow of faeces appeared, the source of 
which could not be ascertained, although the drainage tube was re- 
moved. Afterward, however, air and faeces came from the external 
abdominal ring, and the bullet, therefore, must have entered the ab- 
domen through this natural opening. The patient recovered, showing 
that a temporary faecal fistula might sometimes be established. 

It had been claimed that laparotomy could succeed in cases of per- 
foration of the vermiform appendix and general peritonitis, but he be- 
Heved that, with the latter condition, the operation offered no hope of 
saving Hfe. — Proceedings N. Y. Surg. Soc. 1886. April 26. 

VIII. Pelvic Abscess in the Male. By T. H. Burchard, M. 
D., (New York). Defining the lesion as a phlegmonous inflammation 
occurring in the superior portion of the pelvic cavity, below the cavity 
of the abdomen, from which it is separated by the pelvic reflections of 
the peritoneum, and above the muscular floor formed by the levator 
ani muscle, he calls attention to the fact that the bony lateral boun- 
daries and the dense and almost impervious musculo-membranous floor 
render it possible for abscesses to originate in the pelvis and produce 
most acute constitutional disturbance and even very extensive local 



246 INDEX OF SURGICAL PROGRESS. 

disorganization without any distinguishing external symptoms. The 
burrowing of the pus may be very extensive, passing through the pelvic 
foramina and appearing externally under the gluteal muscles; penetrat- 
ing the acetabulum and destroying the hip-joint, dissecting up the 
aponeurosis of the iliac muscles, producing necrosis of that bone and 
appearing upon its external surface ; emerging from the pelvic cavity 
and traveling anteriorly along the course of the femoral vessels beneath 
Poupart's ligament and appearing on the anterior surface of the thigh ; 
penetrating the hollow viscera and evacuating into the bladder, rectum 
or peritoneal cavity ; in fact there is no direction which it may not take 
after having escaped from its bony confines. The clinical history 
varies according to the acuteness or latency of the attack, both the 
constitutional and local disturbances being the greater in the latter, 
with great pain and febrile phenomena, more or less abdominal disten- 
sion, tympanites, vomiting, flexion of the thighs, difficult or impossible 
micturition, proctitis and tenesmus if the tumefaction projected into the 
rectum, and localized or general peritonitis, if the inflammation spread 
upwards. Abscesses formed thus acutely are more likely to evacuate 
themselves spontaneously in either the rectum or bladder, than those 
of a subacute or chronic character. 

While difficult to specify a time, it is logical to suppose that suppu- 
ration occurs some considerable time before it makes itself manifest by 
external tumefaction, the delay being due to the difficulty the pus ex- 
periences in getting to the surface, because of the depth of the sup- 
puration, rather than to the absence of pus. The constitutional evi- 
dences of internal suppuration are ah along more or less pronounced 
and a carefully conducted examination at this stage may discover the 
location. Chronicity, however, seems to be the rule with non-trau- 
matic cases in the male, which most frequently occur in the poorly 
nourished and cachectic in whom inflammatory processes are slow and 
suppuration tardy ; a widely diffused inflammation may pervade the 
pelvic cellular tissue months before its final breaking down into pus. 
The diagnosis is often very baffling in such cases, owing to the inac- 
cessibility of the parts and the many different tissues, organs, vessels 
and nerves affected. Clinically, it is important to distinguish between 
an inflammatory condition simply and the suppurative stage of the 



f 



CHEST AND ABDOMEA. 247 

same condition, the latter of which can not be recognized too early : 
and Hkewise between a pelvic celluHtis and general or localized periton- 
itis and between it and cystitis, proctitis and prostatitis. Surgically it is 
necessary to differentiate between abdominal, pelvic, ileo-pelvic and 
perineal abscess and abscess of the ischio-rectal fossa, as well as the 
exceptional accidents Hable to be found here. 

The treatment naturally resolves itself into treatment of the cellu- 
litis before suppuration and after suppuration. In the former, rest, 
morphine, quinine, local refrigeration and local depletion by leeches to 
the perineum; in the latter, evacuation at the eariiest possible moment. 
In illustration, five cases are related, two of which died of the disease, 
one of an intercurrent nephritis, one refused assistance and one was 
treated by an opening extending down five inches from the posterior 
superior spinous process of the ilium into the peritoneal cavity, the 
sinus opened and the cavity drained, with recovery. — N. Y. Med. Rec. 
1886. April 24. 

J. E. PiLCHER (U. S. Army). 

IX. On the Operative Treatment of Carcinoma of the 
Large Intestine. By Dr. B. Riedel (Aix-La-Chapelle). Gurlt's 
statistics of the Vienna hospitals show that of some 500 cases of carci- 
noma of the intestinal tract, the small and large intestines were the seat 
of disease in 109 cases whilst the rectum was affected in 399 cases, a 
proportion of about i to 4. Schramm collected in his work, which ap- 
peared in 1884, 34 cases of carcinoma of the large intestine, of which 
but a few Avere situated in the transverse or descending colon, by far 
the larger number being found in the coecum or sigmoid flexure. Dur- 
ing a period of four and a half years, the author has observed 14 cases 
of rectal carcinoma, and 9 of carcinoma of the large intestine. Of the 
latter 3 were situated in the ccecum, one in the descending colon and 
5 in the sigmoid flexure. Only 5 of the 14 cases of rectal carcinoma 
were operative. Of these one died in consequence of the operation, 
whilst 4 are Hving, 3 without relapse, the other, operated two years 
ago, having recently showed signs of return of the disease. Of the 3 
cases without relapse, 2 were operated in 1883, and were very simple 
and easy ones to operate. The oldest and^most difficult case (woman , 



24^ INDEX OF SURGICAL PROGRESS. 

73 years of age,; was operated in 1881. The carcinoma was situated 
so high up that the author, after opening Douglas' cul-de-sac, was 
obhged to pull the lower part of the sigmoid flexure downwards and 
divide it transversely between two elastic ligatures, the gut being ex- 
cised from above downwards. All glands in the cavity of the os sa- 
crum were removed. Patient recovered and is at present in good 
health. Of the 9 cases of carcinoma of the larger intestine, 2 would 
not submit to an operation and died shortly afterwards. In the third 
case (man, set. 65, with carcinoma coeci) an exploratoiy incision showed 
that the disease had progressed too far to admit of a radical operation. 
An artificial anus was therefore made above the ccecum, but this con- 
dition becoming unbearable to the patient, the abdomen was closed 
and the patient died two weeks later from perforation of the carcinoma. 
The fourth and fifth cases (man, aet. 65, woman set. 70, both with car- 
cinoma of the sigmoid flexure) had severe symptoms of ileus on admis- 
sion. In both cases an artificial anus was made, but too late, death 
taking place 24 and 48 hours respectively from peritonitis, caused by 
minute perforations above the small ring-like carcinoma. Case 6 
(woman, 45 years of age) was one of carcinoma of the sigmoid flexure, 
with strong adhesions to the pelvis. When admitted severe symptoms 
of ileus were present, tympanites, vomiting, etc. The colon was 
opened in the left inguinal region. After the contents of the bowels 
had been emptied, it was found that the tumor was absolutely non-op- 
erable, and an artificial anus was therefore made. Patient left the 
hospital in good condition. Case 7. Woman, aet. 54. Carcinoma of the 
sigmoid flexure causing great stenosis. The gut was resected for 6 ctm. 
above and below the tumor. Both ends were attached by sutures in the 
abdominal wound, the author intending to unite them later, when the 
bowels had emptied themselves. The patient, however, was well satisfied 
with her condition and would not consent to undergo another opera- 
tion. She recovered and is at present perfectly well, no signs of 
relapse being observed. 

Riedel's eighth case is a highly interesting one. The patient, a gen- 
tleman, 51 years of age, had been annoyed with intestinal disturbances 
for about one year, having noticed the tumor six months before. When 
first seen by the author, a k,mp the size ol a hen's egg was distinctly 



CHEST AND ABDOMEN. 249 

felt in the right inguinal region. Immediate operarion was urged by 
the author, the patient, however, acting on the advice of Michaux (who 
considered syphilis to be the cause of the tumor) went to Aix-La- 
chapelle for treatment. He continued to grow worse, and consulted 
the author again in August, 1885, being then in an emaciated and very 
forlorn condition, with decided icterus. The tumor was now found to 
have increased very much in size, having several distinct superficial 
prominences, which were thought to be infiltrated glands. No tympa- 
nites or pain present. Operation was not advised, but at the urgent re- 
quest of the patient, an exploratory incision was undertaken. No in- 
filtration glands were found, and a radical operation was at once deter- 
mined on. The carcinoma was situated in the coecum. On account 
of adhesions the whole ascending and a portion of the transverse colon 
had to be removed, the ileum being divided. The mesenterium had 
been necessarily subjected to considerable maltreatment during the 
operation, on account of which it was held to be advisable to suture 
the ends of the severed intestine in the abdominal wound. This was 
fortunate as large portions of the mesenterium became necrotic, and 
abscesses found along the edges of the sutured gut, by means of which 
the necrotic portions of mesentery were expelled. Patient did well ; 
lost his icterus, and his appetite returned. Two months later the in- 
testine was united with sutures of fine silk, after about 6 ctm. had been 
removed from both ends. Eight days later first stool per anum took 
place. In six weeks patient discharged cured. No signs of relapse 
up to the present time. 

Case 9. Woman, set. 50, with large non-operable carcinoma of the 
sigmoid flexure. 

A glance at these cases will show that disturbances in defecation (al- 
ternating diarrhoea and constipation) occur in all cases of car- 
cinoma of the larger intestine. The symptoms of ileus do not ap- 
pear so often in these as in the carcinoma of the sigmoid flexure, the 
faeces being quite fluid and soft, even as far down as the end of the 
ileum, so that they very easily pass through a considerably narrowed 
lumen. In stenosis of the sigmoid flexure the faeces collect slowly until 
large quantities are present, when vomiting, etc. appears, and then per- 
oration above the strictured part. Although the real state of the pa- 



250 INDEX OF SURGICAL PROGRESS. 

tient is not always recognized, a diagnosis should not be difficult. To 
this end injections of water into the rectum may be advantageously 
used. If not more than 200 grammes enter, there is certainly a steno- 
sis present. In carcinoma of the coecum there is often, perhaps, a ten- 
dency to mistake the tumor (movable in all directions) for a benignant 
growth, lying laterally to the intestine,or in the mesentery, inasmuch as 
disturbances of the intestinal functions are often so very slight at the be- 
ginning. Duringthe further progress of the disease the usual symptoms of 
stenosis of course will appear. In most cases the ages of the patients 
ranged from 40 to 60 years, but this form of carcinoma has been fre- 
quently observed in persons of 20 to 40 years of age. Radical removal 
of the new growth has been, according to Schramm's statistics, (to 
which one case of Schede must be added), performed in 22 cases, in 13 
of which the result was unfavorable, recovery taking place in 9. Riedel 
thinks that the operation will never attain any very great results, as the 
patients present themselves too late usually. 

Regarding the technique of the operation, the author cautions against 
uniting the ends of the severed gut, if tympanites be present, preier- 
ring the artificial anus. Union takes place easily and quickly if large 
portions of the serosa are brought in contact with each other. R. 
used very fine rounded curved needles and correspondingly fine silk. 
He has never had a case of gangrene of the edges, nor failed in a sin- 
gle case to get union. On uniting the gut later on, those portions 
which have been secured in the abdominal wound, should be removed. 
The intestine may be divided from the mesentery for a centimeter, 
without risk, care being taken to close the slit in the latter. The first 
row of sutures should unite the muscularis and a small strip of the 
serosa, whilst a second row should bring the surfaces of the serosa to- 
gether, for the space of 7* ctm. The intestines should be thoroughly 
emptied before the operation, to prevent soiling of the same with fecal 
matter. The author advises delay in uniting the intestine ends, owing 
to the impossibility in so many cases, particularly in cases of incarcer- 
ated hernia, of determining the real state of the gut at once. Resec- 
tion and suturing ought not to be undertaken, he says, until the intes- 
tines are thoroughly emptied of their contents, which should take place 



CHEST AND ABDOMEN. 2$ I 

in the course of 24 hours. — Deut. Med. IVoch. No. 15 and 16. Apri 
15 and 22. 1886. 

C. J. CoLLES (New York). 

X. Case of Cholecystotomy. By Dr. A. Landerer (Leipsic)- 
The wife of a shoemaker, set. 35, suffered for about eight months from 
severe pains in the region of the Hver. No stones were passed ; no 
jaundice occurred ; the pains were intermittent in character. A tumor 
of the size of a child's head, with irregular surface and hard to the feel, 
could be made out in conjunction with the liver and participating in 
its movements. The lower portion gave a tympanitic note, and the 
tumor, shghly movable under the integument, was painful on pres- 
sure, especially near its upper part. Urine and pelvic organs normal. 

Incision parallel to the median line over the tumor revealed the tu- 
mor adherent to the transverse colon and covered by hepatic tissue, 
and connected with the mesocolon behmd. Tapping produced mucus 
and pus, and verified the diagnosis of empyema of the gall-bladder. 

As extirpation was impossible, the author stitched the liver to the 
abdominal wall around the incision by means of five silk sutures, and 
applied sublimate and iodoform dressings. After six days during which 
no febrile reaction occurred, a large trocar was inserted into the gall- 
bladder through 272 ctm. of hver tissue and drainage established. 
Subsequently the opening was enlarged by Pacquelin's cautery. 

The patient made a good recovery, the pains were effectually cured, 
and only a fistula remained, through which onlv a few drops of ropy 
mucus were daily discharged. — Miincheiier Med. Wochenschrift. 1S86. 
No. 17. 

XI. Enterotomy for Ileus. By Dr. F. Fuhr (Giessen), and 
Dr. F. Wesener (Freiburg, Baden). In reviewing the various opin- 
ions hitherto expressed of the relative value of enterotomy and lapa- 
rotomy for the relief of ileus, the authors compare the two methods to- 
gether critically, and decide in favor of enterotomy. 

One case is given. A widow, set. 47, had worn a pessary which had 
pressed the sigmoid flexure of the colon against the sacral bone and 
here caused local circular inflammation, which subsequently led to a 



252 INDEX OF S UR GICAL PR GRL SS. 

Stricture of the gut. Ileus set in and the patient's Hfe was saved by 
enterotomy performed in the left inguinal region, the transverse colon 
being stitched to the wound. The faeces, however, could pass the ar- 
tificial anus in part ; and as they could not pass the strictured gut, in 
the course of time the intestine between the artificial anus (in the 
transverse colon) and the stricture in the sigmoid flexure became enor- 
mously distended and pressed upon the abdominal organs to such an 
extent that death ensued, under the symptoms of constipation, ascites, 
icterus, vomiting, singultus, dyspnoea and oedema of the lungs — about 
two years after the operation. An ovarian tumor (cysto-adenoma) 
was also found at the post-mortem, which had not materially influenced 
the case. 

In speaking of the merits of enterotomy as compared to abdominal 
section, the authors point out how the .protrusion of the greatly ex- 
tended intestines through a laparotomy wound prevent their replace- 
ment. 

Puncturing the gut with a fine needle they consider too dangerous, 
for the reason that the internal existing pressure cannot be sufficiently 
accurately estimated, which might be considerable enough to force out 
the contents of the intestine into the abdominal cavity after reposition. 
They concede, however, that the antiseptic method renders laparot- 
omy a less dangerous proceeding than it formerly was. The personal 
inconvenience attending artificial anus is not at all great, and its ex- 
istence is not even suspected by those ignorant of it. The fact that 
statistics show an equal amount of mortaUty after both operations is 
accounted for on the ground that the laparotomies attended by fatal 
results are rarely published. 

As to the objection sometimes urged against enterotomy, that a por- 
tion of the stenosed gut itself might be opened, and thus no relief be 
obtained, the authors believe that the abnormal gut may be recog- 
nized by the fact that it contains transudated blood. Nor is there 
much danger of opening a loop of intestine too near the duodenum, if 
the operation of enterotomy be done in the inguinal region. 

The authors explain the fact that enterotomy frequently leads to 
radical cure of ileus, by pointing out how the operation affords more 



CHES T AND ABD OMEN. 253 

space in the abdominal cavity, so that the invagination and axial tor- 
sion of the gut may be redressed. 

The danger exemplified by the case given, however, still remains an 
objection to enterotomy. Accumulation of fseces between the opening 
and the occluded portion of the gut may cause a fatalissue. — Deiitsch. 
Zeitzch.f. Chir. Bd. 23. Hft. 3, 4. March. 1886. 

XII. A Contribution to the Treatment of Gangrenous 
Hernise and of Artificial Anus. By Dr. Carl Koch (Nurem- 
berg). The author gives two cases of gangrenous hernia, and adds 
another, still under treatment, at the end of the paper. He then dis- 
cusses the subject, advocating the formation of artificial anus for all 
gangrenous cases of hernia. 

1. Decrepit woman, get. 60. Femoral hernia, incarcerated for two 
days ; gangrene of sac and of intestine, and of the cellular tissue. Gut 
stitched to the wound. On third day gangrenous portions sloughed 
off. No fever; no peritonitis, yet death ensued during granulation 
period in consequence of senile marasmus. 

2. Woman 45 years of age. Incarceration of hernia for five days. 
The intestine showed a gangrenous spot 27., ctm. in diameter. Su- 
tures applied to fix the gut in the wound. Sloughing ensued in eight 
days to the extent of two-thirds of the circumference, much more than 
was anticipated. No peritoneal or febrile reaction. Some eczema due 
to the subhmate dressings. After two months Dupuyten's clamp ap- 
plied, three times in all. After five months operation ; intestine freed 
from adhesions to skin and sac, pulled out, and sutured after Czerny's 
method, with forty sutures. Gut replaced and wound closed with su- 
tures. 

Drainage ; subUmate dressings. Reactionary temperature 38° C. 
Good recovery. Patient wears a truss, but hernia apparently again 
forming. 

Although much is to be said in favor of resection of gangrenous por- 
tions of incarcerated intestines with suture of the ends and replacement, 
the author is ot opinion that artificial anus formation with subsequent 
secondary operation is safer as regards the life of the patient. The health 
of a patient having suffered for some time from incarcerated hernia, 



254 INDEX OF SURGICAL PROGRESS. 

when pain, vomiting, local inflammation, fever and albuminuria have 
continued for a time, is too bad to admit of a long narcosis, and col- 
lapse and shock are apt to be the consequence. 

The danger of inducing septic peritonitis by replacing the inflamed 
tissues of the intestine into the abdomen is very great. The local sep- 
tic inflammation occurring after gangrene of the hernia may thus be 
transmitted to peritoneum. 

Another danger threatening peritonitis is the direct entrance of faecal 
matter into the abdominal cavity through the sutured parts. The su- 
ture, being performed upon abnormal gut, may at any time give away. 
Nor can the extent of the sloughing process be accurately estimated 
beforehand in intestines threatened with gangrene, especially if any 
portion of the mesentery has had to be removed. As for Schede's 
proposal to suture the gut and leave it outside of the abdominal cav- 
ity the author beUeves this method to be no improvement on the ar- 
tificial anus. He therefore concludes that only normal gut shonld be 
sutured and returned to the abdominal cavity ; but gangrenous intes- 
tines should be stitched to the wound, an artificial anus formed, and 
subsequently a secondary operation performed. 

This may either consist of Dupuytren's original procedure, which, 
however, is tedious and uncertain ; or it may consist in resection of 
the intestine, with suture and replacement, and closure of the abdom- 
inal cavity — a more preferable, but somewhat unsafe method ; or, last- 
ly, Dupuytren's clamp may be first employed to destroy the septum 
in the artificial anus, and then the gut may be pulled out, sutured and 
replaced, the wound being finally Hkewise sutured. This method is 
easy of execution ; the suture need only be applied to the perforation, 
a longitudinal suture taking the place of the more difficult and tedious 
circular one. Nor need the mesentery be touched in this operation, 
as in resection of the gut. 

This proceeding is, therefore, the one which the author recommends 
for all cases of gangrenous hernia. He adds some more special 
instructions concerning the technical details of the oj^eration. 
—Deutsch. Zeitschr. f. C/iir. Bd. 23. Hft. 3, 4. March. 1S86. 



EXTREMITIES. 255 

EXTREMITIES. 

I. Case of Total Extirpation of Scapula with Excision 
of the Head of the Humerus and the Acromial Portion of 
the Clavicle for Caries, with Final Recovery with Good 
Utility of Arm. By Dr. Schulz, of Sonnenburg in Neumark. A 
farm-hand, aet. i6, was admitted to the Johanniter Hospitalin Sonnen- 
burg, August II, 1884, for pain redness and swelling of the shoulder 
joint. He had gone to sleep July, 1884, and, on awakening, could not 
move his arm. Treatment with tr. iodine. After one week incision 
liberating pus. Fistulse remained below the spine of scapula and in 
the internal aspect of the upper third of arm. Movement was greatly 
impaired. Pressure caused pain ; temperature 40° C; pulse feeble ; 
occasional fainting spells. Treatment — tonic, eggs, wine, quinine, 
phosphates ; repeated incision and drainage ; arm maintained in fixed 
position. 

Subsequently improvement set in. But incision of an abscess above 
the spine of the scapula became necessary ; the focus was scraped out 
with the sharp spoon. Roughened bone could be felt over the whole 
of the scapula with probes, and joint-affection was established. 

September i. Arsenic given, with general improvement ; subsi- 
dence of suppuration ; increase of appetite. Soon, however, another 
abscess appeared near the acromion demanding incision. 

December 12. Extirpation of scapula; incision from spine to angle; 
subscapular artery tied ; head of humerus exsected, as well as acromial 
end of clavicle, both being carious. Sublimate dressings; reactionary 
temperature 38.0° ; subsequent reconvalescence. 

February 10. Patient up and about; can move fingers and forearm, 
and rotate and swing upper arm, but cannot abduct it. 

May 6. Dismissed with a suppport ; can write ; was seen after five 
months again, still improving. 

Some remarks are added and brief mention of twelve other cases 
is made. — Deutsch. Zeitschr. f. Chir. Vol. 23. Hft. 3 and 4. Mar. 
1886. 



256 INDEX OF SURGICAL PROGRESS. 

GENITO-URINARY ORGANS. 

I. On Extirpation of the Kidney. By Prof. Ernst von 
Bergmann (Berlin). A paper was read at an anniversary meeting of 
the Berlin Medical Society, containing, besides references to the sta- 
tistical contributions to the subject by Czerny, Balz and Gross, and 
general remarks, yfr-^ 7iew cases, and six other ones which the author 
had mentioned in a previous paper read at the Magdeburg Conven- 
tion of Scientists in 1885, but which have not as yet been published, 
making eleven in all. 

The unfavorable prognosis of operations for malignant tumors of the 
kidney may yet be improved, in the opinion of the author, by advances 
in the diagnosis and technical execution of the operation. Malignant 
tumors greatly vary in their course, some growing rapidly, others very 
slowly. Some i)resent early metastases, others none at all. In chil- 
dren a very gradual growth is the rule, leading to intermittent haema- 
turia, marasm and weakening diarrhoea, but other cases in which no 
renal symptoms occur are observed as well. The periods of occurrence 
of malignant disease, before the fifth and after the fiftieth year, also 
tend to render the diagnosis easier. The movabiHty of the tumor 
does not, however, appear constant enough to prove valuable in diag- 
nosis, nor is any constancy to be found in the adhesions of the tumor 
to surrounding organs. As to technique the author advocates lumbar 
incision for the removal of malignant neoplasms, and illustrates the 
dangers of anterior peritoneal section by two unsuccessful cases. If 
the tumor is too large to be readily removed an oblique lumbar section 
is to be made, without incising the peritoneum. In this way he 
successfully operated in one case for malignant disease of the kid- 
ney. 

Well developed abscess of the kidney is to be treated solely with the 
knife. The diagnosis can be made from the presence of a lumbar tu- 
mor, and that containing pus. The author was able to limit the diag- 
nosis to one kidney in five cases. 

Two cases of extirpation of the kidney for pyelo- nephritis are given, 
one of which ended fatally. A tumor was present and evening eleva- 
tions of temperature were observed in both cases. The urine was com 



GENITO-URINARY ORGANS. 2$/ 

paratively clear owing to the admixture of healthy urine secreted from 
the healthy kidney. Both patients were females and attributed their 
troubles to pregnancy. In one of these cases a stone in the renal pel- 
vis caused the suppuration. In two further cases the cause of sup- 
puration could not be ascertained. These both terminated favorably, 
as did also another (fifth) case, in which a kidney was extirpated for 
perinephritic abscess of large proportions. These kidneys did not 
bleed when their substance was injured, an observation which materi- 
ally facilitates similar operative procedures. In certain cases where 
the pus is concentrated in one point simple nephrotomy may be pref- 
erable to nephrectomy. Tlie former should be preferred if the diagno- 
sis is uncertain, and if it is uncertain whether the other kidney is dis- 
eased. 

One case, in which the author removed the kidney for suppurative 
processes, ended fatally, and the post-mortem showed that the other 
kidney was similarly affected. An analogous case where simple neph- 
rotomy was successfully performed, is promised shortly. 

In no case did any infection of the wound occur from the incision 
into the suppurating mass. 

Lastly a case of successful operation for hydronephrosis is given, 
in which the author removed the kidney through a lumbar incision. 

The paper abounds in interesting statements and hints pertaining to 
all the questions of the subject, including treatment, and which cannot 
here be more particularly considered. — ArbeiteJi aus der chir. Klinik 
der K'dnigl. Univ. Berlin, i. Th. II. 

W. W. Van Arsdale (New York). 

II. A Rapid Evacuator for Litholapaxy. By E. Andrews, 
M.D. (Chicago). In the evacuators of Bigelow and Thompson the 
rubber bulb makes suction only for an instant ; when it reaches the 
limit of its expansion, it suddenly stops the outward current from the 
bladder and arrests in transit a row of fragments of stone, lying along 
the whole length of the tube, which at the next compression of the 
bulb are all thrown back into the bladder; thus a large part of the 
fragments are pumped out and in many scores of times before they 
finally escape, prolonging the evacuating stage of the operation tediously 



258 INDEX 01^ SURGICAL PROGRESS. 

and irritating the inflamed bladder by the repeated forced expansions 
and by the pelting of the sharp fragments continually shot backward 
into it. To remedy these defects, the author devised an instrument 
consisting of a double chambered evacuating tube of which 
the straight part consists of a cyhndrical tube of verj' thin 
metal with an outside diameter of 8'/2 millimetres, and terminating in a 
rounded tip having a fenestium like Bigelow's, while the outer end is 
bent down, terminating in a piece of rubber tube, 9 centimetres long 
and 1 centimetre inside diameter. Along the under side of the straight 
portion of this overflow tube is soldered a thin concave semi-cylinder, 
making an inflow chamber, which is wrapped half around the outflow 
tube, giving the cross section an oval shape with an outside 
circumference of about 31' /i- millimetres, the diameter of the 
outflow chamber, being S^s millimetres, while that of the inflow 
chamber, is 2 millimetres. The inflow channel terminates in forty 
perforations, each i millimetre in diameter. The outer end of the in- 
flow tube projects in a straight line beyond the curve of the outflow fl 
and terminates in a cylinder of 10 millimetres, outside diameter, and 
having a stopcock of the same cahbre. To the outer end of this tube 
is attached a rubber tubing with an inside diameter of not less than 
one centimetre and a length of about two yards, to the farther end of 
which is attached a strainer through which a stream of water is to be 
syphoned. 

To use it, the evacuator should be introduced into the bladder 
with the fenestrum toward the patient's head and held at a steep slope, so 
that the tip presses the bottom of the bladder gently down toward the 
rectum, making a funnel-shaped depression into which the fragments 
tend to fall ; now turning the stopcock, a warm 1'., '~/c solution of car- 
bolized water is admitted through the inflow division and enters the 
bladder by the small perforations, sweeping the fragments rapidly 
around into the fenestrum of the outflow tube and thence outward into a 
basin set between the patient's thighs ; the current being continuous 
and always in one direction, the evacuation is accomplished with re- 
n.aikable rapidity. The writer refers to a case where the fragments of 
a hard oxalate of lime calculus, over one inch in diameter, were almost 



GENITO- URINAR V OR CANS. 259 

completety swept out in ten seconds, where, perhaps, twenty-five min- 
utes of churning to-and-fro with Bigelow's evacuator would scarcely 
have accomphshed the same result, and sixty seconds more of the cur- 
rent sufficed to remove the last particle remaining. The difficulty 
caused by fragments arching over the fenestrum of the evacuator and 
obstructing the outflow,he overcomes, when the scantiness of the stream 
shows obstruction, by compressing the end of the short rubber out- 
flow pipe between the thumb and finger and with the thumb and finger 
of the other hand suddenly compressing the tube just above ; this 
forces a short but strong pulsation back into the bladder and instantly 
dislodges the obstructing fragments. — four. A?n. Med. Assn. 1886. 
June 5. 

III, Nephrectomy on a Patient Twenty-three Months 
Old. By R. Park, M.D., (Buffalo, N. Y.). In the second winter of a 
child, hitherto apparently healthy, an enlargement appeared on the 
right side of the abdomen, which steadily increased in size ; 
palpation revealed a firm, resisting tumor about the size of a foetal 
head at term , the aspirator drew off a brownish, odorless fluid, exami- 
nation of which gave negative results. The tumor continuing to in- 
crease decidedly in size, after the lapse of a few weeks, the tumor 
being too large for removal by lumbar section, and incision was made 
in the right linea semilunaris ; slight adhesions were found, but the 
peritoneum, covering the growth, was incised and the tumor shelled 
out without much difficulty, proving to be, as had been previously di- 
agnosed, a fibro-cystic tumor of the right kidney, the cystic element 
predominating, and weighing, immediately after its removal, about four 
pounds. The pedicle was tied and dropped into the cavity, and the 
patient proceeded to a rapid recovery. A search into the Hterature of 
the subject seems to show the patient to be the youngest to have sur- 
vived the operation. — Proceedings Am. Surg. Assn. 1886. 

IV. Case of Hydrocele of a Hernial Sac. By R. F. 
Weir, M.D., (New York). A woman, aet. 24, had worn a truss for 
hernia for ten years, and presented at the location of the rupture a con- 
stant tumor which was dull on percussion and without impulse on 
coughing ; on grasping it with the hand, it did not give that pecuhar ir- 



260 INDEX OF SURGICAL PROGRESS. 

regular sensation, which an omental mass would give, and yet on 
pressure the bulging was just as if coils of intestine were underneath. 
In doubt as to the exact condition, but thinking that it might be a 
tatty tumor, it was cut doAvn upon, looking more and more hke coils of 
intestine, until the sac was arrived at, when clear fluid escaped through 
a minute incision. The opening was closed to preserve the cyst en- 
tire, if possible, and it was finally dissected out entire except at its 
neck, which ran up to and through the femoral ring ; on seizing this 
neck and applying a ligature and then dividing it, it was found to be a 
femoral hernial sac, which had been so shut off by the persistent use 
of a snug fitting truss that the sac had undergone conversion into a 
cyst ; it contained some five or six ounces of fluid. — Proceedings N. V. 
Surg. Soc. 1886. May 10. 

V. The Treatment of Varicocele. By R. F. Weir, M.D., 
(New York). The writer concludes as the result of his experience of 
a number of the methods devised for the treatment of varicocele ; (i) 
that for small varicoceles there is nothing better than a single (or 
double) subcutaneous hgature ; (2) for medium sized varicocele or for 
cases declining a more heroic operation, excision, in careful hands, is 
to be advised ; (3) for larger varicoceles, for relapsed cases and for 
those not very large but with a much elongated scrotum, ablation of 
the scrotum with ligature of the veins is preferable. — N. Y. Med. four. 
1886. March 20. 

J. E. PiLCHER, (U. S. Army). 

WOUNDS— INJURIES— ACCIDENTS. 

I. Stunning and Burn by an Electric Lamp. Prof Geo. 
Buchanan (Glasgow). Injuries from electric lamps are becoming not 
unfrequent. In most of the cases related, death has been instaneous. 
In a case reported on January 22, as occurring at Liverpool, the man 
was stunned and remained unconscious for a time and on recovery 
was found to be quite blind. 

A workman, aet. 44, was engaged on a crane when a " Brush'' was 
by some mischance lowered into contact with the chain of the crane. 
Instantly the man was " doubled up," but his hands were compelled to 






BONES, JOINTS, ORTHOPAEDIC. 



261 



spasmodically grasp the chain so that he did not fall. He remained in 
this position for four minutes until the lamp and chain were separated. 
He then dropped down stunned. He recovered consciousness in an 
hour. There was a sHght vesication on the hand where it grasped the 
chain, and at the part of the sole of the foot, through which the cur- 
rent passed into the ground, two square inches of skin were complete- 
ly charred, as was also the neighboring part of the stocking. 

The general symptoms (which soon passed off) were a sHght amount 
of general shock, a feeling of heat in the abdomen and chest, and dim- 
ness of vision. 

Sir Wm. Thomson suggests that if a bystander had taken the man 
by the clothes and drawn his feet from contact with the ground, or had 
thrust a bit of dry clothing under his feet, the contact would have been 
broken and the hand relieved from the chain. 

C. B. Keetley (London). 

• BONES, JOINTS, ORTHOPAEDIC. 

I. On Cases of Sudden Death Resulting from Venous 
Thrombosis and Embolism after Fractures of Bones. By 
Prof. P. Bruns (Tubingen). The author gives one case of his own 
and a tabular synopsis of thirty-five extant cases. Analysis of 
these shows that the fractures occurred most frequently in the lower 
extremity, and in persons of from 40 to 60 years of age. The imme- 
diately cause of thrombosis of the veins consists in compression or in- 
jury of the veins at the seat of fracture; and some predisposition is usu- 
ally present on the part of the patient, such as varicosities or circulatory 
impairment. Embolism may occur at any lime between the fourth and 
seventy-second day after the fracture, and death may result immedi- 
ately, from asphyxia or syncope, or after a longer period of time from 
infarction of the lung, or, finally, recovery may take place. 

II. On the Behavior of the Bodily Temperature in Sub- 
cutaneous Fractures. By Dr. Ernst Mueller, first assistant 
surgeon at the Tubingen Surg. Clinic. Rise of bodily temperature 
after simple fractures of bones was formerly believed to be of rare oc- 
currence ; but of late repeated exact measurements have led to the 



262 



INDEX OF SURGICAL PROGRESS. 



opinion that high temperatures after fractures were a very frequent 
symptom. 

In the present paper the author has considered 359 cases gathered 
from his own chnic, and from those of Stuttgart, Halle, London, 
(Univers. Coll. Hosp,) and from a report by Stickler (New York), and 
concludes that a rise of temperature is found in subcutaneous frac- 
tures in over 85 per cent, of the cases, and is, therefore, the rule. 

The author's own cases are tabulated, and present temperatures 
ranging from 38.0° to 40.0° C. The highest rise was observed on the 
first and second evening after the accident. In some cases the fever 
lasted as long as thirteen days. Transportation after the accident did 
not appear to increase the temperatures. Generally speaking, the 
temperatures incieased in direct proportion to the quantity of extra- 
vasated blood ; but this ratio did not hold good in all cases. 

The Stuttgart cases, which are also tabulated, show lesser elevations 
of temperature throughout than the Tubingen ones, a curious and un- 
explainable fact. 

The author ventures no explanation of the cause of fever after frac- 
tures. — Beitriige zur klin. Chirurg. Mittheil. aus der chir Klink. 
zu Tubingen. II. Bd. i. Hft. I. 

III. Fracture of the Ulna in Its Upper Third Combined 
^A^ith Dislocation of the Head of the Radius. By Dr. Hans 
DOERFLER (Nuremberg). The rarity of this injury and its limited lit- 
erature has led the author to make it a subject of special study, more 
particularly since it is one of great practical importance. He gives 
four cases, some of which were observed by himself. 

The first case is that of a man, 66 years of age, who, 40 years pre- 
viously, was kicked by a horse, and sustained a compound fracture of 
the ulna in its upper third. The radius was luxated. No apposition 
of the fragments was attempted at the time, and no splints applied. 
The bones, in consequence, did not unite, and paralysis of the exten- 
sor muscles of the fingers resulted, due to a lesion of the musculo- 
spiraUs nerve. Arthritis deformans subsequently set in. and the fore- 
arm became entirely useless. 

The second case, which was seen seven years after the accident, 



BONES, JOINTS, ORTHOPEDIC. 263 

presented a compound fracture of the ulna combined with dislocation 
of the radius and subluxation of the styloid process of the ulna, in 
consequence of direct violence, caused by a fall down stairs. 

The third case, that of a child set. 3^/3 years, was one of fracture ot 
the ulna simultaneous with luxation of the capitulum of the radius, sus- 
tained by a fall from a rocking-horse. The fracture alone was diag- 
nosed at first, but seven days later the consulting surgeon discovered 
the dislocation. Complete recovery resulted. 

The last case was one of the same injury acquired by a fall on the 
stairs. The fracture is supposed to have been caused by direct vio- 
lence in consequence of the blow against the edge of the step, and the 
luxation further induced by a fall on the outstretched palm. The 
fragments formed an angle with the apex pointing backwards. 

In discussing the mechanism of the injury the author concludes from 
the study of 19 cases, that direct violence alone less frequently occas- 
ions it, than combined violence, as exercised by a fall, the proportion 
being 5 to 11. 

The greater number of cases occurred between the ages of 3 and 15, 
all others after the 35th year. 

The question in what causative relation the two injuries stand to 
each other, is next considered. Grenier's assertion that the two m- 
juries could not be simultaneously produced by means of any applied 
violence, is disproved by the author, who experimented upon ten ca- 
davers. After chiseling partly through the ulna, he could easily frac- 
ture it, and by continumg the pressure, could occasion luxation of the 
radius. 

He therefore beUeves that both injuries occur simultaneously, but 
that the fracture is primary and the dislocation of the radius secondary. 
Further experiments were performed to prove this. 

Luxation of the radius proved very difficult to effect, but when pres- 
ent, application of further violence entirely failed to fracture the ulna, 
but produced typical fracture of the radius in its lower third. After 
partial incision of the ulna, however, direct violence easily eff"ected the 
desired injury, luxating the capitulum radii forward and outward, if ap- 
plied from behind and laterally. 



264 INDEX OF SURGICAL PROGRESS. 

The post-mortem condition of the parts is accurately described in 
these cases of artificial production of the injury. 

The fragment of the ulna is not instrumental in causing the disloca- 
tion, in the author's opinion, but the radius- head may be displaced 
either by the continuation of the same direct violence which caused 
the fracture, or, by indirect violence, as by pressure upon the extended 
hand. The ft-st of these modes is illustrated when the patient has 
been kicked, run over, hit by a stick, shot, or has fallen against some 
hard object ; the latter, when he has first fallen against some hard body 
and subsequently fallen on his extended hand — as when falling down 
stairs. 

Luxation of the radius cannot occur if the ulna be fractured below 
its upper third. 

These conclusions are drawn from further experiments on the ca- 
daver. 

The symptoms of the injury are given as follows : Inspection reveals 
an angle outlined by the contour of the soft parts of the dorsal aspect 
of the fore-arm. The elbow-joint shows a well-marked bulging either 
towards the front, or laterally and anteriorly or posteriorly combined. 
This prominence, caused by the capitulum radii, moves when prona- 
tion and supination are performed. The circumference of the injured 
joint is increased from 2^2 to 4 cm. 

On the posterior aspect three points can be made out, with the help 
of which a triangle may be constructed, having as its apex, the point 
of fracture of the ulna, and. as its base, a line drawn from the ole- 
cranon to the capitulum radii. This line passes directly over the ex- 
ternal condyle of the humerus, in its middle. The injured arm ap- 
pears shortened to the extent of 172 cm. The dislocation of the frag- 
ments depends upon the direction of the violence ; the lower fragment 
remaining parallel to the radius in all cases, the upper one varying in 
position. The fore-arm is generally found half flexed, and half pronated. 
The elbow is frequently much swollen. Crepitation is always present 
at the point of fracture. Flexion is interfered with, but extension is 
possible ; supination is somewhat impeded. The ulna alone is short- 
ened about 3 cm. 



BONES, JOINTS, ORTHOPEDIC. 265 

Complications of the injury are sometimes present and consist in 
subluxation of the styloid process of the ulna, paralysis of the musculo- 
spiralis nerve — a frequent source of danger — compound fracture, or in- 
jury to the soft tissue, and fractures of the epicondyles or condyles of 
the humerus, the latter being of very rare occurrence. 

The prognosis is quite favorable if the treatment is begun at once, 
or even within the first six weeks. After two months there is less 
hope of success on account of the capsular degeneration ; a new cap- 
sule is soon formed wherever the head of the radius remains, so that 
function may, in a measure, return, if the fragments of the ulna unite. 
If the latter does not occur, the use of the hand is entirely lost. Arth- 
ritis deformans may occur in later years as a result of the injury. The 
prognosis of paralyses is unfavorable. 

As regards treatment, it is of great importance to bear in mind the 
possibility of an existence of a luxation of the radius in all cases of ul- 
nar fracture. After replacing the capitulum of the radius with the help 
of extension and direct pressure from below, the arm is to be fixed in 
a half-supinated position and flexed at an acute angle at the elbow (so 
as to eliminate the action of the biceps) by means of a water-glass or 
starch bandage, to be left on for four or six weeks. The position of 
half-supination is maintained in order to prevent the new-forming cal- 
lus from again occasioning a displacement. 

In old cases where replacement is impossible, resection of the capit- 
ulum radii is indicated, OsteopaHnclasis of the ulna may become 
necessary in some cases. Compound fractures are to be antiseptically 
treated. — Deut. Zeifschr.f. Chirurg. Bd. 23. H. 3 and 4. March 
10. 1886. 

IV Two Cases of Lipoma Arborescens Genu, Compli- 
cated with Recent Synovial Tuberculosis. A contribution to 
the knowledge of tuberculatisation of processes originally of a non-tu- 
berculous character. By Dr. Geopg Schmolck (Halle). Lipoma of 
the knee-joint being rare, S. refers to one such case published by Joh. 
Muller and gives abstracts of six other cases of simple lipoma genu. 
He then describes two cases of arborescent lipoma of the knee observed 
by him in Prof. Volkmann's clinic. Both cases represent simultaneous 



266 INDEX OF SURGICAL PROGRESS. 

lipomatous degeneration of all the normal villous excrescences of the 
synovial membrane of the joint, a condition for which the author sug- 
gests the name " liopmasia of the synovial viUi." This is what the 
name lipoma arborescens signifies. In the six other cases just referred 
to, simple lipomata of the joint were present, and the author differen- 
tiates between the two forms as regards their origin, beheving with 
Koenig that the simple lipomata are of subserous origin and bear an- 
alogy to the peritoneal subserous lipomata. 

Especial interest attaches to both cases for the reason that evidences 
of recent tuberculous affection of the synovial membrane were present 
in each case. The author quotes Riedel as asserting that tubercular 
synovial processes frequently appear secondarily subsequent to fibrin- 
ous synovitis with melon-seed bodies (corpora orzyoidea), and argues 
analogically that secondary tuberculous affections may also occur after 
lipomatous degeneration. 

The first case is that of a theological student, jet. 23, who 12 years 
previously had suffered from an acute inflammation of the knee-joint 
due to contusion and cold, and since then had had recurrences two or 
three times. The diagnosis of fungous (tubercular) inflammation of 
the joint was made. Incision, however, revealed four packages of 
polypous excrescences, which were excised, and also a recent synovial 
tuberculosis. Microscopic examination showed the polypi to be lipo- 
mata and demonstrated miliary tubercles, giant cells and specific tuber- 
cle bacilli. 

The second case was a farmer, set. 52, who had had serous effusion 
into the knee-joint for five years. Villous growths were found in the 
joint and were removed. Recent tuberculous infection was likewise 
revealed. — Deutsch. Zeitschr.f. Clin. Vol. 23. Nos. 3 and 4. March. 
1886. 

V. The Treatment of Scoliosis by Massage. By Dr. A. 
Landerer (Leipsic). Eighteen cases of lateral curvature of the spine 
not due to bone-disease and occurring in youthful individuals of ages 
ranging between 2' 'o and 21 years, were treated by the author with 
massage, and with such excellent results that he recommends this mode 
ot treatment in all similar cases. 



BONES, JOINTS, ORTHOPEDIC. 267 

The cases are given in short and represent both shghter deformities 
of the spinal column and severer scoHotic affections ; many of them 
had already been in the treatment of renowned speciahsts for a shorter 
or longer period, and had had the advantages of the best orthopedic 
appliances and of methodical exercise ; in some cases the trouble had 
existed for as many as nine years. The results almost constantly far 
surpassed the expectations of the author. 

Starting with the proposition heretofore ascertained, that scoUosis is 
deformity caused by the inability of the spine to support so great a 
weight as it is compelled to carry, and confining his subject to those 
forms of scoliosis, either unilateral or serpentine, which are kno^^^:l as 
habitual curvatures, as differing from static, traumatic, and other forms, 
the author proceeds to show that it is the muscular system alone which 
is at fault, and to the inefficiency of which the deformity is owing. 

For this purpose he first examines the physiological or normal action 
of the dorsal muscles, and shows how the normal s-shaped configura- 
tion of the spinal column results out of the simple arc of the spine 
of the infant, by the action of the cervical and lumbar sets of muscles 
and the weight ot the thorax. Thus muscular individuals present more 
pronounced physiological curves of the spinal column than weakly 
ones ; they appear to stand straighter. 

Other sets of dorsal muscles have the function of pjeventmg the 
spinal column from leaning laterally. As a mast of a ship is held in 
its upright position by the shrouds, the spinal column, not unhke a 
mast composed of many segments, is normally retained perpendicular 
by means of the dorsal muscles while other shorter dorsal mus- 
cles perform the function of holding the segments together. 
In scohotic individuals — so the author maintains — the muscles 
of the back are insufficient to perform their function. This 
is made evident by the ease with which one can aggravate scoliosis in 
certain individuals by pressure upon the head. Moreover, scoliosis is 
more marked and more difficult to cure in individuals whose antero- 
posterior curvature of the spine is not well developed. Again, atrophy 
and fatty degeneration of the dorsal muscles is a frequent post-mortem 
symptom of scoliosis. The habit of leaning to one side and differ- 



268 



INDEX OF SURGICAL PROGRESS. 



ences in weights supported by either shoulder are only of importance 
in deciding the direction of the curvatures, but not, as has been be- 
heved, in actually causing the curvatures. Secondary trophic changes 
in the osseous elements finally render such habitual curvature fixed, 
Avhereas in cases of static scoHosis (coxitis, etc.) the curvatures remain 
flexible on account of the better muscular development. 

If, then, scohosis is due to insufficient muscular action, the only 
rational treatment is one affecting these muscles. As massage is very 
efficient in strengthening the muscles, the author beheves this mode 
of treatment a very considerable improvement upon gymnastic exer- 
cise. 

His method is a combination of " tapotement "' and "redresse- 
ment." The child, stripped to the waist, is laid in a prone position 
upon a mattress, with its arms extended out in front. The extensor 
muscles of the back are then tapped with increasing force with the 
fleshy portion of the hand below the little finger, motion being made 
only in the wrist-joint, for a period of five or eight minutes daily, or 
even twice daily. The entire extent of the back, from the hips to the 
neck, is thus treated. The " redressement " is first applied to the 
spinal column and subsequently to the ribs and thorax while the patient 
is standing, the idea being to correct any deformities that are thus 
amenable to treatment as well as rotary conditions. Finally active ex- 
ercises are added, including suspensions. 

In many cases gratifying results can be achieved after ten or twelve 
sittings ; pain and intercostal neuralgia is otten rapidly cured, even in 
cases of fixed scoliosis, where complete cure is not possible. 

Orthopedic apparatus and corsets the author believes much inferior 
to massage for the reason that they tend to make the muscles degen- 
erate still further; and although they permit straight carriage for a 
time, the weakness returns as soon as they are discarded. The patients, 
too, much prefer the treatment i y massage, as it increases their sense 
of muscular action. 

As for the time required for treatment, slight cases may be cured in 
a few months ; others demand one year and more. Much, however, de- 
pends upon the condition of the bones and the age of the patient. — 
Deut.Zeitschr.fiir Chir. Bd. 23. H. 5 and 6. 1S86. 

W. W. Van Aksdale. 



BONES, JOINTS, ORTHOPAEDIC. 269 

VI. The Treatment of White Swelling of the Knee. By 

A. B. JuDSON, M.D., (New York). The writer holds that white swel- 
ling or articular osteitis of the knee is an inflammatory affection at- 
tended by destruction and degeneration and followed as a rule by im- 
pairment of function. Its severity and duration are increased by use 
of the joint and also by impairment of the general health, which is re- 
ciprocally affected by the local disease. It has, however, a so-called 
natural cure, which occurs when the morbid process is supplanted by 
the reparative. The object of treatment is to prevent ultimate im- 
pairment of function and to hasten the natural cure by improving the 
general condition and removing causes of local aggravation. Func- 
tion is to be preserved or restored by subduing inflammatory action. 
The health is to be maintained by appropriate medication and a proper 
amount of out-door exercise. Mechanical means should be adopted 
to secure activity in walking without injury to the affected part. 
Locally, fixation of the joint is suggested by the weakening and loss of 
the hard tissues of the joint and by the presence of hyperaemia, and en- 
forced by the general rule that inflammation should be treated by ar- 
rest of function. The affected part should also be prevented from 
bearing the weight of the body, a precept which is suggested by the 
softened and excavated state of the bones and the infrequent occur- 
rence of the disease in joints which are exempt from this duty, and en- 
forced by the same general rule that the presence of inflammation de- 
mands the arrest of function. Fixation is conveniently secured and 
the deformity reduced by a simple retentive sphnt, making pressure 
from before backwards in the vicinity of the joint, and from behind for- 
ward at the upper part of the thigh and the lower part of the leg. Ar- 
rest of the weight-bearing function, or protection from violence in 
standing and walking, is to be secured by suspension of the limb, 
which is conveniently secured by the ischiatic crutch of Thomas of 
Liverpool, with a high-soled shoe on the foot of the unaffected Hmb. — 
N. Y. Med. Jour. June 6. 

VII. The Use of Drills and Nails after Resection. J. 
A. Wyeth, M.D., (New York), presented some steel drills for fixa- 
tion of the knee-joint after resection, which he considered to be better 



2/0 INDEX OF SURGICAL PROGRESS. 

than nails since they could be introduced by drilling with less danger 
of crushing through the bones ; the parts suffered no concussion or 
chance of displacement as when the hammer was employed ; the drill 
point was smaller than the shaft so that, as it passed through the bone, 
it became tighter and tighter and remained perfectly firm. He used 
three of them in operation, two passing obhquely and laterally from the 
tibia to the femur, and a third in the median line downward from the 
femur to the tibia. 

C. K. Briddon, M.D., (New York), thought that fixation of the 
bones was not attained by the wire suture or by nails as ordinarily 
used. He had observed that the nails cut through the cancellous 
tissue of the bones when driven from the femur into the tibia, or vice 
versa, and he thought that the bones were more surely maintained in 
position if the nails were driven in the exact center of the bone at the 
side and at a right angle to the axis of the bone, about three-quarters 
of an inch above the cut surfaces, one on either side of the femur and 
the tibia ; these nails being wired together at the side of the bones, 
held them securely in position, a plaster of Paris dressing being ap- 
phed outside of the wound-dressing. 

A. G. Gerster, M.D., (New York), reported a case of exsection of 
the knee joint for ankylosis, the result of an acute osteo-myeHtis, in a 
girl, set. 15. The extremities of the bone, on being brought into posi- 
tion, were secured by nails, the first one passing through the dense 
bony substance of the head of the tibia into the femur, and the other 
two passing from above downward from the femur into the tibia, se- 
curing excellent fixation and a good result. He had found the ordi- 
nary dry goods box nail to answer all purposes ; the only precaution 
he should observe was that of placing his index finger between the 
bones and the popliteal space so that no nail could be driven through 
the bones into this space without the operator being aware ofit,and also 
to prevent the occurrence of any lateral displacement during the oper- 
ation. — P}-oceedi>ii^s N. Y. Surg. Soc. 1886. May 10. 

VIII. Excision for Chronic Disease of the Shoulder- 
Joint. By L. W. HuBB.ARD, M.D., (New York). The writer beHeves 
that early excision is the preferable treatment for chronic shoulder- 
joint disease, because of (i) the probabiHty of as good if not better 



TUMORS. 271 

restoration of the function of the limb, (2) the shorter time which will 
elapse before the patient will be able to use the limb ; (3) the immedi- 
ate improvement in general health which follows removal of the dis- 
eased tissue ; (4) the removal of a possible source of general (tuber- 
cular) infection, without causing any deformity or disqualifying the 
patient from engaging in the ordinary pursuits of life — objections which 
are strong against excision of the joints of the lower extremity. — Med. 
News. 1886. April 24. 

IV. Chronic Disease of the Shoulder. By V. P. Gibxey, 
M.D., (New York). The purpose of this paper is to show by clinical 
illustrations the inefficiency of passive motion, with or without an anaes- 
thetic, as a means of relieving fibrous ankylosis, and it may be regarded 
as supplementary to the preceding. — Med. News. 1886. May i. 

James E. Pilcher (U. S. Army). 
TUMORS. 

I. On the Arsenical Treatment of Malignant Tumors. 
By Dr. F. Koebel (Tubingen). The author reviews the results achieved 
at the Tubingen Clinic (Prof. Bruns) in the treatment of certain ma- 
lignant neoplasms by means of internal administration ot arsenic. 

As regards epitheHal carcinomata various experiments were made at 
one time or another in inoperable cases of mammary disease, with 
local injections of arsenic ; but in no cases were favorable results re- 
corded. 

Sarcomata, excepting those of the lymphatic glands, have likewise 
generally been regarded as incurable by means of arsenic. But the 
author gives a case of a man 39 years of age who presented multiple 
sarcomata in rapid growth when admitted to the hospital, and who 
was completely cured after three and one-half years' time by combined 
local and internal administration of arsenic. The diagnosis was as- 
sured by microscopical examination of an exsected portion. 

Lympho-sarcomata were not influenced in their course by arsenical 
treatment, as was proved by the observation of several cases. 

The greater part of the paper is devoted to the consideration of 
malignant lymphomata, in the treatment of which arsenic has always 
played a conspicuous part. 



2/2 INDEX OF SUR GICAL PR CRESS. 

In order to draw more correct inferences the author first reviews 
fifty-two cases collected from various sources, and then adds to this 
number seven cases of Prof Bruns. He then proceeds to draw his 
conclusions. The ages of the patients varied equally between 7 months 
and 72 years. Males were twice as frequently affected as females. In 
27 cases the neck alone was affected, in 13 cases the whole body. 
Statements as to the presence of leucaemia are incomplete. The treat- 
ment consisted in internal exhibition of Fowler's solution, increasing to 
a maximum of 40 to 45 drops daily, and in parenchymatous injections, 
gradually ascending to 0.4 or 0.5 ctm. daily. 

As to the results attained complete cure was observed in 1 7 out of 
the 59 cases ; but in five of these, recurrences are recorded ; in the 
others no further notes are made. The time elapsing before the cure 
was complete varied from one to six months. Recurrences varied in 
the time of their appearance from two to eight months. 

In 14 cases the recovery was partial. In 28 cases out of the 59 the 
treatment was altogether ineffectual. In some cases, however, the 
time allowed for observation was too short. 

The author concludes that the treatment should be continued for at 
least two months in order to ascertain whether it will prove of avail or 
not, and recommends the trial of raedicamental treatment with arsenic 
in all inoperable cases of malignant lymphoma, and in certain ones of 
general sarcomatosis. Although many cases are not cured, some 
brilliant results have been obtained by this method. — Beitrdge zur 
klin. Chirurg. Mittheil. aus der Chir. Klink zu Tuhinge7i. II. Bd. i. 
Hft. lY. 

II. Contributions to the Pathology of Tumors. By Prof. 
WiLH. Zahx (Geneva). (Continued from Vol. III., No. i, p. 95 of 
this journal. 

7. Two Cases of Chondro-osteoid Sarcoma of ike Thyroid Body 
Although malignant tumors of the thyroid gland were formerly believed 
to be very rare, they are at present more frequently observed, since at- 
tention has been directed to them. The author alone saw five cases of 
carcinoma in nine years' time. Sarcomata of the thyroid, however, 
are still very rare, and chrondo-osteoid sarcomata have never yet 



TUMORS. 273 

been described. The author, therefore, now publishes two such cases. 

A. Thyroidal chrondo-osteoid sarcoma ivith etJibryonal transversely 
striated muscle-fibrillcB and pig?)ient cells occurring in a humaii foetus. 

Still-born infant, presenting at birth a tumor the size of a man's fist 
situated on the anterior aspect of the neck and reaching from the chin 
to the sternum and laterally to the right ear. The superficies was un- 
even ; the consistency different in the various parts. The skin above 
it was bluish in places, not adherent to the tumor. The thymus and 
cervical glands were normal. 

The tumor consisted of several large cysts, which were very soft on 
pressure ; a membrane of connective tissue covered each prominence. 
The contents of the cysts consisted of an inspissated reddish fluid, mi- 
croscopically consisting of small round cells (similar to those of lym- 
phatic glands) and capillary vessels. No stroma. Injection of the tumor 
did not give satisfactory results. 

The tumor enveloped the trachea, larynx and oesophagus, and occu- 
pied the place of the thyroid body. An isthmus could be made out 
joining the two portions of the tumor. 

Microscopic examinations revealed various histological elements. 
Small round cells grouped together without any intercellular tissue 
formed the main constituent part of the tumor. Peripherally much 
perfectly formed, highly vascular connective tissue was seen ; circum- 
scribed and well-defined deposits of cartilage, both embryonal and os- 
seous cartilage, were found in both portions of the tumor ; and cavities 
lined with epitheha (embryonal thyroid tissue), in the shape of follicles 
and tubes. Groups of pigment cells and bundles of striated spindle- 
cells (embryonal muscle tissue) were also present. 

The diagnosis made was one of foetal thyroid tumor originating from 
the branchial formations. 

B. Chondro-osteoid sarcoma of the thyroid body and lungs in a dog. 
This tumor consisted in its peripheral portion of firm connective tissue, 
which extended in places into the center of the tumor. Between these 
extensions and enclosed in them was much calcified and uncalcified 
cartilage tissue. Both together formed a reticulum in the spaces of 
which small round cells and spindle-cells were seen. Secondary nod- 



2 74 INDEX OF S UR GICAL PR GRESS. 

ules were also found in the lungs, the smaller of which proved to be 
sarcomata, the large ones, however, also contained hyaHne and osteoid 
cartilage-tissue. An acquired mixed tumor was diagnosed, and the au- 
thor points out how both these two tumors described are of special in- 
terest in regard to the question of formation of mixed tumors ; the one 
being an example of teratoid mixed tumors, the other of organoid ones 
(Virchow), with a co-formation of various elements, or a transforma- 
tion (metaplasia, Virchow) respectively. 

8. A case of papillary cylindro-cellular adenoma of the thyroid body 
in a dog. A dog had suffered from a tumor of the neck, as large as a 
man's fist, and had died from compression of the trachea. The tumor 
showed a canalicular structure with ramifications. The vascular cap- 
sule consisted of fibrillary connective tissue. The trabecular structure 
was composed of blood-vessels, from which capillary loops proceeded, 
covered ■with cylinder-epithelia. In this manner papillae were formed. 
The interstices were filled with fine granular masses, which resembled 
coagulated albumen. — Deiitsch. Zeitschr.f. Chir. Bd. 23. Hft. 3,4. 
March. 1836. 

W. W. Van Arsdale, (New York). 

III. The Extirpation of Tumors of Scarpa's Triangle. 
By E. KiRMissoN, M.D., (Paris). This is a study of the topographical 
anatomy of the groin with especial relation to the removal of tumors. 
The greatest danger of operations here, rendering their performance 
very dehcate, is the intimate relations between tumors and the great 
vessels of the groin. The ablation of superficial tumors, developed in 
the skin and subcutaneous connective tissue, is of but little interest, 
although the possibility that a superficial tumor may be found to have 
pushed out unsuspected deep prolongations, imposed upon the surgeon 
necessity for the greatest care even in apparently simple cases. In 
subaponeurotic tumors, the dissection should begin at their external 
face and extend inward, upward and downward, if necessary, so as to 
leave the tumor adherent only at the point corresponding to the sheath 
of the femoral vessels; then the dissection of the pedicle should follow. 
If the tumor is so large as to inconvenience the surgeon and hide the 
sheath of the vessels, which it is important for him to recognize both 



TUMORS. 275 

with the finger and the eye, it may be removed in fi-actions, that por- 
tion which is the more particularly adherent to the vascular sheath 
being left in place. Not only should the pulsations of the artery be 
constantly under observation, but the plan followed by Denonviliers, 
of first tracing the course of the vessel on the skin, in a case where the 
femoral artery was deviated, might be adopted. In the dissection of 
the adhesions of the tumor to the sheath of the vessels, three condi- 
tions may be found, giving rise to very different prognostic and thera- 
peutic considerations, (i) It may be possible to destroy the adhesions 
completely, the femoral sheath remaining intact ; (2) this sheath may 
be opened to a greater or less extent, and (3) in much the more serious 
cases it becomes necessary to involve the vascular walls in the opera- 
tion by isolated section and ligature of the vein or by resection and 
simultaneous ligature of the vein and artery. Simple denudation of 
the femoral vessels is of little gravity ; in twelve cases of this kind 
death followed but twice and could not be attributed to the venous le- 
sion. Moreover, denudation of the vessels may present two very 
different degrees ; in the first the sheath is simply laid bare without 
being involved ; in the second, a greater or less extent of the sheath 
is excised, and the walls of the vessels are directly exposed to con- 
tact with suppuration. In this case the chances of the development 
of sloughs in the vascular walls and of secondary haemorrhage are 
evidently much greater. In a similar case the plan of Mosetig 
might be followed, who systematically incised the sheath of the ves- 
sels with the bistoury and the grooved director, separated each of the 
vessels from its normal position, and excised from between the two 
a large fragment of the neoplasm. When the femoral vein is in- 
volved, the prognosis becomes much more grave ; of eight of this kind 
four were fatal. This result of lesion of the femoral vein will often 
be present, for the walls of the vein are infinitely less resistant to 
the invasion of neoplasms than the arterial; furthermore, most of 
the tumors, being glandular, are brought into closer relations with 
the vein than with the artery. In case of a wound of the vein, lig- 
ature of the corresponding artery would not control the haemorrhage, 
while ligature of the vein itself, far from causing gangrene, is more 



2/6 INDEX OF SURGICAL PROGRESS. 

rarely followed by it than simultaneous ligature of the vein and ar- 
tery, and should be adopted. 

Coming finally to the cases in which ablation of the tumor ne- 
cessitates resection and simultaneous ligature of the artery and the 
vein, it is observed that these cases are much more grave, since in 
seven cases collected, five terminated fatally ; however, it would 
seem proper to make a distinction between the cases in which the 
resection and Hgature are to be practiced above and below the or- 
igin of the profunda femoris vessels. In the midde of the thigh or in 
the popliteal space, simultaneous resection of the two principal ves- 
sels may be employed. In Scarpa's triangle, on the contrary, where 
the resection would much more frequently occur above the profunda 
vessels, this course exposes the hmb to gangrene and cannot be recom- 
mended. If then careful examination of the patient shows the neces- 
sity of simultaneous resection of the artery and vein at the base of 
Scarpa's triangle, it would be best to abstain. However, it may 
occur that, during the operation itself, lesions may be recognized 
which the most careful examination had not been able to suspect ; 
in these cases the extirpation may be left complete, or, relying up- 
on certain fortunate cases in which Hgature of both femoral vessels 
above the origin of the profunda vessels has been followed by re- 
covery, resection may be adopted. It is a question of indications 
and contraindications, the solution of which will depend upon the age 
of the patient, his general condition and the state of the vascular sys- 
tem. The crural nerve and its branches are less exposed to injury by 
extirpation of tumors of the thigh than the vessels ; cases are lack- 
ing to show the ulterior consequences of section of these nerves. The 
possibility of wounding the peritoneum in this space is noted, and 
the case of Eugene Boeckel, in which this occurred, the peritoneal 
wound being sutured with catgut, with recovery referred, to. The 
possibiHty of the existence of a femoral hernia below a neoplasm 
renders care desirable. Finally, the frequency of erysipelas after ex- 
tirpation of tumors of the groin is remarked and attributed to the 
abundance of lymphatic vessels. — Revue de Chirurgie. 1886. May. 

James E. Pilcher (U. S. Army). 



REVIEWS OF BOOKS, 



On the Supra-Pubic Operation of Opening the Bladder for 

THE Stone and for Tumours. By Sir Henry Thompson, F. R. 

C. S., etc., London. J. and A. Churchill, ii New Burlington 

street. 1886. Pp. 57. 

Sir Henry Thompson has the soul of an artist, and there is always a 
charm about the manner in which he treats any subject he mav chance 
to deal with. As also he writes only on matters of which he has had 
an exceptional, often unique, experience, it goes without saying that any 
surgical book of his must be a valuable book to literature. 

After a few preliminary observations Sir Henry deals with the supra- 
pubic operation in its historical, anatomical and practical aspects suc- 
cessively. He observes, incidentally, that the largest stone he has yet 
removed by lithotrity weighed 2^ j ^ ounces (80 grammes). He adds ' 
" I do not deny that even a larger size may be so extracted, but I do 
not say that it would be often prudent to undertake the task. Much 
depends upon the operator and his experience. Phosphatic calculi of 
still larger weight may be crushed successfully. But there is a limit 
which no man can define, even to the capability of modern lithotrity. 
There are calculi too large and too hard to be removed by that opera- 
tion." There can be no question but that the less experienced the op- 
erator is in deahng with stone, the sooner will the limit of size and 
hardness be reached at which he ought to cut and not crush. As our 
author remarks, stones of large size ought not to exist in these days, 
but, so long as human nature is found in man, there will be patients 
whose timidity and procrastination will give calculi time to grow. It 
is not, therefore, entirely a question of improved surgical education. 

Sir Henry now believes that in the hands of most operating sur- 
geons supra-pubic lithotomy will prove a safer and a far easier opera- 
tion than lithotrity for hard stones when they have arrived at about 17-2 
to 2 ounces in weight. 

The historical account deals with the work of Pierre Franco (1556), 
Rousset (1581), Hildanus (1680), Proby (1694), Douglas (17 19), 
Cheselden (1723) Morand (1725), Heister (1739), Frere Come (1758), 

(277) 



2/8 RE VIE WS OF BOOKS. 

and various surgeons of the present century, among whom may be es- 
pecially mentioned for the value of their papers, G. M. Humphry, C. 
W. Dalles and E. Bouley. 

A short description of the ordinary mode of operating concludes 
with a contrast of the relative risks of supra-pubic and perineal lithot- 
omy by no means favorable to the latter. It is " beset with dangers," 
while there are but two chief risks in the former procedure, viz., (i) to 
the peritoneum ; (2) infiltration of urine. 

Now infiltration of urine is very rare, so that the only real risk is that 
of injury to the peritoneum. Modern researches, especially those of 
J. G. Garson (1877), have shown us how to ensure a safe supra-pubic 
interval in which to operate without endangering the peritoneum. Gar- 
son's memoir, describing the effect on the position of the bladder of 
distending the rectum, and especially calhng attention to its bearing 
on the operation of supra-pubic lithotomy, was read at the Congress of 
German Surgeons on April 12, 1878. " Professor Petersen, of Kiel, 
was present, and there is httle doubt that he was thus led to test by 
practice the theoretical question of the abundant space in this manner 
obtained for the high operation, then raised by Garson." Petersen's 
paper (1880), his methods and results are there outlined, and Guyon's 
account of eight cases noted. Sir Henry Thompson's first case was in 
1883, and, last November, he completed his eighth. 

After no other previous preparation than emptying the bladder, the 
patient is anaesthetized in the supine position, with the head and 
shoulders slightly raised. An empty india-rubber bag rolled into a 
cone and well vaselined is passed well into the rectum completely 
above the sphincter. Then about twelve or fourteen ounces of water 
are gently thrown into the rectal bag, in the case of an adult. 

Thompson next injects through a flexible catheter, slowly and gently 
6, 8 or 10 ounces, feeling his way carefully according to the resistance 
perceived in the act, and the degree of eminence observed above the 
pubes, almost invariably obvious to the eye as well as to the hand, 
taking care to avoid the application of force. "The rectal distension 
is essential, the vesical need not be considerable," The fluid used 
should be a mild antiseptic solution, such as one of boracic acid. The 
catheter being withdrawn, the base of the penis is firmly ligatured \A'Cc\. 
an india- lubber tube. Palpation above the symphysis now demon- 
strates the position of the bladder, most of it lying above the brim of 
the pelvis in the foim of a rounded ball. There is httle to be noted 
about the author's method of reaching the bladder through an ordinary 
median incision about 3 inches long, other than that he uses the index 
finger-nail instead of the knife, except in dividing the skin, the aponeu- 



f 



THOMPSON IN SUPRAPIJBIC CYSTOTOMY. 2/9 

rosis and the fascia transversalis. A small hook fixes the bladder, 
while it is cut enough to admit the right index finger. The left index 
is afterwards insinuated in beside the right, and an opening of sufficient 
size made by gently separating the two fingers to a sufficient extent, 
" thus avoiding the knife, and with it, sometimes troublesome haemor- 
rhage." When operating for tumor, our author passes a loop of stout 
silk through each margin of the vesical opening and hands each loop to 
an assistant who holds it up. 

Instead of forceps, he extracts the stone with his two index fingers, 
applying them separately like the separate blades of a midwifery for- 
ceps. No suture is placed in the bladder, and only one about an inch 
below the upper angle through the abdominal walls. He leaves five 
or six inches of large india-rubber tube for the first twenty-four or forty- 
eight hours" to ensure a free opening in case of haemorrhage, and some- 
times, also, a full-sized catheter in the urethra. 

The patient has generally been reUeved by the removal of these in 
two or three days, sometimes sooner. He lies on his back the first 24 
hours, and then on each side alternately for six hours at a time, and 
all the urine runs easily in this way from the wound, and excoriation of 
the skin is prevented by one side only being wetted for that short 
period at a time. " No other dressing than layers of lint soaked in 
weak carboHc acid solution, or in one of boracic acid, has ever been 
employed by" Sir Henry Thompson. 

One patient, aet. 73, died " of sheer exhaustion " on the ninth day. 
Each of the others made a good recovery. In getting down to the 
bladder, the author has lately, for convenience sake, used an ivory 
" separator" instead of the finger-nail. 

When the patient is a female or the bladder has been already 
opened from the perinaeum, that viscus cannot be kept distended with 
fluid and has therefore to be opened on a sound, h.'s, soon as the 
opening has been thus made it has often happened in former times 
that the bladder has slipped away, and the surgeon has perhaps torn 
its connections a good deal in the endeavor to get his finger into it. 
Thompson describes a special hollow sound to obviate this. Its ex- 
tremity is open obliquely, and when it reaches the wall of the bladder, 
a hook is thrust into it through the vesical wall, the latter being thus 
secured before it is opened. 

We find it difficult to believe that, given a sufficiently sharp hook 
and a deliberate, careful surgeon, any special form of sound can be re- 
quired to assist in fixing the bladder, nor can we think that Sir Henry's 
" ivory separator " is really much more useful than the handle of an or- 
dinary scalpel. It is to be regretted, therefore, that he has apparently 



280 RE VIE WS OF BOOKS. 

made an attempt to encumber surgery with two more instruments. 

The author estimates highly the probable value of the supra-pubic 
operation as a means of removing vesical tumors. In addition to its 
freedom from haemorrhage it permits a somewhat more extended use 
of the sense of touch than is practicable by the perineal incision ; and 
it adds thereto the abihty to see to a certain extent, conferring also an 
opportunity to apply the cautery or styptics. 

The book concludes by the recital of eight cases. Whoever pro- 
poses to do the supra-pubic operation for the first time cannot do bet- 
ter than study it with care. He will find the task no unpleasant one. 
Whoever is practically acquainted with the operation will take a natural 
interest in the able, thoughtful and graphic narrative of one who has 
been over the same ground himself 

C. B. Keetley. 

Practical Notes on the Treatment of Deformities. By Henry 
F. Baker, F.R.C.S. (Edin), Assistant Surgeon (late house-surgeon) 
to the Royal Orthopaedic Hospital, etc., etc. London, Ed. Stanford, 
1886. Pp. 71. 

This book describes nothing new and destroys nothing old, and yet 
it is a genuine contribution to orthopaedic surgery. Its value is due to 
the fact that it is an honest, clear and short description of the practice 
at the largest, and, we believe, the oldest orthopaedic institution in En- 
gland, an institution well known throughout the world in association 
mth a majority of the most renowned British names in that branch ot 
surgery. 

There is but little pathology in the book, and what there is is mainly 
fanciful. Mr. Baker can scarcely be blamed for this. He accepts, 
with an evident modesty and ingenuousness, the theories of the school 
whose practice he follows, theories evolved from their own moral con- 
sciousness by surgeons so profoundly satisfied with the results of 
their treatment that they almost uniformly deduced their notions of 
pathology from their notions of treatment ; and naturally disfigured 
their books with gross misstatements, scarcely to be paralleled in any 
other department of surgical literature. Tenotomising for everything, 
everything is, with them, of muscular origin. Mr. Baker is so far car- 
ried away by this idea that he begins his book with the suggestion that 
" relapsed" cases of club-foot owe the difficulty of dealing with them 
to the fact that the tendons have not been properly divided and have 
formed adhesions. We should greatly like to see the proofs of this 
statement, which appears to us to be without foundation. If he had 



MORRIS ON DISEASES OF THE KIDNEY. 28 1 

written that so-called " relapsed " cases of club-foot, and of some other 
deformities, especially genu valgum, had never been cured at all, not 
even when they had been treated at the Royal Orthopaedic Hospital, 
he would have been much nearer the mark. In most of such cases, 
the imaginary cure consists in hiding one deformity by the addition of 
another, and when nature has had time to remove the latter, the orig- 
inal (older and more obstinate) reappears and a relapse is said to occur. 
This is a statement the proofs of which stare everybody in the face, and 
are invisible only to the " muscular " school of orthopaedic patholo- 
gists. In illustration of the almost comic light in which this school 
view certain things, take the following two sentences from pp. 43 and 
68 of this book respectively. " In extreme cases of genu valgum in 
adults osteotomy maybe necessary," (in extreme cdAt%, — niayht neces- 
sary !). " If the progress of the case continue unchecked, the interver- 
tebral cartilages become compressed on the side corresponding to the 
concavity of the curve." That's all ! Who would suspect from this 
that the bodies of the vertebrae alter in shape more quickly and more 
seriously than the cartilages, and that no one has ever yet demonstrated 
a scoliotic spine, however incipient the curvature, in which the wedge- 
shaped change in the bodies did not exist ? 

However, in spite of these strictures on the faulty side of the book, 
it has great merits, both negative and positive. It does not contain a 
single ill-natured word, and is entirely free from those absurd and mi- 
pertinent suggestions of orthopaedic incompetence in general surgeons, 
which swarm in certain books I should name if naming would not too 
well serve their authors' main purpose, namely, advertisement. The 
style is clear and unaffected. But the chief value of the work is due 
to the fact that it is a practical account of the favorite methods of an 
able man who has been for a period of no less than ten years resident 
surgeon at a great metropolitan orthopaedic hospital, and who, more- 
over, had an exceptionally sound and practical training in general 
medicine and surgery before that period. 

C. B. Keetley. 



Surgical Diseases of the Kidney. By Mr. Henry Morris. Lon- 
don: Cassell. 1885. 

The present progress of surgery is nowhere so much observable as in 
the appearance of works which deal with the surgical treatment of 
those regions, which have only recently come under the hand of the 
surgeon, and the above named work is well worthy of perusal. 

A somewhat large proportion of the book is devoted to the consid- 



282 REVIEWS Of BOOKS. 

eration of the anatomy of the kidney, including its mahbmiations. Un- 
fortunately, notw-ithstanding the fact that many attempts have been 
made and rules laid down lor the detection of the presence of a single 
kidney, there is no record of a correct diagnosis having been arrived at 
tmtil after death. It does not even appear to be certain, as Mr. Mor- 
ris asserts, that abnormaHties of the generative organs are in any way 
connected with those of the kidney. 

The question of injuries of the kidney is then fully considered, and 
the formation of blood cysts in connection with it, and it is pleasant to 
observe that the term traumatic hydronephrosis which has been some- 
what unhappily appHed to such conditions, does not find place in the 
book before us. 

On the subject of renal calculus Mr. Morris is most explicit in the 
principles on which he insists, and on the differences which he lays 
down between the modem operation of nephrolithotomy, and the in- 
cision of the kidney to relieve an abscess which has been produced by 
the irritation of a calculus. " NephroUthotomy," he says, " there- 
fore, is the operation for stone in the kidney. Nephrotomy is 
the operation for calculous pyelitis, or calculous hydronephrosis, 
or pyonephrosis," etc. Now, whilst fully endorsing these remarks, we 
confess it is a little arbitrary to deny the term nephrolithotomy to a 
case because some pus is present, when it is admitted that the stone 
was the cause of the pus, and that its removal relieved the patient of 
pyuria, if it did not leave him with an uninjured kidney. 

The surgical treatment of kidney tumors is but little referred to, 
probably because the author feels he is treading on debatable ground, 
and is unable to advise in many cases their removal by any surgical 
operation. 

In conclusion we can cordially recommend this book to our readers 
as giving an excellent resume of the present state ot our knowledge 
on the subject. W. Bruce Clarke. 



RECENT GERMAN SURGICAL PUBLICATIONS. 

Verhandlungex der Deutschen Gesellschaft fur Chirurgie. 
ViERZEHNTER CoN'GRESs, abgehalteu zu Berlin,vom S-ii. April, 1885. 
mit 13 Tafeln, Aobildungen und Holzschnitten. Berlin, 1885. Ver- 
lag von Aug. Hirschwald. New York, G. E. Stechert. {Frocecdifigs 
of the German Surgical Association, \\e\d. at BerHn, April 8-11,1885. 
With 13 tables, illustrations and wood-cuts. * 



RECENT GERMAN SIJRCICAL flJ IH.ICAI loN .\. 283 

2. liKi'ikAKOK ZUK KLiNiscHKN Chikukoik. MitUiciluiigcii auH dcr cliir- 
urgischen Klinik zu Tubingen. Herausgegebcn von Dr. Paul 
BkUNS. Zweiter Hand, Erslcs Heft. Tubingen, 1886. H. Laupp. 
New York, (). E. Stechert. {Conlrihutions to Clinical Surgery. 
Reports frotn the Surj^ical Clinic of 'r'uhin^en. Ivlitcd by I)r. I'.nil 
I'runs. 2d Vol, Part i). 

3. AkJsKITRN AUS DKk CMIKUkOISCMK.N KmNIK DKU KoKNIGMCMKN UnI- 

vickSiTAET BKkMv. Herausgegcbcn von Dr. EkNsr vov HkkOMANN. 
Erster Theil. Mit Vier Tafeln. Berlin, 1886, Aug. Hirschwald. 
New York, 0. E. Stechert, {Contributions from the Surgical Clinic 
oj the Royal University of Berlin. Ivdited by iJr, l'>nsl von Berg- 
iiiann. Part i. With four plates). 

4. MniMi'.n.uNoKN AL's lii'M KoKi.NKk Ji(jj<(;i,)< H<jsi'irAi.. Uerausgege- 
hen von (Jberar/t l'r(;f. \)x. BAkni.NiiKUKk. ICrstes Heft: (Jsteoplas- 
tische kesertion des .Manubrium Sierni.Mitzehn Tafeln in Eichldruck, 
Koln und Leipzig, Albert Aim, 1886, New York, (i, ]•:. .Stechert. 
{Reports from the Municipal I/oKpital in Cologne. Edit<-d by I'n.f. 
Bardenheuer, chief surgeon. 

I-'irst part: Osteoplastic resection oJ the manubrium stcrni. 

5. Dire Krankiikiikn uvm Vao(.va. V(jii l)r. A. P.kKisKV, O. O. I'to- 
fessor der Oeburtsliillfe und ()ynakol(;gie an der j)euls<hen (Jiiiver- 
sitiit zu Prag. Mit 47 Hol/.schnitten, Pp. XVIII-205. {Diseases 
of the Vaj^ina. }iy Dr. A. Breisky, Professor of Obstetrics and 
OyniCfology at the (Jerrnan University at Pr.tL'ii<:. With .^7 wriod 
cuts), 

6. DiK I.riiRK VON OKN KNOf:nKNi;Ki:i.(.iii-..\. Von Dr. Pal/. JJulns, 
Professor in Tubingen, Mit 239 Holzschnitten. Zwcite Hiilfte, 
Pp, Xf,VI, 410-630, {Tfeatise on /''ractures. By Dr, /'an/ Ihnns, 
Professor at Tubingen. With 239 wood-cuts. Second ImK ;. 

7. Mn./i;kANt> UND RAUscHMkANO, BcarbeitCH von Wilhklm Koch, Mit 
8 in den Text gcdruckten Holzschnitten und 2 litliographisrhen Ta- 
feln, Pp. XXIV-154, {Splenic /''ever and danders. I5y Dr, 
William Koch. Willi 8 w(jod-tuts incorporated with the text, and 
2 lithographs). 

8. VliKLET^UNGEX UND CuikUkfilSCHK KUANKHKHKN DES GeSICHTS. 

Von Prof, Dr, TkENDRLENULko. Mit 30 Holzschnitten und 5 Lilho- 
grarfilen Tafeln, Erste Hiilfte, Pp, 194, {Injuries and Surgical 
Diseases of the I'juce. By Prof. 7'rendelenburj^. With 8 wood-cuts 
and 5 lithographed plates. First half). 



2 84 RE VIE WS OF BO OKS. 

9. Die Verletzungen der Oberen Extremitaeten. Von Dr- 
Bernard Bardenheuer, Oberarzt am Kolner Biirgerhospital. Erster 
Theil. Mit 196 abbildungen im Text. Pp. XXVIII-738. {In- 
juries of the Upper Extremities. By Dr. Bernard Bardenheuer, 

Surgeon-in-chief to the Cologne Municipal Hospital. First part. 
With 196 illustrations in the text). 

10. Die Chirurgische Anatomie in ihrer Beziehung zur Chir- 
URGiscHEN DiAGNOSTiK, Pathologie und Therapie. Von Prof. 
Dr. Max Schuller in Berlin. Heft. I. Die obere Extremitat. Berlin, 
Georg Reimer, 1885. New York, G. E. Stechert. Surgical ana- 
tomy in its relation to surgical diagnosis, pathology and therapeutics. 
Part I. The Upper extremity. By F7-of. Max Schilller, of Ber- 
lin. 

11. Handbuch der Kriegschirurgischen Technik. Eine gekronte 
Preisschrift von Dr. Friederich Esmarch. Kiel, Lipsius & Tischer, 
1885. New York, G. E. Stechert. Manual of the technique of 
military Surgery, by Friedrich Esmarch, of Kiel, receiving the Ger- 
man Empress' prize at the Vienna International Exhibition. Third 
edition. 647 wood-cuts. 

12. Compendium der Lehre von den Frischen Traumatischen 
Luxationen, fur Studirende und Aertze, von Dr. Stetter. Berlin, 
Georg Reimer, 1886. New York, G. E. Stechert. A Compend of 
Instruction in Recent Traumatic Dislocations, \)\ Dr. Stetter'). 

I. The report of the Fourteenth Congress of German Surgeons,which 
has taken some time in preparing, contains, in uniform arrangement 
with the former ones, a full report of the papers read at the congress 
together with the discussions following, all given verbatim, and matter 
relating to the business aspect of the congress, including a catalogue 
of members, etc. It surpasses its predecessors in volume, containing 
543 pages of printed matter, besides a number of handsome plates. 
The subject-matter has been reported in due season in the Annals 
OF Surgery. 

2. This second volume contains further essays of surgical interest 
from members of the Surgical Clinic of Tubingen. 

Prof. Bruns was one of the first directors of German Clinics, who 
preferred editing the essays originating in his clinic in book form to 
publishing them in the extant periodicals. Whether they are as uni- 
versally read and widely circulated as they would be in the periodicals, 
is questionable. 



RE CENT GERMAN S UR GICAL P UBLICA TIONS. 285 

We subjoin a list of contents referring our readers to the separate 
notices in our Index of Surgical Progress for more special informa- 
tion. 

P. Brujis, on cases of sudden death after fractures of bones, result- 
ing from venous thrombosis and embolism. 

E. Mailer, on the behavior of the bodily temperature in sudcu- 
taneous fractures. 

O. Habermaas, on tuberculosis of the mammary gland and some 
other rare cases of surgical tuberculosis. 

Eugen Miiller, on the intracapsular extirpation of thyroid cysts. 

E. K'obel, on the arsenical treatment of malignant tumors. 

A. Worner, on the final results of the operation for labial cancer. 

3. This volume contains a number of essays all originating from the 
Berlin Surgical Clinic, some of which have been previously pubhshed 
in the Archiv fiir klinische Chirurgie and the Berliner klinische 

JVochenschrift;2iXid have been noticed in the Index of Surgical Progress 
in the Annals under their proper headings. 

Two articles are from the pen of Prof, von Bergmann himself, one 
on traumatic compression of the brain and one on extirpation of the 
kidney. 

Two papers are by Fehleisen, on displacement of the bladder by 
tamponade of the rectum; and on exostosis bursata respectively, while 
F. Grimm writes on chyluria and E. Scheuerlen on suppuration by 
means of chemical irritants. An elaborate treatise upon arterio-venous 
aneurysm by F. Bramann, over 100 pages in length, is included, which 
had been already reported in a condensed form in the Archiv filr 
klin. Chirurgie. 

For those who do not subscribe to the periodicals mentioned, this 
book will prove a handy addition to their Ubrary, containing, as it does, 
papers by the highest German authorities on the respective sub- 
jects. 

4. This pamphlet contains the first of a series of essays from the 
pens of Prof. Bardenheuer and his assistants, which are to be edited in 
book-form, for the reason that they are too voluminous to be printed 
in the periodicals. Among the nine subjects announced as ready for 
publication in this series we notice "Transverse Exsection of the Tarsal 
Bones," " Resection of the Epididymis for Tuberculous Testicle," "Ex- 
tirpation of Kidney," "Cholecystotomy " and " Operative Treat- 
ment of Caries of Anterior Portion of Sacral Bone," The au- 
thor's well-known participation in preparmg Billroth and Liicke's 
" Deutsche Chirurgie " has heretofore prevented him from giving 
these articles to the public. 



286 RE VIE WS 01' BO OKS. 

The pamphlet under consideration is about 80 pages in length and 
treats of the indications and the modes of performing the operation of 
resection of the upper portions of the sternum. 

The indications are given when the innominate artery, the first part 
of the subclavian or the intra-thoracic part of the carotid is to be 
ligated. 

This may become necessary for injuries to the arteries, for traumatic 
or spurious aneurisms, or for retro-sternal tumors involving the ar- 
teries. 

Further indications are represented by tumors situated behind the 
sternum and requiring removal ; by similarly situated abscesses, by 
diseases of the sternum proper, requiring its removal, and by the 
necessity of performing tracheotomy when the trachea is not approach- 
able above the sternum, as in cases of malignant inoperable tumor of 
the thyroid. 

In the second half of the paper the author details the various opera- 
tions mentioned from a technical point of view, adding anatomical 
notes wherever necessary. 

Descriptions are given of Graefe's, PirogofPs and Mott's manner of 
operating for ligation of the innominate, and the author's own method 
is detailed at length with references to cases. After making two long 
incisions through the skin at right angles to each other and crossing at 
the upper margin of the manubrium sterni, and duly elevating the per- 
iosteum, he saws through the right clavicle and the first two ribs 3 or 
4 cm. from the sternal articulations, and, raising them up, advances 
between the posterior periosteum of these bones and the sternum 
respectively, until he can, by chiseling through the sternum, take out 
its whole upper portion. The sternal articulations of the correspond- 
ing bones of the left side are exsected. The periosteum remaining is 
then incised, and thus access gained to the parts underneath: 

In a similar manner the operations for ligating the subclavian ar- 
tery, and for the other indications mentioned are given, and cases, 
illustrated by handsome phototypes, are added. 

The author does not believe the operation to be too difficult of per- 
formance or to demand too much time for execution, if the surgeon have 
previously practised it. 

The obvious objection to the operation, that the danger incurred by 
laying* open the mediastinum, and the danger of wounding the pleura, 
the large veins of this region, the thoracic duct, etc. is too great, is 
met by the assertion that the removal of the sternum in point of fact 
facihtates the operation by permitting free access to these parts, and 
that it therefore reduces the danger. The after-treatment of the wound, 



I 



RE CENT GERMAN S UR GICA L P UBLICA TIONS. 2 S 7 

moreover, may be much more safely conducted by plugging the entire 
cavity with thymol gauze after removal of the sternum, and better 
drainage thus ensured than is possible in retrosternal operations. The 
cavity closes rapidly by granulation. The sternum and portions of the 
clavicles which have been removed, are reproduced by the periosteum, 
although of shghter proportions, and narrowing of the chest and scolio- 
sis results. 

W. W. Van Arsdale. 

Numbers 5 to 10 are all monographs belonging to Billroth and 
Liicke's Deutsche Chirurgie (Stuttgart, F. Enke, 1886), and are re- 
spectively numbers 60, 27, 9, 2)Z '^^^ ^3 of that encyclopaedia. 

5. With Prof. Breisky's work surgeons are already familiar, since it 
originally appeared in the " Handbuch der Frauenkrankheiten." We 
note in the present edition the addition of fifty pages of new matter, as 
well as an exhaustive bibhography, which shows that the learned author 
has made a careful study of American and Enghsh as well as French 
and German authorities. Prof. Breisky is well known as one ot the 
few German admirers of American gynecology, which fact ought to 
make his book a popular one among us. 

The arrangement of the present volume shows a marked improve- 
ment over the former one, while the copious foot-notes renders it ex- 
ceedingly valuable for purposes of reference. 

Chapter III, on atresia and stenosis of the vagina, has been recast 
and now concludes with a carefully prepared table of the author's 
own cases, eighteen in number, all of which terminated fortunately. 
The following chapter; on prolapse of the vagina, is less satisfactory, 
especially the paragraphs referring to operative treatment. 

Chapter VII in the old edition is now chapter IX. Chapter VII 
(pages 101-145), treating of inflammation of the vagina, is new, as are 
the accompanying wood-cuts (Figures 27 to 32 inclusive), from Ruge 
and Chiari. The latter, with the exception of Fig. 32, are unfortun- 
ately rather indistinct. The subject of vaginitis is ably treated under 
the following subdivisions : 

I. The catarrhal inflammations, including acute catarrh, folHcular, ve- 
sicular, emphysematous and exfoliative vaginitis. 2. The exudative in- 
flammations (vaginitis diphtheritica, dysenterica, erysipelatosa and 
septica). 3. Peri-vaginal inflammation and abscess. The chapter 
concludes with photographs on syphihtic and tuberculous ulceration, 
gangrene and ulcus rotundum vagi?ice. 

Some of these sub-varieties may appear to the EngUsh reader to be 
forced, but the author's careful descriptions prove that he records the 
results of his own observations. 



288 RE VIE WS OF BOOKS. 

Chapter VIII, " New Growths in the Vagina," (formerly chapter 
IX, consisting of 25 pages), includes pages 145-180, and is exhaustive. 
We are glad to note the omission of the old figure 31, which was most 
unpleasing to the eye. 

The concluding chapter on fistulse, formerly the eighth, has been re- 
modeled, especially the descriptions of operations. The paragraphs 
on recto-vaginal fistula show that the author has not failed to be in- 
fluenced by Emmet's teachings. The section on entero-vaginal fistulse 
has been thoroughly modernized in its essential features. 

In concluding this hasty examination of a scholarly work we would 
again call attention to the .thoroughness of the revision ; to the im- 
proved arrangement of the subject-matter and to the great value of the 
collected bibHography. The absence of an index is to be deplored. 

6. Prof. Bruns prefaces the second half of his monograph with up- 
wards of thirty pages of references, which can not fail to awaken the 
admiration of the surgical reader 

Continuing the subject of the after-treatment after consohdation of 
fractures, the author considers on the opening page (401) the possible 
compHcations which may arise at this period, especially oedema, mus- 
cular atrophy, paralysis and contracture, and stiffness of the joints. 
Chapter VI is entitled " The Indications for Amputation and Resection 
of Joints in Fractures." Dr. Bruns lays down the positive rule, that 
aside from complete crushing of a limb, where gangrene is inevitable, 
primary amputation is clearly indicated only in those cases " in which 
there is but a remote possibihty of healing under conservative treat- 
ment " (P. 409). On another page (410) he repeats and emphasizes his 
previous opinion that "«^ cojnpound fracture by itself no matter how 
extensive the conunimition, is an indication for primary amputa- 
tion., but only aji accompanying irreparable destruction of the soft 
parts.'''' 

The seventh section, treats of the immediate and subsequent com- 
plications of fractures and their treatment and concludes the subject. 

7. Dr. Koch's work will possess more interest for the veterinary sur- 
geon. With the exception of about twenty pages, it is devoted to 
splenic fever, which affection is discussed most thoroughly. 

Particular attention is paid to the pathological anatomy ; the bacteri- 
ology receives due mention, and is illustrated by a fair Uthograph. The 
bibliography is copious. 

8. The first part of Prof.Trendelenburg's monograph on facial injuries 
and diseases promises only fairly. It contains five chapters (the 



RECENT GERMAN SURGICAL PUBLICATIONS. 289 

first and the fifth should really be combined) which treat respectively 
of congenital deformities, wounds and other injuries of the face, in- 
flammatory swellings, new growths and failures of development. 

Under chapter I are included failures of development of the frontal 
process (hare-lip and cleft palate) and of the upper branchial arch with 
the operations for their cure. There is nothing particularly new in 
this portion of the book, although it is fully up to date. The chapter 
on wounds and injuries, (stabs contusions, burns and frost-bite) is 
brief and rather more superficial than the reader would expect in a 
monograph; the same may be said of chapter III. in which brief para- 
graphs are devoted to such important matters as anthrax erysipelas 
and the syphilides ; to furuncle, noma and lupus are allowed three 
pages each. 

Chapter IV, on new growths (including pages 74 to 139) is more ex- 
tended. Macroglossia is (rather curiously) described at length under 
this chapter, the author regarding it as a " congenital lymphangioma of 
the tongue." Fifty pages are given to angioma, the subject being well 
covered. The interesting keloid growths which develop on the lobe of 
the ear are described and figured (pages 107-109) also dermoid cysts 
and the sarcomata (page 109). Epithelioma, of course, claims the 
larger part of this chapter (27 pages), and the section in which it is 
discussed is, in the main, satisfactory, although there are too many 
tables of statistics, and too little about treatment. Theories regarding 
the etiology of the disease occupy nearly one-half of the section. Chap- 
ter V, entitled " Defects and Failures of Development of the Face, 
Plastic Operations," forms the concluding topic, and is more carefully 
elaborated than those which precede it. The first section is introduc- 
tory, and treats of plastic operations in general, the different forms and 
methods of obtaining skin-flaps, etc.; the second is devoted to rhino- 
plasty (pages 153-176), the third to cheiloplasty, the three concluding 
sections to melo-blepharo and otoplasty. The operations are described 
briefly, but in a manner sufficiently clear to the surgical reader ; the il- 
lustrations are, unfortunately, few in number, and not always of the 
newest. The plates at the end of the volume, illustrating various 
forms of facial disease and deformity are very good. There is neither 
a table of contents nor a biWiography in the book, but doubtless these 
will be supplied in the second part, for the appearance of which we 
should wait before passing judgment upon the character of the work 
As far as it has gone, we venture the criticism that it is rather disap- 
pointing, as compared with most of the monographs which have pre- 
ceded it, in that it is uneven and incomplete in some portions. While 
one or two of the chapters are thorough and exhaustive, others are 



290 RE VIE ] IS OF BO OR'S. 

abridged to an extent that would not be expected in a special treatise. 

9. We are compelled to pass in hasty review the first volume of Dr. 
Bardenheuer's wc-k, which, when completed, will be what the (ier- 
mans call " kolossal." We can give but a very imperfect idea of it 
here. Of the fourteen chapters in Part I, the first deals with general 
questions of anatomy, pathology and diagnosis, the next two with frac- 
tures of the clavicle and scapula and dislocations of the former bone, 
the fourth, fifth and sixth with fractures and dislocations of the hu- 
merus ; the tAvo succeeding chapters treat of injuries of the axillary and 
subclavian arteries and brachial plexus, the next of traumatic inflamma- 
tion of the shoulder-joint. Chapter X describes the different methods 
of exarticulating and amputating the humerus. ChaplerXI, injuries of 
the muscles, nerves and blood-vessels of the upper arm. The three con- 
cluding chapters are devoted to injuries and operations around the el- 
bow-joint. Considering the limited field of this bulky volume, the 
reader will at once infer that each topic is considered with true Ger- 
man thoroughness, and such is indeed the fact. Yet there is no ten- 
dency on the part of the author to indulge in useless details. His style 
is frequently epigrammatic ; each paragraph is complete in itself- 
Statistics are introduced where they are needed, but always in a con- 
densed form, elaborate tables being omitted. The drawings are nu- 
merous and good ; many of them will be quite new to readers of En- 
glish works. 

It is unnecessary to analyze each chapter in detail ; a brief review 
of one will serve to indicate their general arrangement. The anatomy 
of the special injury is first described, followed by the etiology, symp- 
tomatology, diagnosis, prognosis and treatment ; each section is pre- 
ceded by a brief historical sketch. The principal points in the diagno- 
sis and differential diagnosis are stated in as few words as possible, and 
rather with the view of furnishing practical hints for the surgeon than 
of displaying well-rounded periods. 

The chapters on operations (X, XI and XIII) are, of course briefer 
than in works on operative surgery, but they are quite comprehensive. 
The anatomy and surgery of the subclavian arteries are thoroughly pre- 
sented in chapter VII. It would be unjust to the author of such an 
elaborate treatise to judge of the character of his work from this hasty 
notice. It is worth a careful perusal, and will certainly find a worthy 
place among surgical monographs. It is marked throughout by the 
two cardinal virtues in an author — clearness and brevity. The impres- 
sion left after a careful perusal is this — that Prof. Bardenheuer has 
written from his own experience and at the same time \\\\h. an honest 
desire to give every man the credit of his work without regard to his 



RECENT GERMAN SURGICAL PUBLICATIONS. 2gi 

nationality. When it is completed, it will not be easy to find a rival 
for such a monument of patient industry. H. C. Coe. 

10. The anatomy of the human body is treated from a somewhat 
broader point of view in this work of the well-known German surgeon, 
than is usually customary in topographical and so-called surgical ana- 
tomies, and throughout the first volume now before us abundant evi- 
dence is easily detected even at a cursory glance, of that thorough- 
ness, both in origmal research and in the acquaintance with others' ob- 
servations, which has marked the author's previous writings, and to 
which he deservedly owes his reputation. 

The reader is supposed to have a complete knowledge of descriptive 
anatomy and a fair idea of the topographical relation of the parts as 
well as a general knowledge of pathology and the surgical treatment of 
diseases and injuries. 

Presuming upon such knowledge, the author professes to guide the 
reader in the examination of the living healthy subject and the normal 
cadaver, and to point out the parts dissected in the one through the 
uninjured integument of the other, as well as to give him hints and di- 
rections in producing pathological conditions in the cadaver resem- 
bling those frequently occuring in surgical practice, and aiding him in 
their diagnosis and treatment. 

In the present volume the author first describes the external aspect 
of the upper extremity from a surgical point of view, as it relates to in- 
spection and palpation, and enumerates the deeper seated parts as 
they can be made out by the sense of touch, as well as the topographi- 
cal situation of such ones as cannot be felt, and the })oints for reaching 
them by incision. He considers all these things as they vary under 
the influence of movements, disease and injuries. 

In the anatomical descriptions of the parts the author has taken 
special care to explain the forms and relations of the lymph-spaces and 
serous cavities, employing injections of the intermuscular spaces, joints 
and tendon-sheaths to demonstrate his statements. Original experi- 
ments and deductions from them are likewise especially noticeable 
under the headings of the various forms of dislocations ; and in the 
treatment of the subject of injuries to the larger vessels frequent allu- 
sions to special experiments are to be found. 

The subject-matter has thus become quite extensive, and in this first 
part of the work, treating only of the upper extremity, 370 large octavo 
pages are contained. 

The work contains in a readily accessible form much information 
which surgeons, especially those who have been instructors as well as 
operators, have hitherto had to look up in monographs and periodical 
literature ; and for this reason alone, even without consideration of 
such origininal matter, as of itself attests the worth of the book, it will 
prove a very valuable addition to the library of all readers of German. 

II. The third edition of Esmarch's Military Surgery will be wel- 



292 REVIEWS OE BOOKS. 

corned by the public with the more pleasure, as it has been awaited for 
so long a time. The first two editions were already out of print in the 
year 1881, the book proving a great favorite, and owing to the failure 
in business of the original pul)Hshers, the reappearance of the book 
has been delayed till now. 

The book is so well known that a mention of its contents appears 
superfluous. 

The third edition bears evidence of several alterations. It appears 
in two volumes, the first containing the subjects of wound-dressing and 
bandaging ; the second operative surgery. 

The antiseptic method is given more prominence than before ; direc- 
tions are included for preparing antiseptic dressing material, and for 
the disinfection ot septic wounds. 

In the second volume numerous additions have been made. Chap- 
ters, such as the one on suture of the intestine, have been extended so 
as to comprise recent methods (as Czerny's suture), and other chapters 
have been inserted, as the ones on resection of ribs and on the osteo- 
plastic resection of the tarsus after Mikulicz-Wladimirow. 

The book now appears in small octavo and the type is smaller, 
which rather detracts from its elegance, although it may lessen its cost. 
The handsome chromo-lithographs of the first edition have also been 
omitted and replaced to some extent by wood- cuts. This applies to 
the transverse sections of the limbs, and. to the operations of ligating 
the arteries. 

In the latter the surrounding portions of the limb have been omitted, 
which so well served to impress the localization of the vessels upon 
the mind of the reader, and enabled him more easily to find his place. 
The wood-cuts are well executed, but the differentiation of the vessels 
by shading does not compare in distinctness to the former coloring. 
Several new wood. cuts representing the course of the main arteries are 
added. 

12. This is a concisely written, handsomely-published hand-book of 
about 120 pages intended for the use of students, and giving in few 
words the mechanical pathology, symptoms, diagnosis and treatment 
of dislocations occurring in the daily surgical practice — one of a class 
of books not very frequently met with in German medical literature on 
account of its emmently practical character. 

Luxation of the spinal vertebrae is somewhat quickly disposed of, 
the author stating that local symptoms are frequently not well marked, 
and the nervous symptoms tiot practically available for diagnosis. 

Other forms of luxation, however, such as that of the elbow, appear 
treated with perspicacity and at sufficient length. 

The author, being instructor in surgical bandaging at the University 
of Koenigsberg, intended the volume as a hand-book for the use of his 
students. The purpose is evidentlv adequately attained. 

W. W. Van Arsdale. 



EXCISION OF THE BONES OF THE TARSUS FOR 
TUBERCULAR DISEASE, WITH REPORT OF 
A CASE IN WHICH EXTENSIVE EXCI- 
SION OF THE TARSUS WAS PER- 
FORMED IN BOTH FEET/ 

BY FRANCIS J. SHEPHERD, M.D., 

OF MONTREAL. 

PROFESSOR OF ANATOMY IN M'gILL UNIVERSITY; SURGEON TO THE MONTREAL 
GENERAL HOSPITAL. 

FORMERLY when a case of tuberculous disease of the 
bones of the feet presented itself for treatment the only- 
resource was amputation, but with the advent of antiseptic 
surgery and the establishment of conservative principles of 
treatment, other methods of procedure have been adopted 
with success. In cases of tuberculous and carious disease of 
the bones of the foot the necessity for amputation is not im- 
mediate, and it is the duty of the surgeon to endeavor first to 
remove the local disease before sacrificing the extremity. In 
diseases, for instance, of the tarso-metatarsal articulation only 
the diseased parts of the bones entering into this articulation 
should be removed, and the same may be said of the tarsal and 
ankle joints. The principle I wish to advocate in these cases 
of tuberculous disease of the bones of the foot is not a new 
one, but one that is not sufficiently insisted on. It is this, viz., 
that it is not always necessary to remove a definite portion 
of the foot by a Hey's Chopart's or Syme's amputation, even 
when the disease is very extensive ; on the contrary, the dis- 
eased parts should be cut down upon wherever they exist, and 
only the bones affected with disease should be removed. The 
removal of the disease, however, should be thorough, and it is 

^Read before the Surgical Section of the Canada Medical Association, Quebec,Au- 
gust 1 8, 1886. 



294 FRANCIS J. SHEPHERD. 

better to remove too much than too Httle, as the more com- 
plete the removal the more rapid the cure.' 
I have several times performed partial excision of the 
tarsus and ankle joint with the best results. In children 
the necessity for amputation rarely occurs, removal of the dis- 
ease by scraping and gouging being nearly always sufficient. 
The following case illustrates this : A. B., set. 3 years, a deli- 
cate child with a strumous history, had for some time com- 
plained of a sore foot, and latterly had walked lame. When 
seen, April, 1884, there was a small fluctuating swelling over 
the scaphoid bone of the left foot, the whole foot was enlarged 
and inflamed. The swelling was incised and a quantity of thin 
curdy pus let out. On passing in a probe carious bone was 
felt. The child was immediately put under ether, and the 
carious portions which involved the scaphoid and cuneiform 
bones was thoroughly scraped out with a Volkmann's spoon. 
The cavity was afterwards stuffed with iodoform gauze and the 
foot dressed with sublimate jute. In the course of a couple 
of months the cavity had completely filled up, and soon after- 
wards the child was running about as actively as ever. Now, 
in this case, had the disease been allowed to go on, the whole 
tarsus would have been involved, and a much more serious op- 
eration would have had to have been undertaken. Up to the 
present time there has been no return of the disease. The 
next case I shall relate is one of extensive disease of both feet 
in a young girl, aet. 17. In one foot excision of ankle joint 
and tarsus was performed, and in the other partial excision of 
tarsus. 

Mary T., set. 17, a delicate looking girl, was admitted into the Mon- 
treal General Hospital, May 27, 1885, for disease of both feet. 

No distinct history of phthisis or scrofula in the family, but some of 
relations died of " lung disease." 

Patient up to one year ago had always enjoyed good health, when 
she noticed that both feet were commencing to swell. The swelling in 
the right one was over the ankle, that in the left over the dorsum of 

^Dr. Conner in an exhaustive paper in Vol. I of the Transactions of the Amer- 
ican Surgical Association reports two cases of excision of the entire tarsus; the 
patients recovered with useful feet. In the same paper he gives a table of loS case s 
of excision of two or more bones of the tarsus. 



I 



EXCISION OF THE BONES OF THE TARSUS. 295 

foot. The swellings " broke " some eight months ago, and have been 
discharging ever since. Had not walked for the last two months. On 
examination several sinuses were seen in each foot ; in the left, they 
were situated below the internal malleolus and led down to the carious 
bones ; in the right several were situated over the tarso-metatarsal joint 
on the dorsum of the foot, and one was seen in middle of sole of foot. 
Both feet were much swollen, and could not bear pressure without 
pain. Movements of left ankle joint exceedingly painful, but no 
roughness felt in movement. It was decided to remove the diseased 
portions of left foot first. On June i the patient was etherized, and an 
incision made below the tip of internal malleolus from the tendo 
AchiUis downwards along the inner border of the foot in the course of 
the discharging sinuses. Bare bone was soon reached and several se- 
questra removed, the cavity was gouged out with a Volkmann's spoon 
and afterwards stuffed with iodoform gauze. A jute pad was then applied, 
which was sufiticiently firm when covered with antiseptic bandage to 
keep the foot in proper position. The dressings were removed once a 
week, and for a time the patient markedly improved, but later it was 
found that all the disease had not been removed, that carious action 
was still going on, and that suppuration was more profuse than it ought 
to have been. On the 15th of August, 1885, patient was again ether- 
ized and an incision made in the same Hne as the former one and the 
parts more freely exposed. It was found that the ankle joint was in- 
volved, and that there was disease also of scaphoid and cuboid bones. 
The astragalus had an abscess the size of a filbert in its centre. I re- 
moved the lower end of the tibia, astragalus, part of cuboid, external 
cuneiform, scaphoid, and a portion of the os calcis, but left the external 
malleolus which was apparently healthy. The wound was dressed as 
before with iodoform gauze and jute pads. A drainage tube was also 
passed through the cavity, emerging beneath the external malleolus. 
The patient did remarkably well, rarely having a temperature over 
100° F. The dressings were changed about once in ten days or two 
weeks, as required. 

In September, owing to the prevalence of small-pox in the city, all the 
patients in the hospital were vaccinated, this one amongst the rest. 
She got a severe attack of erysipelas on the arm and had to be re- 
moved to the infectious ward, and after recovery, not wishing her to re- 
enter the surgical wards, and she being much pulled down by the at- 
tack of erysipelas, I advised her to go home to the country for the 
winter and come back in the spring to have the other foot attended 
to. When she le!t the hospital the cavity in the left foot had entirely 



296 



FRANCIS J. SHEPHERD. 



healed with the exception of a small fistulous opening below the site of 
the internal malleolus. 




FIG. I. RESULT AF] ER EXCISION OF THE TARSUS. 

Right foot ; Three cuneiform, part of cuboid, scaphoid, and bases of metatarsal 
bones removed. 

Left foot : Lower end of tibia, astragalus, three cuneiform, cuboid, and scaphoid 
bones removed. 



On the 5th of April, 1886, she returned to the hospital much im- 
proved in general health. There was still a small sinus at site of op- 



EXCISION OF THE BONES OF THE TARSUS. 



297 



eration in left foot, which discharged a little glairy synovial looking 
fluid. The right foot was in much the same condition as before, the 
disease having kept fairly stationary, and being apparently confined 
entirely to the tarso metatarsal joint. The foot was swollen and pain- 
ful. Carious bone could be felt with a probe through all the sinuses. 




FIG. 2. RESULT AFTER EXCISION OF THE TARSUS. 

Same case as Fig. i; different view. 



On the 25th of April she was again etherized, and the diseased bone 
removed from the left foot. Two longitudinal incisions were made, 
one on the outer and the other on the inner side of the foot. The soft 
parts were lifted from the dorsum of the foot and the extent of the dis- 



298 FRANCIS J. SHEPHERD. 

ease seen. The three cuneiform bones Avith the bases of the inner 
three metatarsal bones were found to be in a carious condition ; also 
the anterior portion of the scaphoid. The cuboid bone also was in- 
volved, where it articulated with the external cuneiform. But the ar- 
ticulations between the cuboid and the two outer metatarsal bones were 
healthy. The bases of the metatarsal bones were removed with a 
fine saw, and the three cuneiform bones taken away. The anterior por- 
tion of the scaphoid and the greater portion of the cuboid were re- 
moved also. A large space was now left, the posterior part of the 
foot being only connected with the toes by the soft parts. The cavity 
was washed out with an antiseptic solution and stuffed with iodoform 
gauze (freshly made), and the foot covered with a jute pad, and over this 
an outside gutta-percha splint was moulded. The sinus in the left 
foot was scraped out. 

From the time of the operation the progress of the patient towards 
recovery was uninterrupted. The wound was redressed every ten or 
fifteen days, in all four times, when it was completely healed. The 
foot, though somewhat shortened and flat, was of good shape. The 
temperature throughout never rose above 99.5°,and the foot never gave 
the slightest pain or kept her from sleeping. The sinus in the left foot 
after the scraping, rapidly healed. On the 30th of July patient was 
walking about the ward. 

There was some inversion of the left foot owing to the presence of 
the external malleolus, which made the outer side of the foot much 
firmer than the inner. This inversion was corrected by a suitably made 
boot with an inside metal rod fixed to the sole and fixed above to the 
leg by a leather collar. Had I to perform a similar operation I should 
remove the external malleolus, even if it was healthy, as by this means 
the symmetry of the foot would be preserved. I once before left it in 
excising the ankle joint for a badly set Pott's fracture, ^vith good re- 
sults. This case exemplifies well the advantage of conservative 
metliods of treatment, the patient having now two fairly useful feet. 
The accompanying cuts show the present condition. 



ON THE ADVANTAGES OF SUPRA-PUBIC LITH- 
OTOMY, WITH A REPORT OF A CASE.^ 

BY ARPAD G. GERSTER, M.D., 

OF NEW YORK. 

Surgeon to Mt. Sinai, and the German Hospitals. 

SINCE modern surgery has more and more succeeded in 
extending the appHcation of antiseptic principles to the 
oral cavity, the rectum, and to the bladder, epicystotomy has 
been reclaimed from undeserved neglect. Germany and Aus- 
tro- Hungary have especially contributed a respectable series 
of successful cases, demonstrating that many of the chief ob- 
jections to this procedure have, by dint of improvements of the 
method, lost most of their weight. It is interesting to note 
that the last and most weighty opponent of this method was Sir 
Henr}^ Thompson, a countryman of the brothers Dr. James 
Douglas and Mr. John Douglas, who in 1717 and 1718 first 
demonstrated on the cadaver and successfully performed on 
the living subject the operation, as the venerable Cheselden 
informs us in his excellent little treatise, "On the High Opera- 
tion for the Stone," published in 1723 in London. 

Viewing the more recent literature of the subject without 
prejudice, it must be acknowledged that the range of the indi- 
cations for the performance of epicystotomy had been until 
recently unnecessarily narrow. The main objections raised 
were two : First, the difficulty of its performance, especially 
in adult subjects, which refers principally to the danger of in- 
juring the peritonaeum. Second, the difficult after-treatment, 
involving the knotty question of suturing the bladder or choos- 
ing the open treatment instead, and finally the avoidance of 
urine infiltration and its consequences. 

•Read before the New York Surgical Society, May 10, 1886. 
(299) 



300 ARPAD G. GERSTER. 

Garson and Petersen have shown that distension of the rec- 
tal pouch by a suitable soft rubber bag filled with water, when 
in position, will raise a full bladder of an adult subject suffi- 
ciently above the level of the symphysis pubis to permit a free 
incision of six centimetres in length into the organ without the 
least risk of cutting the peritonaeum. 

Willie Meyer, lately of Bonn, at present of this city,reported 
in 1884, in Langenbeck's "Archiv," forty-one cases of suture of 
the bladder, sixteen of which were successful ; in seventeen 
cases suppuration followed, but ended in cure. Eight patients 
died in consequence of the operation — one of erysipelas and 
seven of septicaemia. The results reported since by Bergmann, 
Ant.al, and others have much improved, which may be un- 
doubtedly ascribed to a more careful selection, all cases ac- 
companied by septic processes being rejected and treated by 
the open method. 

The open method, however, as advocated and practiced by 
Dr. Trendelenburg, offers the greatest safety as regards avoid- 
ance of septicaemia due to urine infiltration, phlegmon, or ery- 
sipelas. An essential part of this is the semi-prone posture 
of the patient to be observed after the operation. In this po- 
sition not a drop of urine can be retained in the bladder, 
but it must escape through a soft drainage-tube suitably at- 
tached. 

The enormous advantages of epicystotomy in cases where 
an exact exploration of the bladder by touch and sight be- 
comes necessary need not be dwelt upon. The exact diagno- 
sis of the more intimate relations of one or more encysted 
stones and their removal, the stanching of rebellious cystic 
haemorrhages by ligature or the cautery, the diagnosis and safe 
and complete removal of cystic tumors, will be rational and 
safe processes, even in cases of a very much enlarged prostate, 
instead of being hap-hazard, dangerous and often incomplete 
and unsatisfactory endeavors, as they frequently must be if 
the perineal section is exclusively employed. 

Not wishing to take up too much of your time, I refer you, 
for a closer study of the merits of the question, to the lucid and 
veiy interesting paper of Dr. Meyer alluded to ("Arch. f. klin. 
Chir.," vol. xxxi, p. 494), which contains abundant casuistic 



AD VANTA GES OF S UPRA-P UBIC LITHO TOM V. 3° ^ 

material to bear out every statement made therein in favor of 
the operation. 

I deem it proper to bring the subjoined case to your notice, 
although it terminated fatally, first on account of its inherent 
pathological interest, and chiefly because it was marked by per- 
fect safety and ease in exposing and incising the bladder with 
hardly any loss of blood, and by the facility with which the 
stones could be grasped and extracted under the guidance of 
the eye from bladder and diverticulum. The history is as fol- 
lows : 

Martin Gyr, a Swiss laborer, aet. 50, was admitted to the German 
Hospital on April 8. He stated that he had been suffering from diffi- 
culty of micturition for more than ten years, having had no treatment 
whatever until within a few days, when a cystic stone was detected by 
Dr. Meyer, at the German Dispensary. The usual symptoms of the 
most pronounced character were present. The patient could not retain 
more than an ounce of water, and had to urinate every fifteen minutes 
by day and night. Examination of the alkaline urine gave evidence 
of intense cystic catarrh and of pyelo-nephritis, casts and pelvic epithe- 
lia being found. The filtered urine contained a considerable amount 
of albumin. 

The patient presented an abject picture of emaciation, pain and suf- 
fering, and was delighted at the possibility of getting relief by an 
operation. Slight elevations of temperature were observed every even- 
ing. 

Physical examination demonstrated a normal condition of the inter- 
nal organs, excepting the kidneys and bladder; anaemia, with rapid 
and rather feeble pulse. The stone-searcher established the presence 
of stone in the bladder, but, fearing a possible reaction, no extended 
examination and measuring of the stones was insisted upon. So much, 
however, was clear, that the much-contracted bladder contained either 
a single large or a number of smaller stones. By introducing the finger 
into the rectum a rather massive protrusion of a hard body toward 
that organ could be felt. The patient was made comfortable by the 
free administration of opiates, and all endeavors were employed to im- 
prove his general condition by abundant stimulation and food. In 
weighing the admissibihty of an operation, the wretched state of the 
patient made it clear that any operative interference would be fraught 
with unusual danger from shock, yet, in view of the iact thiit longer 
delay was inadmissiJDle, and that, unrelieved, the patient would have 



302 ARPAD G. GERSTER. 

to succumb soon and certainly, it was decided proper to offer him a 
chance, however slender, of recovery by operation. Regarding the 
selection of the method, it had to be borne in mind that a prolonged 
anaesthesia, such as litholapaxy would render necessary, was inadmis- 
sible in this case. A grave objection to any one of the perineal sec- 
tions was the unavoidable hgemorrhage, the amount of which varies 
considerably in different cases, can never be estimated beforehand,and 
occasionally is serious. The high operation was naturally thought of, 
first, because it would permit bloodless access to the bladder ; seconds 
because it would permit rapid completion of the extraction of the stone 
or stones ; and. finally, because it would secure perfect drainage. The 
question which anaesthetic should be employed was decided in favor of 
chloroform, on account of the danger that the administration of ether 
would entail in the presence of the renal condition. 

On April, 12, the patient having been brought under the influence 
of chloroform, a soft-rubber bag was introduced into the rectum and 
was distended by about 500 c. c. of tepid water. After this the blad- 
der was filled with 200 c.c. of tepid boro-saUcyHc solution. A longi- 
tudinal incision was carried through the integument and linea alba 
down upon the fascia transversahs whh minute loss of blood, com- 
mencing at about three inches from and extending downward to a lit- 
tle beyond the symphysis. The fascia transversalis having been sev- 
ered, the peritonaeum became exposed to view, and doubts were en- 
tertained about the possibility of now incising the bladder. Thereupon 
it was decided to inject 100 c. c. more of fluid into the bladder. While 
this was done it could be distinctly seen how the bladder rose up from 
behind the symphysis, pushing before it the reflected fold of the peri- 
tonaeum marked by a clearly defined transverse depression. An incis- 
ion of one inch and a half being made into the bladder, its contents 
escaped. The edges of the incision were drawn apart, the remnant of 
the boro-salicyhc solution was mopped out, and thereupon the pres- 
ence of more than one stone could be seen and felt. First an ovoid, 
smooth, hard stone was grasped and extracted. After this a second 
rather rough, very hard stone became visible, which was not so freely 
movable as the former, but seemed to be attached somewhere on its 
posterior face, and yielded only after being forcibly rotated. On in- 
spection, the freshly broken-off surface of a stalactitic projection was 
seen on its posterior side, indicating that a continuation of it had ex- 
isted, projecting either into a ureter or into a diverticulum. This sec- 
ond stone showed two facets — a large one corresponding to the round 
smooth stone first extracted, and another smaller one of apparently re- 



II 



AD VANTA GES OF S UPRA-P UBIC LITHO TOM V. 3^3 

cent formation. On introducing the finger into the bladder, a conical 
stone was felt to project from a diverticulmii situated posteriorly and 
to the left side, the site of this corresponding to the resistant tumor 
felt in the rectum. The index-finger was cautiously inserted into the 
orifice of this diverticulum, which was felt to yield to this gentle dilata- 
tion. A forceps grasped and extracted the stone easily from its bed. 

It was clear that another stone remained to be extracted ; but, the 
patient having been under the influence of the anaesthetic for twenty 
minutes and his pulse becoming thready, it was deemed imprudent to 
continue further search. As it was intended to leave the incision open, 
the extraction of this remaining stone, it was thought, could be easily 
accomplished at the first suitable occasion. A number of camphora- 
ted ether injections were administered hypodermically and the patient 
was put to bed. Previous to this a T-shaped drainage-tube, prepared 
according to the directions given by Trendelenburg, was inserted into 
the bladder, and another drainage-tube was passed into the bottom of 
the diverticulum. The position occupied by the patient in bed was 
semi-prone, his left hip resting upon a ring-shaped air-cushion, his 
knees being drawn up, and his back being supported by a number of 
pillows held up by the back of a chair. The skin of the belly was 
freely anointed with vaseline, and a pus-basin was placed underneath 
the projecting ends of the drainage-tubes, from which urine was seen to 
escape in driblets. Hot bottles and stimulants were used, but, in 
spite of the insignificant loss of blood and of the small quantity (lo 
grammes) of chloroform used, the shock of the operation proved to be 
too great. He rallied three or four times, to relapse into a collapsed 
condition, and died five hours after having been placed in bed. 

This not wholly unexpected result of the operation proves that the 
resistence of the patient had been lowered to such an extent that even 
this mild and bloodless procedure led to a fatal termination, and that 
any other operation, such as lithotrity or a perinseal section,would have 
caused death more speedily. Further, it seems to be clear that in this 
case an extraction of the stones from the diverticula by the lower op- 
eration or lithotrity could not have been accomplished. 

On post-mortem examination, the fourth stone, contained in a smaller 
diverticulum, was remoygd. It was then seen that its detection and 
extraction could have been easily accomplished. The aggregate 
weight of the four stones was 51 grammes, the heaviest being the round 
smooth stone extracted from the bladder itself, weighing 2272 grammes, 
its longitudinal diameter being 3Y3 cm., its transverse diameter 2^3 
cm. The next in weight, 1 5 grammes, was a pear-shaped stone re- 



304 ARPAD G. GLRSTER. 

moved Irom the larger diverticulum, its length being 4^/2 cm., its thick- 
ness 3 cm.; its apex, which had projected into the bladder, showed an 
obhque facet corresponding to the smaller facet of the other stone 
found in the cavity of the bladder. The third stone just alluded to as 
found in the bladder was irregularly shaped, having two facets and a 
stalactitic fracture-surface about 72 cm. in diameter. This weighed 10 
grammes, and was apparently one with the fourth; the smallest stone 
found in the second diverticulum, which weighed 372 grammes, was 
pear-shaped and was 272 cm. long and 17^ cm. wide. All the stones 
show, where they have not been worn smooth, a crystalline surface of 
whitish color. They consist of alternate layers of carbonate and of 
oxalate of lime, the latter substance preponderating. 

In studying the position and relations of these stones it seems al- 
most certain that there were originally only two stones present, the 
largest smooth one being the oldest. The remaining stones must have 
been originally one body, the main part of which was situated in the 
bladder and gradually sent out two pear-shaped projections, each of 
which was found to be lodged in a diverticulum of corresponding size. 
The larger one, the presence of which could be felt before the opera- 
tion by touch through the rectum, must have been broken off some 
time previous to the operation. The fractured surfaces, preserving 
apposition, became worn into facets. The peristaltic motion at defe- 
cation may have played an important part in the production of this 
phenomenon. 

The post-mortem examination revealed a normal urethra, enormous 
concentric hypertrophy of the bladder, the two diverticula above de- 
scribed within its posterior wall, and very much distended ureters. The 
latter resembled infantile small intestines, their width varying between 
I and 3 ctm., the thickness of their walls also varying to a considera- 
ble extent. The greatest amount of distension was noticed in that 
part of the ureters lying next to the bladder. Both kidneys were some- 
what enlarged, their capsule could be stripped off very easily, color 
pale, cahces and pelves much thickened and dilated, the kidney tissue 
in an advanced state of fatty degeneration. 



CLINICAL OBSERVATIONS ON FIBROMYOMATOUS 
TUMORS OF THE UTERUS/ 

By FREDERICK LANGE, M.D., 

OF NEW YORK, 

SURGEON TO THE GERMAN HOSPITAL ; CONSULTING SURGEON TO THE PRESBYTERIAN 
HOSPITAL. 

AMONG a limited number of the fibryomyomatous tumors 
of the uterus which have altogether come under my ob- 
servation, I had the opportunity in three instances to see a 
rather uncommon termination of the disease, namely, in two 
cases by expulsion of tumor-masses after spontaneous slough- 
ing ; in the third case by shrinkage of the tumor after central 
suppuration and softening. In all of these cases more or less 
surgical help became necessary to aid the natural process, but 
all of them, in spite of protracted serious illness, at last ended 
A'ith recovery, and illustrate in a very eloquent manner, the 
ability of nature to find, in spite of serious obstacles, its way 
toward ultimate recovery. The following short histories may 
sufficiently point out the essential features of these cases. 

Case I. — On the 12th of October, 1883, I saw in consultation with 
Dr. Schaide, of this city, Mrs. B., then set. 45, who was suffer- 
ing from a large abdominal tumoT, which had existed for about three 
years, and by a number of physicians, both here and abroad, had been 
diagnosticated as fibromyoma of the uterus. To Dr. S. I owe most of 
the following notes about her history. Mrs. B. had been advised 
everywhere not to have an operation done on account of the great risk 
attached to it. Within the last year she had been treated repeatedly 
for long periods of time with ergot, administered hypodermically as well 
as internally, but without any noteworthy success, in reference to 
haemorrhage as well as size of the tumor. The latter, when I saw the 

1 Read before the New York vSurgical Society, May 24, 1886. 

(30s) 



FREDEh'ICK LANGE. 

patient, filled as a resistant, somewhat irregularly shaped mass, almost 
the entire abdomen. Having at that time already operated success- 
fully upon several patients with exceptionally large solid uterine tumors, 
I proposed, in view of the intense suffering of the patient, the radical 
operation. The patient decHned. In the beginning of November her 
condition became feverish, there appeared an offensive discharge from 
the vagina, and the patient lost rapidly in flesh. On the i8th of No- 
vember Dr. S. was able to remove a piece of the tumor about the size of 
the fist, in a decomposed necrotic condition, from the vagina, which, 
for the next two weeks, was almost daily followed by others of smaller 
or larger size. A particularly large piece was extracted from the uterus 
at the end of November. I then saw the patient again in consultation. 
To my surprise the enormous tumor had so much disappeared that the 
uterus now was not larger than at about the fourth or fifth month of 
pregnancy. There existed still a very offensive discharge, which, how- 
ever, ceased very promptly, after I had extracted from the uterine cav- 
ity the remainder of an entirely separated mass of tumor. The offen- 
sive smell of this sloughed tissue was beyond description. The uterine 
cavity was disinfected as thoroughly as possible, and disinfecting irri- 
gations kept up for some time after. The patient, though very much 
run down, made a rather rapid recovery and was able, four weeks later, 
to see Dr. S. at his office. The latter had the kindness to inform me 
that Mrs. B. is now in perfect health. About a year ago her menses, 
which had become quite normal, ceased. There is no recurrence of 
the tumor, and the parts seem to be in an almost normal condition. So 
far as I remember, the mass of the tumor at my first visit must have 
weighed at least fifteen to twenty pounds. 

Case II. — Mrs. H., aet. 46, who had never been pregnant, 
consulted me in October last. Though otherwise in good health, she 
had suffered for the last two years from profuse and prolonged men- 
struation, now and then associated with severe pains in her back and 
vomiting. Within the last month, a few days before and after men- 
struation, a white discharge appeared. There was no doubt that her 
trouble was due to a fibromyomatous tumor of such size that the 
uterus, on examination, reached within about two fingers' breadth of 
the umbilicus. During the time from the 12th of October to the 6th 
of November about eighteen hypodermic injections of Squibb's fluid 
extract of ergot were administered in the hypogastric region. They 
caused a good deal of pain and inflammatory irritation, which, how- 
ever, by cold applications was kept down, so that no abscesses oc- 
curred. Small indurations, however, remained at the points of injec- 



FIBROMYOMATOUS TUMORS OF THE UTERUS, ^O^J 

tion. During the menstrual per:od the patient rested at home, did not 
get any hypodermic injections, but took the ergot internally, 15 to 20 
drops twice a day. On the 14th of December I was called to see 
Mrs. H. at her house. She had a bloody, somewhat offensive dis- 
charge from the vagina, and suffered from great restlessness and pain 
of labor-like character. The vaginal portion of the uterus was softened 
and dilated, and a soft mass could be felt within it. On the following 
day, under chloroform, a considerable mass, about a pound and a half, 
of sloughed fibromyomatous tumor was removed from the uterine cavity, 
alter lateral incisions into the vaginal portion had been made. On 
account of the narrowness of the sexual passages and the impossibility 
of pulling down the uterus, I could not pass my finger high up into the 
uterine cavity. But I was able to ascertain that a good many necrotic 
irregular pieces of tissue remained undetached as yet. Two drainage 
tubes were introduced into the uterus, and repeated irrigations made 
with a warm solution of salicylic and boracic acids, and once or twice 
a day of corrosive sublimate solution i : 5000. But in spite of my en- 
deavors, I did not succeed in preventing further decomposition. The 
drainage tubes were so often closed by small particles of necrotic tis- 
sue that they did not act satisfactorily. Besides that, their presence in 
the internal orifice seemed to be the source of constant irritation. I 
thereiore removed them, and appHed irrigation several times a day, by 
passing a Fritsche's uterine irrigator high up into the uterine cavity, 
usually injecting, first a stronger solution (1:2000) of corrosive sub- 
limate, followed by injection of bor-salicylic acid, according to 
Thiersch's prescription. 

Very soon, under repeated chills and high fever, the palpable symp- 
toms of peri- and para-metritis set in. Especially in the cavum Doug- 
lasii, where a fibroma, inserted at the supravaginal portion of the 
cervix, was felt before, a diftuse infiltration and exudation could be 
made out, pushing the lower portion of the uterus toward the sym- 
physis. Dr. Noeggerath was called in consultation, and was hkewise 
convinced of the extremely precarious condition of the patient. It was 
decided to renew the attempt to remove the source of infection from 
the uterine cavity, and on the 23d of December, in the presence and 
Avith the kind help of Dr. Noeggerath, sloughed masses, much less, 
however, than the first time, were again removed, partly by forceps, 
partly by curette. It was discovered that from the anterior as well as 
the posterior aspect, tumor-like prominences protruded toward the 
uterine cavity, and that the process of sloughing was particularly seated 
posteriorly and toward the fundus. The uterus, by this time, had al- 



308 FREDERICK LANGE. 

ready become considerably reduced in size. On the 5th of January 
made a deep incision into the exudation through the posterior cul-de 
sac, evacuating pus mixed with small pieces of necrotic tissue, as 
supposed, from the centre of the fibroma which had undergone sup 
puration, and from that time, while the discharge from the uterus be 
came gradually less, and almost daily small pieces of necrotic tissue 
were expelled, the patient's condition became decidedly better. Sev- 
eral times shght hseinorrhage accompanied the expulsion of sloughs. 
At present, for more than a month, the discharge has entirely ceased. 
The uterus is very little larger than its normal size. There is still a 
decided induration at the seat of the para- and peri-metritic inflamma- 
tion, which, however, is gradually diminishing. The general condition 
is very good, and twice already, if I am not mistaken, the menstrual 
flow has appeared again, normal in quantity and duration. Mrs. H. is 
now 47 years of age, and certainly very near the end of her menstrual 
life. I think there is very little probability that a new formation of 
fibromyomata will occur. I am under the impression that in this case 
the whole mass of the tumor had not sloughed, but that several lumps, 
together with the gradual contraction of the uterus, have disappeared 
either -by atrophy or fatty degeneration. It seems, further, that in this 
case the administration of the ergot had a causal relation to the necro- 
sis and elimination of the main part of the tumor. 

Case III. — Miss B. L., 28 years of age, was in good health until four 
years ago, when she began to suff"er from profuse menstrual haemor- 
rhage and pain in her back, which were ascribed by a physician as due 
to the presence of a uterine tumor. For about three months she was 
treated with hypodermic injections of ergot, altogether about thirty in 
number, but without success. Three years ago, in making a forced 
attempt to prevent herself trom falling down by throwing herself back- 
ward, she felt a severe pain in the aodomen, and had the sensation as 
if something had been torn ; the pain in her abdomen persisted during 
the summer. Ergot, internally, was used again, but gave her no re- 
lief. In September, 1883, I saw the patient in consultation with Dr. 
Dieffenbach, when she presented a deep-seated phlegmon of the ab- 
dominal wall, apparently in the retroperitoneal space below the umbi- 
licus. On the 15th of September, through an incision in the linea alba, 
a great quantity of pus was discharged ; a drainage tube was passed at 
one point to such a depth, into a rather small appendix of the cavity, 
as to allow of the conclusion that it must reach some distance into the 
abdominal cavity. After some time, when infiltration and pain had 
sufficiently ceased, it could be made out that a uterine tumor, origi- 



FIBROMYOMATOUS TUMORS OF THE UTERUS. 309 

nating from the fundus of the uterus, was adherent to the abdominal 
wall, and that a pus cavity passed to some distance into its mass. 
Suppuration went on for several months, and the tumor gradually de- 
creased in size, having presented originally about the dimensions of a 
small child's head. Small, irregularly shaped calcareous masses were 
repeatedly washed out or extracted from the bottom of the wound. On 
the 31st of December, 1883, after having enlarged the existing open- 
ing, I removed from the rather narrow cavity by scraping, elevator, 
forceps and finger, quite a considerable quantity of calcareous spiculge, 
shells and irregular shaped bodies, in all perhaps as much as a table- 
spoonful. Four weeks later cicatrization was complete, and since then 
the patient has enjoyed perfect health. A hard lump in connection 
with the scar, about the size of a duck's egg, can be still felt, but does 
not cause the slightest inconvenience, while menstruation has at all 
times been normal. I cannot say what connection exists at present 
between the tumor and the uterus, the patient not having undergone 
an examination of sufficient thoroughness. It seems in this case, 
through an injury, perhaps by partial rupture of the insertion of the tu 
mor, its nutntion has been interfered with until finally central softening 
■with suppuration occurred, which gradually led to its diminution and 
arrrest of growth and development. No medical treatment was used 
after the operative interference. 

Though quite a number of cases are on record in which, after 
the manner described in the preceding histories, fibromyoma- 
tous tumors have disappeared, they are rather exceptional, and 
withal this natural way of healing is not free from danger, no 
small percentage of cases ending fatally. We are, therefore, 
in no way entitled to trust to such an exceptional and unreli- 
able course of the disease so far as to give it any important 
weight in regard to our prognosis of fibromyomatous tumors 
of the uterus. We know only too well that sometimes these 
tumors will have an unbounded development, and, after they 
have attained a certain size, become dangerous, and in an im- 
perative way demand our surgical help, and that so much more 
as in these cases medicinal treatment is usually nothing but 
loss of time. 

With reference to the question, how far the extirpation of 
the ovaries may effectually check the development of fibromy- 
omatous tumors, I am unable to give a satisfactor>^ answer 



3 1 FREDERICK LANCE. 

from my own experience. I have attempted the operation once, 
but only to find out that in that case the removal of the ova- 
ries would have been a very tedious operation, and probably not 
much less dangerous than the removal of the whole mass. In 
those five cases in which so far, I have seen the necessity of 
performing supravaginal amputation of the uterus for the dis- 
ease in question, the tumors were of such uncommon size, and 
were mostly so complicated by adhesions, that it would have 
been no easy thing at all to get the ovaries, and this, together 
with the question whether, in such cases, castration promises 
the desired result, has led me in all of those five cases to give 
preference to the radical method of operating. All have ended 
in recovery; two of them have been reported to this Society in 
previous years, one being complicated with pregnancy ; the 
third one was operated on about a year and a half ago ; of the 
last two cases which have been operated upon in the course 
of this year, I present before you the tumors removed. With 
reference to the third of the before-mentioned cases, I would 
say that it was that of a married lady of about 33, who for sev- 
eral years at every menstrual period had bled so abundantly as 
to become quite anaemic, her whole way of living finally being- 
devoted to the purpose of building herself up to withstand the 
drain of the next menstruation. She suffered repeatedly from 
very alarming attacks of weakness of the heart, which seemed 
to be dilated in its right half, and there was no doubt that, 
every [other remedy having proved ineffectual, she would 
finally have died from the consequences of a fibromyomatous 
degeneration of the uterus, which, as the specimen afterwards 
proved, consisted of a large number of tumors of different size 
and location, massed together in the different layers of the 
uterus, and forming a tumor of the size of the uterus in the 
seventh month of pregnancy. 

The operation was performed in the same manner that I am 
about to describe in the following cases, and recovery took 
place without any untoward symptom, except that about two 
months after the operation the elastic ligature by which the 
stump of the uterus had been secured, passed away through 
the external os. The lady is now in flourishing health. About 



FIBROMYOMATOUS TUMORS OF THE UTERUS. 3 I I 

nine months ago she passed a considerable quantity of blood 
with her urine for three or four days, with some feeling of pain 
in her back and a general sensation as if she had her period. 
The urine afterward became normal, and, so far as I know, no 
such hcxmorrhage has recurred. She pretends to enjoy sexual 
intercourse without impairment as compared with her healthy 
period of married life before the operation. Lately she has 
become rather stout. 

Case IV.— In January of this year Miss W., 2,1 years of age, con- 
sulted me for an abdominal tumor which had been noticed for the past 
three years, but only lately attention had been called to it, by its more 
rapid growth and large size having been the source of disturbance. 
The whole abdomen seemed to be occupied by a resistant, rather 
smooth tumor reaching from the os pubis high up to the epigastrium 
and the free border of the ribs. The tumor was very movable and al- 
lowed of passing the fingers partly under it toward the entrance of the 
small pelvis, so that on the first examination it did not seem to take 
Its origin from a pelvic organ, though its movements were communi- 
cated to the uterus. A closer examination, however, revealed a con- 
nection with the fundus uteri, and made the diagnosis of a peduncu- 
lated fibrous tumor the most probable. 

In this case the operation was comparatively simple. 
Though it would have been possible to remove the tumor 
without sacrificing the internal sexual organs, I still deemed it 
advisable to perform the supravaginal amputation for the fol- 
lowing reasons : First, I thought of the possibility, that from 
its rapid growth within the last months the tumor might have 
assumed a more malignant character ; and secondly, several 
small beginning fibromata could be distinguished lower down 
within the walls of the uterus which, if left behind, would have 
developed further and perhaps more rapidly. 

The operation was performed in the following manner : Through 
an incision in the linea alba reaching from the epigastrium almost down 
to the symphysis pubis, the tumor was slowly and without difficulty 
brought before the abdominal walls ; the adhesions were but very 
slight. Enormously dilated veins occupied the broad ligaments. Then 
from both sides in a horizontal direction the broad ligaments were tied 



3 1 2 FREDERICK LANCE. 

in several portions between two ligatures until dose to the lateral 
edges of the uterus, and cut across. I then passed an elastic ligature 
under the peritoneal covering of the cervix uteri, and tied it by means 
of coarse silk thread. About 3 cm. above this ligature the uterus was 
amputated and thus the whole mass removed. The tissue of the 
stump was then excised in the shape of a funnel, so that the mucous 
membrane was removed as low down as the elastic hgature permitted. 
At the deepest point the actual cautery w^as applied and a small quan- 
tity ot iodoform powdered over the eschar. The funnel was then 
closed by a number of deep catgut sutures, between which the peri- 
toneal covering was adjusted by superficial ones. The ends of ah the 
hgated tissues were then cauterized, sprinkled with iodoform, and the 
abdomen closed by peritoneal and other sutures in the usual manner. 
The patient had a very rapid recovery almost without any feverish 
reaction, and is so far entirely well. 

In a case like this the operation does not present any great 
difficulty, nor does it involve any particular danger if only 
proper care is taken not to expose the patient to an unneces- 
sary loss of blood. I think the patient, apart from the blood 
that was contained within the removed parts, lost hardly more 
than an ounce of blood. The way of passing the elastic ligature 
beneath the peritoneum was intended to secure a certain 
amount of nutrition for the stump. The latter, in fact, did not 
become entirely bloodless, but presented, during the act of 
being tightly closed up by stitches, some slight oozing which, 
however, was checked by the sutures. 

The weight of the tumor now, after a five month's preserva- 
tion in alcohol, is nine and a half pounds. It is throughout all 
its substance a fibromyoma. 

The second specimen, which I present here, was obtained by 
an operation of much more seriousness and difficulty. In fact, 
the operation was only undertaken at the urgent request of 
the patient. 

Case V. — Miss L., 33 years of age at the time of operation, had 
from her twenty-sixth year suffered from abundant menstrual haemor- 
rhage due to a tumor. She was treated with hypodermic injections of 
ergot, some of which, she states, w^ere injected into the mass of the tu- 
mor itself and gave rise to an intense peritonitis which lasted for six 



FIBKOMYOMATOUS TUMORS OF THE UTERUS. 3^3 

weeks. No relief followed. The tumor gradually increased in size. 
Within the last months her suffering had become most intense. She 
had constant pain ; was hardly able to walk ; her digestion became im- 
paired, and she lost rapidly in strength and flesh. The external exam- 
ination revealed the presence of hard, lumpy, irregular masses in the 
lower part of the abdomen, which, on the left side, extended close to 
the border of the ribs. A large portion of the tumor could be felt 
from the vagina reaching far down into the small pelvis, displacing the 
OS uteri toward the symphysis pubis and pushing it in an upward direc- 
tion*, Everything seemed fixed and immovable. On the nth of Jan- 
uary the tumor was removed. Gradually the numerous adhesions 
^^'ith the anterior abdominal wall, the omentum, and intestines were re- 
moved. There existed venous vessels in such quantity and of such 
enormous size as I have never seen before, and requiring careful Hga- 
tion. A great difficulty was experienced in sheUing out that part of 
the tumor, which on both sides had grown under the peritoneum be- 
tween the layers of the broad hgaments. At last the cervix uteri was 
reached, an elastic Hgature applied, and the mass removed. The 
rather free hsemorrhage from the extensive raw surface, which corre- 
sponded to the subserous attachment of the tumor, was at last checked 
by ligatures, sutures, and the actual cautery. A careful toilet of the per- 
itoneum followed, and the abdomen was closed. Repeatedly during 
the operation the patient had very alarming attacks of heart-weakness, 
which obliged me to interrupt the operation and at one time apply ar- 
tificial respiration. It seemed to me that these attacks depended on 
forced tractions which could not very well be avoided during the at- 
tempt to get under the immovable and fixed mass. 

In this case the cervix uteri was entirely void of peritoneal covering, 
which had been lifted from it by the adjacent subserous tumor masses. 
The mucous membrane of the cervix was excised as in the case before, 
but the indication to finish the operation was so urgent that I had to 
desist from any further details in treating the stump of the uterus. Al- 
together the operation had lasted about three hours and a half. The 
patient had a very protracted convalescence disturbed by peritonitis 
and the formation of an abscess, which discharged itself spontaneously 
through the cervical channel. Another abscess formed itself near the 
anterior abdominal wall, and was opened in the Une of the original in- 
cision, leaving a fistula. On the 24th of April I dilated the cervix on 
account of persistent offensive suppuration, and extracted quite a num- 
ber of coarse silk hgatures, but was unable to find the elastic Hgature, 
which apparently was safely encysted. Several other ligatures were re- 



3 1 4 FREDERICK LANGE. 

moved through an incision in the abdominal wall a few centimetres to 
the left of the original cut, and since then the discharge has almost en- 
tirely disappeared ; the patient does not suffer any more, and can be 
regarded, I think, as definitely convalescent. The weight of the alco- 
hol specimen is ten pounds. 

I may be permitted to add, that a patient from whom I re- 
moved the uterus for myxosarcoma about four or five years 
ago, and whose specimen and history were presented before 
this Society, is so far enjoying good health. I saw her about 
one year ago, and there was no evidence of any recurrence of 
the disease. She promised to let me know if in any way she 
should be troubled. 

I should also like to mention a case of multiple fibromyo- 
mata of the uterus, in which my operative efforts were not fol- 
lowed by such good fortune : 

Case VI. — A recently married woman of about 30 years, nullipara, 
had been suffering similarly to the above-mentioned patients during 
her menstrual period. Lately a great deal of pain and tenderness in 
the hypogastric region had supervened, and the patient, asking for a 
radical curative effort, and having exhausted other treatment without 
success, was subjected to laparomyomotomy. Two pedunculated 
fibromata about the size of a small fist were found, arising from the 
fundus uteri ; the one impacted in Douglas's space was easily recov- 
ered after hgating the pedicle. The other, to the right side of the 
uterus and in front of the broad ligament, had become necrotic in con- 
sequence of torsion of its pedicle, and was imbedded in a sac of ad- 
herent peritoneum, which, however, could be detached without great 
difiiculty. There was no exudation of pus or fluid. The tumor 
looked gray, with a greenish tint, and contained no fluid blood. I 
tried to tie the pedicle within its living part, but a small necrotic por- 
tion remained beyond the ligature. A third myoma, about the size of a 
small hen's egg, was broadly inserted on the anterior wall of the uterus 
right above the cervix, and for its removal and shelling out a thin 
layer of uterine tissue had to be severed. There was considerable 
capillary oozing from the bed of the tumor, and the efforts to check 
the haemorrhage by Paquelin's cautery, stitches and ligation, made the 
operation prolonged. Death occurred on the third day, apparently 
from septic peritonitis. No autopsy was conceded. 



FIBROMYOMATOUS TUMORS OF THE UTERUS. 3^5 

I presume infection may have started from the place where 
the necrotic fibroma was embedded. Here, perhaps, infectious 
germs existed, which, though made harmless for the time by the 
adherent peritoneum, were set free by the operation, and found 
outside of their prison ver>^ favorable chances for their deleter- 
ous action. The torsion of the pedicle illustrated very beau- 
tifully the way in which such tumors at last might be depri/ed 
of their blood supply, and finally undgo retrogressive meta- 
morphosis. 

With reference to the supravaginal amputation of the uterus 
I should like to mention, in a few words, the different ways in 
which the uterine stump is secured and treated. Thus, as 
previously in ovariotomy, the extra- and intra-peritoneal 
method stand against each other, and on both sides equally 
good results are obtained. Schroder and Martin, in their very 
extensive practice, trust to tight suture of the stump after fun- 
nel-like excision. Schroder first advised etage suture. They 
do not use the permanent elastic ligature, and are strong ad- 
vocates of the intraperitoneal treatment. So is Olshausen, 
who uses the elastic ligature, Rose, and others ; while extra- 
peritoneal treatment is given preference by Hegar, Kalten- 
bach, Pean and others, as involving less risk in reference to sep- 
tic poisoning, and leaving the stump accessible in case of sec- 
ondary haemorrhage. 

There exists, perhaps, no more striking illustration of the 
safety of aseptic proceedings than the fact that such large 
masses of tissue as the ligated stump of the fibromyomatous 
uterus can be left in the abdominal ca.vity, deprived of blood 
supply, without undergoing decomposition, and giving rise to 
infection. On the other hand, it cannot be doubted that a cer- 
tain amount of risk will always be attached to their way of act- 
ing, and that those methods which secure nutrition to the 
stump with intraperitoneal treatment will have to be regarded 
as the most proper ones. That good results can be achieved 
by the extraperitoneal method nobody will doubt, and repeat- 
edly successful cases of it have been reported to this Society. 
I am, however, convinced that, by-and-by, just as it has been 
with ovariotomy, the intraperitoneal treatment will be more 



3l6 FREDERICK LANGE. 

and more adopted. I should certainly give preference to 
Schroder's method of securing the stump by tight etage su- 
tures, above all others, if with reference to haemorrhage I 
should regard it as free from all danger. It may be safer in 
the hands of operators, who are working on such a large scale 
as Schroder and Martin do. I must myself concede, that here- 
tofore only the apprehension of a possible haemorrhage has 
prevented me from following them. In order to combine the 
advantages which the elastic ligature offers in regard to haem- 
orrhage, with those offered by suturing the stump, I have tried 
in one of the above cases, to apply the ligature beneath the 
peritoneum, so that a certain amount of blood can be furnished 
to the stump through its peritoneal covering, which, of course, 
must be detached as little as possible above the ligature. 
Further observations will have to be made, in order to ascer- 
tain whether this procedure will always yield as good results 
as it has in my case as above recorded. 

One mechanical contrivance I would mention, and of which 
I like to make use in all abdominal operations wherever prac- 
ticable, is Thiersch's ligature spindles, with or without holder, 
which I have presented at a former meeting of this society. 
They are, indeed, very handy, and allow of securing pedicles 
and fleshy adhesions with more constricting force, than can be 
exerted in the ordinary way of tying. 

The abdominal incision ought to be long enough to allow of 
an easy access to the operating field. I certainly prefer too 
large an incision, to one which obliges the operator to work in 
the dark, or to do uncertain manipulation. For this latter rea- 
son, often one of the principal dangers in these operations is 
incurred, namely, unnecessary and abundant loss of blood, 
simply because the operator does not in time and with easiness 
get at the bleeding point. If one has seen those enormously di- 
lated veins in these tumors, one must be convinced that bleed- 
ing from such a vessel for a very short time must be sufficient 
to endanger life. For this reason, also, every undue tearing 
force ought to be avoided, and it is safer and more wise to 
work slowly and cautiously, than to hurry at unnecessary haz- 
ard. The length of the abdominal incision adds almost noth- 



FIBR MYOMA TO US TUMORS OF THE UTER US. 3 1 7 

ing to the danger and gravity of the operation, and incisions of 
fifteen or more inches will heal without difficulty. To obviate 
loss of warmth from extensive denudation of intestine, the use 
of large, flat sponges dipped in a weak aseptic fluid seems to 
me the most commendable. 



EDITORIAL ARTICLES. 



THE TREATMENT OF COMPOUND FRACTURES OF THE SKULL. 

The current number of Volkjuann' s SamiJilung klinischer Vortrage^ 
contains an elaborate contribution to the subject of compound fractures 
of the skull, with special regard to their treatment, by Dr. W. Wagner, of 
Konigshiitte, which appears worthy of special notice, not only for the 
reason that a large number of new cases is recorded, and that excep- 
tionally good results have been achieved, but more especially on ac- 
count of the author's divergence from the indications and mode of 
treatment heretofore generally accepted in compound injuries to the 
skull, and the attention given to the antiseptic method. 

Thus the author, it will be seen, is not in favor of trephining for rup- 
ture of the middle meningeal artery, at least not in any but extreme 
cases of intracranial pressure ; nor does he think it necessary to elevate 
smaller depressed pieces of skull ; but if the slightest quantity of for- 
eign matter, or as much as a hair have penetrated through a fissure in 
the skull, he deems it an unavoidable necessity to lay open the cranial 
cavity— a point which our readers will remember to have been insisted 
upon by Wiesman, of Ziirich-, in a recent contribution to the subject. 

The cases, all treated from the same pointe of view and in the same 
hospital, the hospital for coal miners at Konigshiitte, during a period of 
nine years are 95 in number, and consist for the most part of severe 
injuries to the skull, such as miners are constantly exposed to. The 
greater majority were received into the hospital immediately or very 
soon after the injury, and the mortality percentage of these cases is 
1.23. About one-seventh of the number, however, did not apply for 

•Nos. 271 and 272. Chirurg. No. 85. April 20, 1886. 
^ Vide Annals of Surgery. Vol. H. P. 502. Dec, 1885. 
(318) 



TREATMENT OF COMPOUND FRACTURES OF SKULL. 319 

treatment until ai least twenty-four hours after the accident ; and in 
this group the mortality averaged n^j,, per cent. The difference 
in these figures is due to antiseptic prophylaxis. 

The author only cursorily considers the pathology and symptomat- 
ology of the subject, confining himself, as has been remarked, almost 
exclusively to the therapy of the injuries to the skull ; and after giving 
quite a detailed review of the history of his subject, with special refer- 
ence to the operation of trephining, he first considers the dangers of 
septic infections of skull-wounds. The smallest wound of the integu- 
ment, when infected with septic matter, may lead to the most serious 
disturba nee by the progress of the septic inflammation towards peri- 
ostitis, purulent ostitis, osteo-phlebitis, meningitis, encephalitis ; or 
the course of the infection may lead from periostitis through os- 
teophlebitis to thrombosis of the venous sinuses and pyasmia. The 
dangers incident to septic infections increase as the injuries to the tis- 
sues penetrate more deeply. 

If the peritoneum is severed, or if the bones of the skull are injured, 
the infectious matter is rapidly disseminated by means of the veins of 
the diploe, and infection of the brain and its tissues or pysemic metas- 
tases result. If the cranial cavity is laid open, the septic infection leads 
to an inflammation of the dura mater, pachymenmgitis externa, which 
may spread to the soft tissues enveloping the brain. But when the 
dura mater is injured as well, the danger for the patient is much en- 
hanced by the immense susceptibility of the pia mater to septic infec- 
tion. 

A few hours suffice, in these latter cases, for the infection to gain a 
firm hold, so that nothing can stay the rapid development of inflamma- 
tory processes during the following days. 

Erysipelas also plays an important part among such infections of 
scalp wounds, but does not materially differ as regards its prophylactic 
treatment from the other inflammatory processes. 

Antiseptic prophylaxis, in fact, represents the key-note in the pres- 
ent treatment of all wounds and injuries to the skull, and should indi- 
cate what active therapeutic measures are to be chosen in each case. 

Thorough cleansing of the injured parts and their immediate and 



^-O EDITORIAL ARTICLES. 

more remote surroundings should be the first step in all cases without 
exception. This precaution is of the utmost importance as the scalp 
is always soiled by fatty substances, the secretions of the sebaceous 
and sudorific glands, and by dust and floating matter from the air. 

Simple scrubbing with soap water and a brush is not sufficient. A 
better way is to first scrub the scalp with soap and carbohc (3%) or sub- 
limate (1%) solution and then shave the parts surrounding the wound. 
The hair of the entire head is then to be washed by means of wads 
of cotton soaked in ether, turpentine or absolute alcohol, until all fatty 
substances have been removed. Then the scalp is to be cleaned with 
soap and warm water, and finally with an antiseptic solution. The 
wound is then to be examined. In case the bone or even the [)erios- 
teum can be felt by means of the inserted finger, the wound is to be 
opened up, either with retractors, or if necessary by incision, and, 
after Hgating all bleeding arteries and thoroughly cleansing the wound, 
the parts minutely inspected. It may be necessary to anaesthetise the 
patient before doing this. 

The simplest case of compound fracture of the skull is injury ^to the 
external lamina, generally produced by sword cuts. Frequently frag- 
ments of this layer are met with, which should be completely removed, 
excepting in those cases where large continuous pieces of bone have 
been sliced off and are still connected with the skull by means of the 
periosteum. These latter fragments may be held in position by su- 
tures, and drainage effected by perforating them. In other cases 
disinfection, evening off of the margins of the wound, exact suture, 
drainage and application of an antiseptic dressing suffices. ; 

In case a penetrating fissure is found to exist, the treatment should 
vary according to whetner foreign bodies, hairs, etc., have become im- 
pacted between the fragments or not, and whether the margins of the 
fissure are comminuted or soiled. If neither is the case the wound is 
to be closed as before ; the patient should be kept in bed for at least 
three days, and calomel (0.25 gm. b. i. d.) administered. These 
dressings, which should include the whole head to the middle of the 
forehead and the chin, and should be so applied as to exert a certain 
pressure upon the wound, may be changed on the fourth day, when 



TREATMENT OF COMPOUND FRACTURES OF SKULL. 321 

the drainage tubes are to be taken out ; and again on the eighth in 
order to remove the sutures ; they should not be completely left off 
until all parts have ceased to granulate, for fear of erysipelas. 

In those cases, however, in which hairs or other bodies appear im- 
pacted in the fissures, they should at once be removed with the chisel 
and hammer. 

Comminuted fragments of bone and soiled margins of fissures should 
be removed in the same way. But in case the fissure extends through 
the cranium for some distance under uninjured portions of the integu- 
ment, no interference is necessary. Nor do slight difi'erences in eleva- 
tion of the fragments caused by depressions, indicate operative inter- 
ference. Indeed, even fractures in which pieces of bone have been 
very appreciably depressed, by no means necessitate operative pro- 
cedures, as long as no infection has taken place, although formerly such 
depressed pieces of bone formed indications for trephining. For the 
symptoms theoretically attributable to ( ompression of the brain are in 
practice so confused with those of concussion and contusion of the brain, 
that the indications are not sufficiently clearly defined. The dangers 
of intracranial pressure are greatly exaggerated. The brain easily ac- 
custcms itself to depressed fragments, and can well bear the pressure 
of a moderate haemorrhage from the middle meningeal arteries until 
the clot is absorbed. It is of far greater importance to prevent the 
infection of intracranial tissues than to relieve the brain from pressure; 
and it is this danger of infection arising from soiled wounds that may 
often demand operative interference. Entrance of foreign bodies into 
the wound, and injuries caused with unclean objects therefore indicate 
the use of the trephine or the chisel. Detached pieces of bone should 
be eliminated in order to anticipate a possible necrosis with prolonged 
suppuration. In cases where pointed instruments have penetrated 
through the bones of the skull, a sufficiently large piece of bone should 
be removed with the instrument to permit of perfect disinfection of the 
deeper injured parts. Septic infection can never be excluded with cer- 
tainty, while an antiseptic operation may be done without incurring 
the least risk. 

Extensive comminuted fractures are to be treated after the same 



322 EDI'IORIAL ARTICLES. 

principles as given above ; nor should the presence of more alarming 
nervous symptoms referable to commotion and compression of the 
brain defer the surgeon from the conscientious exercise of antiseptic 
measures. Osseous fragments are to be extracted, the wound freely- 
laid open, coagula of blood removed, foreign bodies extracted, unless 
such a procedure would necessitate injuries to the brain. Haemor- 
rhages occurring in the brain-substance should be stilled by means o^ 
the actual cautery. In case there is reason to fear an accumula- 
tion of blood beneath the dura, the latter should be incised. Elevation 
of large masses of depressed bone may be necessary in some very ex- 
tensive compound fractures of parts of the skull, when the patient has 
escaped immediate death. 

In the adjustment of the dressing care must be taken that the drain- 
age tubes do not enter too far into the wound. The wound may be 
covered with the help of plastic methods. 

The general treatment should be adapted to the general condition 
of the patient. In the stage of depression after concussion of the brain 
excitants should be given, subcutaneous injections of ether and cam- 
phor ordered, and sinapisms and hot packings be applied to the skin ; 
the head laid low. 

In the stage of excitation following, the head should be raised, an 
ice-bag applied to the head and a brisk cathartic administered. Intra- 
cranial pressure demands the same trt?atment. In both cases the ap- 
plication of leeches in the region oi some emissary does excellent ser- 
vice. Of the action ofergotin the author has little experience. But the 
main importance should be attached to the local surgical treatment. 

Special precautions are necessary wlien fracture of both walls of the 
frontal sinus has established direct communication between the nasal 
cavity and the brain tissues. In this case the effective application of 
an antiseptic dressing occluding the wound is rendered difficult ot per- 
formance. The author advises tamponade of the frontal sinus with an- 
tiseptic gauze in all such cases, even though it should be necessary to 
enlarge the external wound and at the risk of establishing a frontal 
fistula — disadvantages which are of Httle consequence in comparison 
to the dangers of septic infection incurred by permitting free access of 



TREATMENT OF COMPOUND FRACTURES OF SKILL. 323 

air to the cranial cavity. Absorption of the secretions by the gauze 
may cause artificial compression of the brain in these cases, a danger 
which should be borne in mind. 

These considerations apply to other cavities situated in the imme- 
diate vicinity of the brain as well, and especially to the orbita and to 
the auditory meatus. Resection of a part of the orbital margin may 
become necessary in order to extract foreign bodies and to remove in- 
fectious matter. The auditory canal, after being cautiously cleansed 
by means of antiseptic solutions, may be filled with iodoform powder 
and loosely plugged with gauze. In cases of fracture of the ethmoid 
bone abundant dusting of the entire upper portion of the nasal cavity 
with iodoform is to be preferred to anterior and posterior tamponade. 
Iodoform inflation is also to be used in less recent cases when puru- 
lent secretions of the cavities mentioned have already appeared. 

The author believes that his favorable results in cases of fracture of 
the base of the skull were entirely due to the adoption of this mode of 
treatment. For although many cases of fracture of the skull terminate 
fatally in the course of a few hours after the accident, in consequence 
of injuries affecting the central organs, and some of the author's cases 
took this course, yet, of all those who have survived the first 24 or 48 
hours, and who were treated in the manner described, he subsequently 
lost not a single one — a result referable only to the antiseptic prophy- 
lactic treatment. The number of these cases amounts to twenty- 
three. 

As to the treatment of less recent injuries to the skull, in which sep- 
tic processes have already become established, it should not differ in 
principles from that of inlected wounds situated in other parts. 

For the purposes of disinfection the author uses an 8-per cent, solu- 
tion of chloride of zinc and application of iodoform powder, after 
having cleaned the wound thoroughly with the help ol a Volkmann's 
spoon, and incised all phlegmonous foci and recesses. Extensive 
phlegmons and erysipelatous inflammations of the scalp are treated 
with lotions containing acetate of alumina. 

Inflammations of the intracranial tissues are not amenable to treat- 
ment; but if incipient forms of meningitis are to be treated, the author 



324 EDITORIAL ARTiCLES. 

is in favor of thorough disinfection of all accessible parts, or at least 
of an attempt to do so, and even of trephining for this purpose, if there 
is any hope of rendering the focus of infection aseptic. 

The cases accompanying the paper are many of them individually of 
the highest interest and will repay minute perusal ; some of them are 
also made the subject of valuable, special and general remarks in the 
text. 

Although the chief result of the paper will be to have given more 
prominence to the propriety of considering the chance introduction of 
foreign matter into fissures and wounds of the skull as an urgent indi- 
cation for trephining, yet the position taken by the author in regard to 
the question of trephining for intracranial pressure is one of such 
special interest at the present moment, when there is a controversy 
being carried on, and traceable through periodical literature, relating 
to these very questions, that it must play a conspicuous part in decid- 
ing the battle. 

Without here entering into a more detailed discussion of this latter 
subject, we would refer, besides to Wiesmann's, to Von Bergmann's 
Kroen lein's more recent contributions to the subject.^ 

^Vide Annals of Surgery, August 1886, p. 167; Sept. 1886, p. 232. 

W. W. Van Arsdale. 



ON THE CONTAGIOUSNESS OF LEPROSY. 

The question whether leprosy be contagious has been much discussed 
recently at the Academy of Medicine of Paris. The theory of con- 
tagion has its partisans and its opponents, and the latter seem to be in 
the majority in that learned assembly. It may not be without interest 
to publish the results of researches on the subject undertaken in the 

Sandwich Islands, Mauritius and Reunion, as well as in British Guiana. 

These have recently been summarized in an interesting contribution to 
the Progres Medicale, by Dr. R. Suzor, of Mauritius and from which 
we shall freely quote. 

It is of secondary importance to know if leprosy existed in the Sand- 



THE CONTAGIOUSNESS OF LEPROSY. 325 

wich Islands prior to 1848, if M. Quoy has seen it there in 1819. The 
fact remains that at any rate the disease was exceedingly rare m 1848 
At about that time commenced the immigration of the Chinese, and 
amongst them the presence of leprosy was recognized. Ten years 
later, in 1858, the disease was for the first time mentioned as common 
in the country. Either it did not exist before the arrival of the Chi- 
nese, and therefore it was they who introduced it; or, it it did exist 
before their time, how can we explain the extreme slowness of its de- 
velopment before their arrival and its sudden extension in the follow- 
mg ten years to such an extent that a tenth of the population became 
lepers? If the latter hypothesis be true, it reminds us forcibly of the 
case of Europe m the Middle Ages. Leprosy existed, but it was com- 
paratively rare. The Crusaders, while in the East, went into the an- 
cient homes of the scourge, and shortly after their return to their ovm 
country the disease became so prevalent that people talked of epi- 
demicsofleprosy. and in France alone more than 2,000 leper-houses 
were established to isolate the sick. Another fact is to be noted, that 
wherever isolation has been stringent the number of the affected has 
rapidly diminished. It is the inverse of what has passed at the Sand- 
wich Islands, and the two facts seem to militate in favor of the idea of 
contagion. 

Mauritius and Reunion until the 17th century were uninhabited, and 
the first colonists permanently established were French. Then came 
nnmigrations of Africans, Hindoos and lastly Chinese. At the present 
time hundreds of lepers can be counted without difficulty, of all races 
even Europeans. Now it is proved that several lepers have landed 
there, coming from Africa or Asia as slaves or as coolie laborers In 
British Guiana the history ofleprosy IS still clearer and more interest- 
mg. ist period, prehistoric. The country was inhabited exclusively 
by Indian tribes. 2d period: European colonies established. No 
eprosy. 3d period. Slavery. Among the African slaves who were 
landed there a few were attacked with leprosy. They were rigorously 
isolated on the confines of the plantations, and the cases all remained 
limited to the blacks. In 1831 there were altogether 431; and a 
special establishment was founded on the banks of the river Pomeroon 



326 EDITORIAL ARTICLES. 

where they were all sent, But at this spot there were already estab- 
lished several tribes of Indians — Carribs. Accoways, Arrowacks, War- 
rows, etc. Disliking their new neighbors they all left the district ex- 
cept the Warrow tribe, who fraternized and had intimate relations with 
the lepers. In 1842 McClintock wrote: "We have taken a census of 
the whole Indian population. We have met with a great number of 
lepers of both sexes, but all invariably belonged to the Warrow tribe". 
This points to contagion. The Bovianders, hybrids of Negroes and 
Warrow Indians, are also frequently the subject of leprosy. This points 
to heredity. 

In 1838 came the emancipation of the slaves, who spread them- 
selves all over the colony, going wherever it seemed best for thera 
and mixing freely with the general population. At about the same 
time the planters imported coolies from China and India, and among 
these, as usual, lepers were sometimes found. To-day there are two 
lepers per thousand of the population, and the whites and mulattoes 
furnish their contingent to the disease as well as the Negroes and 
Indians. 

Some cases may be cited : 

1. Cases of Dr. Regnauld, observed at Mauritius. 

(a). A black woman, a widow with a child aet. 5 by her first hus- 
band, married again a man suffering from leprosy. The latter fondled 
the child a great deal and they were constantly together. The disease 
soon appeared in the child. There was no trace of hereditary leprosy 
in the woman or in her former husband. 

(b). A white man acquired anaesthetic leprosy with ulcers. His wife 
assisted the doctor every day in the dressing. She was probably less 
careful in afterwards washing her hands. At any rate, a month after 
the death of her husband, a leprous spot developed on the right cheek, 
and two months later she was everywhere covered, and the disease grew 
worse. 

A great many cases of this kind could be cited. Simple coinci- 
dences, they may be called, but in this case we should have to say 
that " the exceptions are more numerous than the rule." 

2. A young Scotchman, born in Scotland, of parents who had never 



I 



THE CONTAGIOUSNESS OF LEPROSY. 32/ 

left Europe and whose hereditary histor}^ was in every respect perfect, 
arrived at Guiana. One night, being drunk he had connection ^vith a 
woman, whom he found to his horror the next day to be a confirmed 
leper. Ten months later he developed the first symptoms of leprosy, 
of which he died. (Drs. Manget, Edge, Watt). 

The author knows seVeral other similar cases, one of which was in 
his care. 

3. Joseph Francis C, aet. 20, Portuguese, white, born in Demarara, 
his parents still living and healthy. Ten years ago he was attacked 
by leprosy, the tuberculous form like the preceding. A sister, aet. 18, 
is also leprous. They were both vaccinated with lymph taken from an 
infant belonging to a leprous family. Their brother and three sisters, 
who were not vaccinated from the same source, are perfectly well. 

The Drs. Manget, Army Surg. Gen'L, and Hillis, Physician to the 
Lepers' Asylum of British Guiana, who personally knew this family, 
consider the facts as absolute proof of the propagation of the disease 
by vaccination. It would be easy to quote others. 

The cases of hereditary leprosy are numerous. Let it suffice to cite 
the works of Boek, Danielson, Carter, Hillis, etc. Here area few facts 
borrowed from the last author. 

(a). J. L'Esperance, confirmed leper at 2 years. Mixed form of the 
disease. Father and mother both leprous, the father having the tuber- 
culous variety, the mother the anaesthetic. The mixed form usually 
only develops between the ages of 20 and 40 years. 

(b). Marie B., «t. 43. Parents leprous. She herself still free from 
any manifestation of the disease, but she has six children from 10 
months old to 14 years — all with tuberculous leprosy — which generally 
does not appear till after puberty. 

(c). Dr. Saturnin (Trinidad) and the committee of the R. Col. of 
Physicians, of London, quote two cases of leprosy in the new born. 

These facts without answering the requirements of Kaposi's eminent 
annotators, who desired to see a child born in Paris, of a leprous 
mother, and being immediately separated from her, afterwards becom- 
ing leprous, appear to us to shake somewhat the position of the adver- 
saries ot the hereditary transmission of the disease. How shall an af- 



328 EDITORIAL ARTICLES. 

fection, which is propagated by heredity, by contact, by sexual inter- 
course, by vaccination, which shows itself most often on the uncovered 
part of the body, which takes on the skin a serpiginous course, be 
considered contagious or not ? The same question might be as well 
asked with regard to syphilis, which is far from being contagious in all 
its stages, and which does always produce its hereditary character. 

Finally it will be possible, we hope, to take up the experimental 
study of the question. For some time we have been trying the culti- 
vation of the bacillus of leprosy in human blood. If pure cultivations 
are obtained, we shall have the opportunity of renewing the tentative 
inoculations by Neisser. It will also be interesting to study the bacillus 
of tubercle in this new medium. 

P. S. Abraham. 



INDEX OF SURGICAL PROGRESS. 



GENERAL SURGERY. 



I. Malignant Anthrax. By Dr. A. Bois. M. B., ast. 65, a ro- 
bust man of sanguine temperament, living in good hygienic surround- 
ings, but recently much harassed, had for long carried a subcutaneous 
cyst, as large as a fowl's egg, at the lower part of the nape of the neck. 
After the fatigues of a long journey, a part of the skin covering the 
cyst became red and rather painful. As inflammation and suppuration 
threatened, he submitted to the removal of the cyst. Early in October 
an incision, several centimetres in length, was made, and the grumous, 
greyish, semi-liquid, foetid sebaceous contents removed. The interior 
of the sac was carefully cleaned, cauterized with a nitrate of silver 
pencil, and filled with plugs of lint. By degrees suppuration was estab- 
lished, and the cavity was again several times, and at sufficiently long 
intervals, cauterized, and fragments of the caustic left in the cavity, 
in order to ensure more certamly the exfoHation and adhesion of the 
secreting membrane. Towards the middle of November very little of 
the cavity of the cyst remained, but a small, hard and painful tumor ap- 
peared on the nape of the neck, a few centimetres above the part pre- 
viously occupied by the cyst. It gradually developed and progressed 
tow^ards the hairy skin, but not in the region of the cyst. It was evi- 
dently an anthrax, at first benign and developing slowly, and sponta- 
neously suppurating after some days. It extended but little at the end of 
the month, and as it freely discharged under the influence of poultices, 
and gave but Httle pain, it was thought for some days that active interven- 
tion would not be needed. This abstention of active treatment seemed 
justified by the authoritative opinions expressed in 1881, at the Societe 
de Chirurgie, in the discussion on the treatment of anthrax. Early in 
December the anthrax commenced to increase on the left side of the 
neck, at the same time mounting towards the scalp, and the regions 

(329) 



330 INDEX 01 SURGICAL PROGRESS. 

newly engaged began to take on a wooden hardness. The urine con- 
tained no trace of sugar. On the 5th of December it was ascertained 
that the centre of the tumor, for a space as large as a 5 franc piece, 
was boggy, and bled freely from numerous fine openings. It was the 
prelude of a serious slough, such as was seen several years ago in a sim- 
ilar case which rapidly terminated in death in spite of repeated and 
deep incisions. It was resolved to employ the thermo-cautery, after 
the method recommended by M. Verneuil — a plan which controls the 
haemorrhage and modifies the development of the disease, more effect- 
ually than the incisions made with the bistoury. Twelve deep in- 
cisions, diverging in the form of a fan, were made under chloroform, 
with the instrument at a dark red heat. The Hmits of the affection 
being reached but not passed by the incisions. The anthrax, however, 
continued its invading growth, and on the 8th of December the cau- 
tery was again used. The incisions were prolonged i or 2 centime- 
tres beyond the margin of the disease and this time its encroachment 
was definitely stopped. In the following days fragments of slough sep- 
arated with abundant suppuration, and exposing a red and granulating 
surface. For some days sulphocarbolate dressings were used. The 
day after the second operation attention was called to a new focus of 
suppuration, which was rapidly developing in the middle of the dorsal 
region, and with a surrounding induration already reaching 5 or 6 cen- 
timetres in diameter. The patient was again chloroformed and eight 
or ten deep radiating lines were traced with the thermo-cautery, each one 
8 or 10 centimetres in length. Here the effect was instantaneous. The 
second focus did not further develop, and the sore left by the operation 
took on a healthy aspect. But the infection of the system was not ar- 
rested. On the loth of December a hard and painful swelling was 
manifest beneath the right deltoid muscle, without change of color of 
the skin. To combat it with the thermo-cautery did not seem possi- 
ble, and tonic treatment had to be relied on. The deep inflammation 
extended and reached the inner part of the arm. The fever became 
more pronounced, and on the 15th deep fluctuation could be observed 
at the right deltoid. An incision gave issue to blood mixed with some 
threads of pus. The suppuration became well established by the in- 



GENERAL SURGERY. 331 

cision, and there was some temporary arrest of the general condition, 
as well as a rapid subsidence of the swelling. Death, however, ensued 
on the 2ist of December, 

Two facts are evident from this case : (i), that the thermo-cautery 
has an incontestible power in stopping the progress of anthrax, even 
when malignant, provided that it be used beyond the Hmits of the dis- 
ease ; (2), that an anthrax may for some days maintain a benign course, 
increasing insidiously and causing a false security, and then taking on 
suddenly the serious character of a disease beyond our resources in 
consequence of the septicaemia which it engenders.— /'rc'^r^^ Med. 
Oct. 1885. 

P. S. Abraham (London. ) 

II. On Transfusion and Infusion. By Dr. Landerer (Leip- 
zic). Since 1880 L. has been investigating this subject experimentally 
and clinically. Alkaline salt solutions produce only transitory improve- 
ment where the loss of blood has been great, more than 472% of the 
animal's weight. A patient thus treated died one and a half hours 
later of a second collapse. 

L. then used a mixture of one part defibrinated blood to V5 parts al- 
kaline salt solution, with better results. Loss of blood up to 5 % might 
then be quickly recovered from. In a case of severe poisoning with 
nitro-benzol Thiersch let 900 cc. blood and replaced it by 1,000 cc. of 
this mixture, with a successful result — no fever or other customary se- 
quelffi. The lesser amount of fibrin ferment introduced makes this 
method safer than when all defibrinated is employed. 

Since, however, recent investigators all pronounce against the use of 
blood at all he has sought some substitute. Very favorable results 
were obtained by adding 3% of cane sugar to the alkaline salt solu- 
tion. Animals repeatedly bled until only 1-172% of body weight in 
blood remained recovered rapidly and replaced the loss — as shown by 
counting the blood corpuscles — in an unusually short time (about 
fourteen days). Hsemorrhage in one patient was successfully treated by 
an infusion of 300 cc. This sugar salt solution has several advantages. 
It suppHes a quickly available nutrient material, draws fluids with much 



332 INDEX OF SURGICAL PROGRESS. 

energy into the circulation from the surrounding tissues, has greater 
consistency, and increases the blood-pressure materially. In animals 
poisoned by nitro-benzol, chloral, chloroform, L. made a depletory 
venesection, and by infusing this mixture kept them alive — control an- 
imals dying. In cholera it would appear to be counterindicated. It 
is theoretically important that in poisoning it is not at all necessary to 
supply oxygen-bearers — red corpuscles. — Report of XV Congress of 
German Surgeons in Centlbl. f. Surg. 1886. No. 24. 

W. Browning (Brooklyn). 

VASCULAR SYSTEM. 

I. On Compression of the Innominate Artery. By Prof. 
Thomas Annandale (Edinburgh). Man, set. 53, while lifting a heavy 
weight felt something give way at the root of his neck, and the same 
evening a pulsating swelling was noticed above the centre of his right 
clavicle. This occurred in April, 1884. On the 27th of May, 1885, 
the innominate was exposed by a median cervical incision so as to al- 
low the finger to pass behind the vessel and press it against the sterno- 
clavicular joint. An india rubber drainage tube half an inch in diame- 
ter was introduced and so adjusted that one end lay behind the artery 
and the other protruded from the wound. The intention was to leave 
the tube in position until the tissues had become accustomed to its 
presence and until the risk of a septic condition of the wound was di- 
minished, and when the latter condition had been obtained, to intro- 
duce the small bladeof a compressor, which Mr. Annandale had devised, 
into the drainage tube, and carry on compression of the artery more or 
less continuously, according to the effect produced. On the 7th of 
June, however, there was some blood on the dressing. Next day there 
was profuse bleedmg and the artery was compressed by the finger. 
Several attempts to pass a hgature between the bleeding part and the 
aorta failed, but the compressor was applied and the bleeding stopped. 
The patient died in five hours. The innominate was found to have 
ulcerated just below the bifurcation from pressure of the tube, and the 
trachea showed signs of commencing absorption. The author thinks 
that in future compression might be applied by the finger, or an instru- 



\ 



NERVOUS AND VASCULAR SYSTEMS. 333 

ment, through an incision, while the patient was under an anaesthetic. 
Such compression should not be too continuous and should be com- 
bined with distal ligature or compression, or if thought advisable, elec- 
trolysis. — Lancet, March 13, 1886. [See an account of ligature of the 
innominate by the reporter in the American Encyclopedia of Surgery, 
or, with a report of all cases, in Brit. Med. Journal, October 14, 1882. 

II. Popliteal Aneurism in an Ataxic Subject Cured by- 
Pressure. By Dr. Longhurst (London). Patient, jet. 51. An Es- 
march's bandage was apphed to the limb for an hour and a half; then 
a screw tourniquet to the femoral, and so on during the day. Pressure 
was omitted at night. A shot bag weighing iiVi pounds was tried in- 
stead of the tourniquet, and this treatment was pursued for the next two 
days. On the evening of the third day no pulsation was visible. The 
pulsation did not return. — Med. Press and Circular. March 31, 1886, 

III. Traumatic Inguinal Aneurism. By C. Mansell Moul- 
LiN (London). Man, aet. 34. Four weeks before admission received 
blow in the groin from edge of flat piece of iron. Swelling and discol- 
oration followed and disappeared, but three weeks later the swelling 
recurred and continued to increase. During an effort, immediately be- 
fore admission, he was seized with violent pain and a large pulsating 
tumor made its appearance in the groin, extending into the scrotum and 
perineum. An abdominal tourniquet was applied and the swelling 
opened over the femoral artery, in which a slit was found immediately 
below Poupart's ligament. The artery was tied below this point. The 
external iliac was then tied. The man recovered and pulsation could 
be detected in the posterior tibial four months later. — Lancet. March 
6, 1886. 

IV. Traumatic Aneurism Caused by Punctured Wound 
of Buttock. By Joseph Littlegood (Nottingham). Boy, aet. 16. 
Received accidental wound in left buttock posterior to great trochan- 
ter. A pulsating tumor was noticed on the fourth day and rapidly 
reached the size of a cocoanut. On the eighth day the wound was 
rapidly enlarged, but so great was the haemorrhage that it was neces- 
sary to apply an abdominal tourinquet. The distal end of the artery 



334 INDEX OF S UR GICAL PR GRESS. 

was found without difficulty and tied ; the proximal end was found after 
a long search, just within the great sciatic notch. The patient re- 
covered. — Lancet. March 27, 1886. 

Wm. Thomson (Dublin). 

HEAD AND NECK. 
I. A Case of Cerebral Abscess Subsequent to Orbital 
Periostitis. By Crawford Renton, M.D., (Glasgow). The pa- 
tient, a boy set. 12, was admitted to the Glasgow Eye Infirmary suf- 
fering from symptoms of right orbital cellulitis, which had persisted for 
ten days. On the sixth day after admission a free incision was made 
along inner side of upper eyelid, a considerable quantity of pus was 
evacuated and drainage tube inserted. Four days afterwards the dis- 
charge had ceased, the swelling gone, and the patient had become 
almost convalescent. Two days after this note was made, however, he 
complained of severe pain in the head, intermittent in character, and most 
severe over the right temporal region. Vision normal ; ophthalmo- 
scopic examination showed a normal fundus. No evidence of any 
fresh formation of pus in the tissues around the eye, but the wound 
was re-opened and a probe passed along it, but without detecting any 
bare bone ; the drainage tube was re-inserted. Ice applied to the 
head and small doses of calomel given internally. Pulse 64 ; tempera- 
ture normal. The symptoms continued for some days, and vomiting 
set in. But ultimately the pain and vomiting subsided, and complete 
relief ensued. After, however, four days of rehef, the symptoms again 
recurred and death subsequently took place, being preceded by spasms 
of the left side which rapidly became general. The temperature was 
never higher than 99° and the pulse varied from 76 to 52. Post mor- 
tem examination showed extensive necrosis of the right orbital plate, 
and an abscess occupying the anterior half of the right frontal lobe. 
There was no direct communication between the pus from the orbit 
and the cerebral abscess, and the dura mater was only inflamed over 
the necrosed portion of the orbital plate. The right eye was healthy. 
Two secondary diseases, the author remarks, follow suppuration in the 
orbit — meningitis and abscess. The diagnosis in this case was diffi- 
cult, the symptoms pointing chiefly to meningitis. 

H. Percy Dunn (London). 



II 



HEAD AND NECK. 335 

II. On the Operative Treatment of Empyema of the An- 
trum Highmori. By J. Mikulicz (Cracow). Heretofore in this 
affection the artificial opening, when needed, has been made through 
some point in the roof of the oral cavity. This method has the ad- 
vantage of perforating the antrum at a point easily accessible and favor- 
able for drainage. It has, however, disadvantages. The opening is 
not always permanent enough, since suppuration frequently lasts for 
months or years ; and if a suihciently wide opening is obtained bits of 
food pass in too easily and keep up the suppuration. The most ra- 
tional procedure would be to re-open the natural passage into the 
nasal cavity as proposed long since by Hunter. Although this is 
hardly practicable yet it is not difficult to penetrate the antrum from 
the lower nasal passage at the level of the inferior turbinated bone and 
thus open a wide lasting communication with the nasal cavity. The 
inner wall is thin as paper at this point and can be easily bored through 
with a sharp cutting instrument. M. uses a special short-bladed stylet 
with a properly curved handle and a little flange to prevent the blade 
sinking in too deeply. This is passed into the nostril with the point 
downwards, and when at the inferior turbinated bone the point is 
turned outwards to get up around the bone. With a vigorous stab the 
antrum-wall is perforated and as much of a piece cut from it as possi- 
ble. By preserving a direction downwards and forwards no harm can 
be done as the wall here becomes thicker, and resists the instrument. 
In this way a sHt 5 to 10 mm. wide by 20 mm. long is produced. Too 
free haemorrhage can be controlled by tamponing with iodoform-gauze 
for a day or two. After-treatment consists in washing out the antrum 
with a balloon-syringe having a nozzle bent like the above-mentioned 
stylet. M. finds the operation easy to execute on the cadaver. An 
abnormally narrow nostril or an overthick turbinated bone might be 
too great an impediment. This operation he has performed once suc- 
cessfully on a man set. 33. The patient made the injections himself 
from the fifth day, tAnce a day for four weeks, and has remained cured 
now for six months. — Report of XV Congress of German Surgeons 
in Centbl. f. Chirg. 1886. No. 24. 

W. Browning (Brooklyn). 



336 INDEX OF SURGICAL PROGRESS. 

III. Tonsillar Abscess, CEdema of the Glottis and Tra- 
cheotomy in a Child 2^1. i. Recovery. By Dr. F. Katter- 
FELD (Curland). Author reports following case: Male child, aet. 
11^/4 months, admitted in a state of great dyspnoea, which had devel- 
oped after an attack of measles. On examining the cavity of the mouth 
both anterior palatal arches were found highly congested and swollen, 
as were also the tonsils. On these latter were yellowish brown crusts 
which were easily removed. Externally on both sides of the neck there 
was a large swelling, rather tough in consistency, in the region of the angle 
of the lower jaw. These phenomena were more fully developed on the 
••eft side. No oedema of the glottis. When pressure was made with the 
finger on the base of the tongue, there escaped from the anterior part 
of the left tonsil a quantity of yellowish, non-offensive smelling pus. 

Respiration somewhat difficult. Slight febrile movement only. This 
condition was followed in a few days by great dyspnoea on inspiration, 
showing that the swelling, until then only subchordal in its character, 
had now involved the glottis. Cricotracheotomy, according to Schin- 
zinger's method. After this the temperature rose slightly, but fell to 
normal in three days, and the swelling of the tonsils decreased stead- 
ily. No return of the glottis oedema. Appetite good and general 
condition much improved. This satisfactory course was interfered 
with, however, owing to the development of an acute catarrh with con- 
siderable febrile movement and return of the dyspnoea. The latter 
ceased after a quantity of bloody muco-purulent matter and granula- 
tion mass had been expectorated. A shorter and thinner canula was 
then introduced and applications of a iVj% solution of arg. nitric, to 
the ulcerated spot in the larynx were made. Recovery soon followed. 

Cases of tracheotomy with recovery in children under one year of 
age are very rare, G. Chaym having found not more than forty cases 
in searching through all the literature on this subject. — Deutsch. Med, 
Wochenschrift. No. 28. July 15, 1886. 

IV. Two Cases of Stenosis of the Larynx as a Sequel 
to Typhoid Fever. By Dr. K. Orth. Case I. Patient, male, 
set. 42, suffered much in his childhood with articular rheumatism and 



HEAD AND NECK. 337 

attacks of colic. Had a general tendency to bronchial catarrh, and 
eight years before had dysentery. About five months previous to his 
admittance, severe attack of typhoid fever, lasting ten weeks, during 
which some difficulty in breathing had aeveloped. Since then several 
attacks of dyspnoea, which are becoming worse. Respiration labored. 
Voice rough and hoarse, not aphonic however. Pressure on the cricoid 
cartilage painful. On examination with the laryngoscope the mucous 
Hning of the larynx found intensely injected and swollen. The glottis 
appeared much narrowed, and at about the level with the true vocal 
cords two congested and swollen prominences discovered. Tracheo- 
tomia superior at once undertaken. Examination again nine days later. 
Mucous membrane less swollen, but the stricture is about the same. 
On closing the canula patient could breathe but for a few seconds only 
through the mouth. On comparing the conditions during respira- 
tion and phonation, it was shown that the swellings causing the stenosis 
did not He in the plane of the vocal cords, but lower down. Diagnosis 
was, therefore, perichondritis of the anterior portion of the cricoid, to 
which the previous attack of ileo-typhus, the pains on swallowing and 
on palpation of the parts, and finally the result of the laryngosopic 
examination all pointed. Daily introduction of laryngeal catheters, the 
size being gradually increased, and applications of arg. nitric, to the 
swelled parts once or twice weekly. Insufflations of alum sufficed to allay 
any symptoms of irritation from the use of the catheters. In the course 
of a few months of this treatment, Schrotter's thick laryngeal cathether 
(No. 5) could be introduced. A few weeks after beginning the treat- 
ment patient was able to breathe for half an hour with closed canula, 
the stenosis being so much reduced. In ten months time he could 
work the whole day with the canula closed, but was obUged to have it 
open while sleeping. Canula was withdrawn about fourteen months 
after commencement of treatment. Voice was then clear and respira- 
tion perfectly easy. 

Case II. Patient, girl aet. 19. Admitted in July, 1882. Typhoid 
fever in March, April and May of same year. About two weeks after 
commencement of this latter illness, pains hi the neck and larynx set 
in, accompanied by difficulty in swallowing. After the disease had 



33^ INDEX OF SURGICAL PROGRESS. 

subsided patient was in wretched physical condition. There was com- 
plete aphonia and occasionally pain in the larynx. Difficulty in 
breathing began about four weeks before seen. These attacks of dysp- 
noea are at times very bad. When admitted respiration labored. Stenosis- 
murmurs heard over whole chest. The following day sudden orthopnoea 
during meal. Sinapism gave some relief. Dyspnoea became so great, how- 
ever that tracheotomia superior was undertaken. Examination with lary- 
ngoscope eleven days later. The left arytenoid cartilage and plica aryep- 
iglottica very much swollen and oedematous. The two false chords over- 
lap one another, covering every part below. In the anterior parts there 
protrudes between the false chords a smooth, round portion of tissue 
about the size of a pea. Attempt to use the larynx-sound was very 
painful and its introduction impossible. Scarifications of the left ary- 
tenoid cartilage and aryepiglottic folds. Patient discharged in October 
following. During the first few weeks of her subsequent treatment the 
throat was kept warm and cataplasms occasionally applied. Insuffla- 
tions of alum made twice weekly. Under this treatment swelhng and 
oedema of the parts became less. No signs of an abscess in the larynx 
were observed. At the beginning of March in the following year all 
inflammatory symptoms had subsided. On examination both arytenoid 
cartilages found normal, also the aryepiglottic folds. The false chords 
still swollen and the small protuberance of tissue between these still re- 
mains. Applications of arg. nitric, two or three times weekly to these 
parts. Cavity of the larynx appeared to be completely obliterated. 
In the following August sound passed for the first time. It was then 
ascertained that the cavity of the larynx was not obliterated as sup- 
posed, but its lumen reduced to a minimum. The introduction of 
catheters now ordered, together with the local applications. In Octo- 
ber a very thin English catheter (No. 9) could be passed, and patient 
could breathe through this when canula was closed. In November 
(1883) patient was able to force some air through the larynx and say 
" good morning " in a croaking voice. 

This treatment has been kept up ever since. In December, 1885, 
she was able to close the canula for fifteen to twenty minutes at a time. - 
In speaking the help of the false chords is necessary and the voice is 
somewhat stronger. Patient is still under treatment. 



CHEST AND ABDOMEN. 339 

The case was undoubtedly one of perichondritis of the arytenoid 
cartilages (principally of the left), and also of the cricoid. — Deutsch. 
Med. Wochen. No. 29. July 22, 1886. 

C. J. COLLES (New York.) 

ABDOMEN. 

I. Surgical Intervention in Certain Cases of Biliary Cal- 
culus. By T. Thiriar. The origin of biliary calculi has never yet 
been clearly explained. Dr. Thiriar holds that they only form where 
bile stagnates, and when from sedentary Ufe, advanced age, or preg- 
nancy the bile becomes less alkaline and so permits of a deposit of 
cholesterine. Thus they may only be expected to form in the smaller 
bile ducts when the main ducts are obstructed from any cause. In 6,000 
post-mortem examinations made by Prot. Wehenkel, of Brussels, no in- 
stance was found of the formation of gall-stones within the liver. The 
gall-bladder is therefore taken as almost necessary for the formation 
of gall-stones, and its removal is held to be a radical cure against 
them. 

The paper begins with a brief sketch of the history of cholecystect- 
omy. Three cases then related. One was performed by Dr. Langen- 
buch, of Brussels, and was pronounced cured in nine days. The other 
two were done by Dr.Thiriar himself One was practically healed in six 
days after the operation, in the other hysterical symptoms appeared in 
the patient before and after the operation : these subsided and in two 
or three months she was doing well, The subsequent history of these 
three cases is not related in detail, but they seem to have made good 
recoveries, and to have been afterwards relieved from all the previous 
attacks of biliary colic. In another place the author refers to the two 
first cases of the operation performed in July, 1882. Three years after, 
in July, 1885, the patients were in excellent health, except that one 
had been unable to shake off a habit of taking morphia, although the 
need for it had ceased. 

Mode of operating, (i) For 48 hours before, the operating room is 
kept at a temperature of 3o°C (86°F). (2). About one hour before 
the operation the patient receives an enema containing 1-2 grms. (7*- 



340 INDEX OF SURGICAL PROGRESi.. 

-72 dr.) of laudanum, and 2-4grms (V2-1 dr.) of chloral. The patient 
is bathed a few days before, and shortly before the operation the abdo- 
men is washed first with soap and water, then with ether and carbolic 
lotion. During the operation a carbolic spray is used. The cut sur- 
faces are washed with i to 1000 corrosive sublimate. Sponges are re- 
placed by subHmated wool tampons ; instruments and hands are dis- 
infected. Incision follows outer border of right abdominal muscle 
(Rectus). Muscular fibers are cut transversely three fingers' breadth 
below false ribs. After adhesions with the colon are broken down, the 
gall-bladder is seen. The cystic duct is then isolated, hgatured with 
silk in two places and divided. The margins of the opening in the 
duct are carefully sewn together with fine subUmated silk. The gall- 
bladder is removed and the abdominal wound closed. Catgut stitches 
are used, and some stress is laid on the importance of uniting like 
structures together, thus peritoneum to peritoneum, fibrous and cellu- 
lar tissue to fibrous and cellular tissue each to each. The shock of 
the operation is much lessened by the enema of laudanum and chloral, 
as the opium soothes and diminishes muscular sensibility, and the 
chloral specially lessens the irritability of the spinal cord. This enema 
is always used in the author's ovarian cases. 

The operation of cholecystotomy is contrasted with that of cholecys- 
tectomy, and objections to the latter are examined. The difficulty of 
the latter operation is considered no obstacle, as it is no greater than 
any surgeon may be expected to overcome, and less indeed than that 
of ovariotomy and of hysterectomy. Neither is the larger extent of 
incisions considered of moment when antiseptics are used. As to dan- 
ger, out of the 7 cases on record (5 by Langenbuch and 2 by Thiriar) 
there are no deaths which can be attributed to the operation ; two of 
the patients died not long after their operations, but one death was the 
result of a cerebral tumor, and the other of ulceration of the bile duct 
from the presence of a calculus in it. 

Is removal of the gall-bladder efficacious ? From the view he holds 
of the origin of gall-stones Thiriar believes that it is. So far also as 
the cases go they confirm his opinion. 

When should the surgeon operate? The gall-bladder should be re- 



CHEST AND ABDOMEN. 341 

moved when efforts to hasten the flow of bile and to increase its alka- 
Hnity have failed to relieve attacks of biliary coHc. Cholecystotomy is 
not to be used, because it does not make a radical cure, because if a 
ligature slips shortly after the operation bile might escape into the peri- 
toneum, and because biliary fistula delays the cure and allows bile to 
leave the body. 

If it were said that the presence of a gall-bladder is necessary. Dr. 
Thiriar would reply that some animals, such as the elephant and the 
horse have none ; that from some animals it may be experimentally re- 
moved with mipunity ; and that in man it may be wanting, atrophied 
or obhterated without bad results. 

Thus the indication for cholecystectomy is a frequent return of severe 
biliary colic which has resisted medical treatment. 

When a calculus blocks the cystic duct and causes dropsy of the gall 
bladder, the distended bladder is to be aspirated, and, if this fails, it is 
to be excised. When the common bile duct is blocked, causing per- 
sistent jaundice, and when the diagnosis has been established, the ab- 
domen is to be opened and an effort made to crush the stone through 
the walls of the duct, and failing this the duct may be incised to re- 
move the calculus and the edges of the cut sewn up again. If this also 
fails Cholecystotomy is to be performed and an effort made to estab- 
lish a biliary fistula into the intestine. — Revue de Chirurgie. March. 
1886. 

Charles W. Cathcart (Edinburga). 

II. On the Operative Treatment of Abscess of the Liver. 

By Dr. Kartulis (Alexandria). In Thierfelder's collection of cases 
of abscess of the liver treated by operation we find that of 10 cases 
operated by Curtis; but two recovered; J. Clark operated in 13 cases 
with 8 cases of recovery, and only 6 of Murray's 17 cases were cured. 
Warring collected 81 cases of operation with but 15 cases of recovery, 
showing a mortality of 81%. De Castro reported that of 61 cases 
operated 27 died, or 44.26%. Heinemann (Vera Cruz) treated 2 
cases by puncture, both with fatal results, and of 20 cases where Po- 
tain's aspirator was employed, but 2 recovered. 



342 INDEX OF S UR GICAL PR O GRE SS. 

The introduction of antiseptic principles in surgery formed a new era 
in the treatment of this disease. Lister, in i878,was the first to open an 
abscess of the Uver with the knife, under the observance of antiseptic 
rules, the result being satisfactory. The reports of the hospitals in 
Egj^t, however, do not show that the results of opening these abscesses 
under strict observance of antisepdc precautions are very much better 
than formerly, nor do the reports of English surgeons in India tend to 
encourage this mode of treatment, but rather recommend the use of 
the trocar. 

The author considers these unfavorable results to be largely due to 
the retention of pus in the cavity of the abscess, through defective 
drainage, leading consequently to pyaemia, hectic fever, etc. To ob- 
viate this defect he was induced first in the following case, to under- 
take resection of the rib, thus givmg free vent to the discharge, and 
undoubtedly thereby saving his patient. 

The patient, a man, set. 30, was healthy until 20 days before admit- 
tance, during which time he had had much distress in the region of the 
liver, with fever. Nothing sho\ving the presence of an abscess formed, 
however, and a change of cHmate was advised. A month later he re- 
turned with undoubted symptoms of abscess of the liver. Puncture in 
the 6th intercostal space performed twice, there escaping each time 
about 500 c. cm. of pus. No improvement. Incision then made, 
giving vent to 400 c. cm. of pus. The cavity, 12 cm. in depth, washed 
out with a 272% solution of carbolic acid, a drainage-tube introduced 
and antiseptic dressings applied. Although the patient's condition im- 
proved somewhat duriug the first few days after the operation, change 
for the worse set in, owing to defective drainage. Two weeks later, 
therefore, 3 cm. of the 7th rib was resected, giving vent to a large 
quantity of bad smelling pus. Recovery was then rapid, the cavity be- 
ing completely closed 19 days later. 

In the author's second case, the patient, aet. 30, had complained in 
the region of the liver for five weeks p'^evious to operation. Liver 
found much enlarged and painful to touch. Patient very weak. Punct- 
ure with trocar in the I oth intercostal space, allowing the escape of 
400 c. cm. of thick pus. Considerable rehef was experienced by the 



CHEST AND ABDOMEN. 343 

patient after this, and he was able to sleep for the first time in many 
days. No movement of bowels, and tenderness on pressure remained 
as before. Four days later puncture was again made, some 270 c. cm. 
of purulent matter escaping. Patient easier after this, but still very 
weak and exhausted. His condition becoming worse, however, ac- 
companied by high fever, resection of the rib was undertaken on the 
7th day after his admittance. Incision over the 9th rib, 10 cm. in 
length, in the axillary line, and 5 cm. of rib resected. The abscess 
was then easily opened, giving vent to a large quantity of pus. The 
cavity, 15 cm. in depth, was washed out with a 5% solution of car- 
boHc acid, two drainage-tubes introduced, and antiseptic dressings ap- 
plied, the whole being covered by a Martin rubber bandage. Five 
hours after the operation the patient was without fever and in the best 
of spirits. Recovery was rapid, the cavity being completely filled up 
on the loth day, and two days later the bandage was left off. No re- 
action in the wound took place, change of dressings showing these 
each time to be odorless. 

Dr. Zancardt, in Alexandria, has also treated a number of cases in a 
similar manner, and with the same favorable results. 

The author thinks the chief danger in carrying out a resection of the 
rib, lies in the possible injury to the diaphragm, which may be incised 
according to the position of the abscess, when no adhesions have 
formed. He advises then resection of two or more ribs and drainage 
of the cavity of the pleura. As a rule, however, the operation presents 
no compUcations as adhesions are generally present, owing to the in- 
creased size, etc., of the liver. Abscesses of the left lobe are more 
rarely met with and usually much smaller than those of the right lobe. 
They heal often after one puncture. Author advises, in cases where 
larger and deeper abscesses are present with no adhesions to let the 
canula remain for some time, under observance of antiseptic precau- 
tions, incision of the abscess to be eventually carried out. 

In abscesses of the right lobe, on the other hand, incision should be 
undertaken at once in connection with resection of the rib. We should 
not wait for adhesions to form, as such a delay is of too great a risk 
for the patient. — Detitsch. Med. Wochensch. No. 26. July i. 
1886. 



344 INDEX OF SURGICAL PROGRESS. 

III. A Case of Penetrating Pistol-Shot Wound of the 
Abdomen. Resection of the Intestine. Recovery. By Dr. 
M. Freyer (Darkehmen). The operation in the following case was 
undertaken under very unfavorable circumstances, little or no assistance 
being obtainable : 

Patient, male, set. 19, suffering from pistol-shot wound in the abdo- 
men. When first seen by the author six hours after the accident, he 
was in a greatly collapsed state. On examination a large loop of in- 
testine was found protruding through the wound, this latter being situ- 
ated above the anterior superior spine of the right ilium. On nearer 
inspection several small openings in the protruding intestine were dis- 
covered, through which fecal matter was oozing. Resection deter- 
mined on. In order to prevent the feces from entering the abdominal 
cavity, a roll of twisted cotton-wool wetted in carboHzed water was 
placed around the neck of the loop of intestine, which was drawn fur- 
ther out and excised. Haemorrhage from mesenteric vessels consider- 
able. The mesenterium was first sutured and then the ends of the di- 
vided intestine. In suturing the latter serosa was united to serosa, the 
mucous edges in this way turning inwards of themselves. Twenty 
stitches were made, fine silk being used, as also for the ligatures. For 
the restoration of the intestine it was found necessary to enlarge the 
wound somewhat. This allowed the removal of several small shot 
found lying in the torn and ragged peritoneum near the wound, and 
also of a piece of paper wadding. On turning the patient over on the 
wounded side a large quantity of clear serous fluid escaped from the 
wound. The lower part of the abdomen was much distended and very 
sensitive to touch. Wound not closed. Three rubber drainage tubes 
introduced and antiseptic dressings applied. Patient next seen two 
days later. Pain was reHeved by opium. Only sHght amount of fever. 
Pulse 120. Dressings removed and wound looking well. Abdomen 
less sensitive. Irrigation with solution of sahcylic acid. On the third 
day stool per anum. General condition very fair. On the sixth day 
fecal matter was found on the diessings, a fistula having formed. Stools 
passed regularly per anum, however, excepting on the seventh and 
eighth days. Edges of wound painful and red. As soon as the ne- 



CHEST AND ABDOMEN. 345 

crosed portions of these latter had been cast off, definite closure of the 
fistula was undertaken seventeen days after it was formed. Three 
pieces of good-sized catgut passed through the whole depth of the 
wound and tied on both sides over strips of adhesive plaster. Ten days 
later two more sutures, this time silk being used, were introduced in 
the same manner, the right thigh being placed in suspension, in order 
to relieve tension. It was found necessary, however, to repeat this pro- 
cedure three times more before closure of the fistula was obtained. Pa- 
tient recovered completely by the forty-eighth day and returned to his 
hard work. 

On examination the excised portion of the intestine was found to be 
^^x\.oi \h&'\\t\m\.~Deutsch. Med.Wochenschrift. No. 28. July 15, 
1886. 

C. J. CoLLES (New York). 

IV. Colotomia Iliaca. By Dr. A. Podrez (Harkoff, Russia). 
In his Surgical Clinic Dr. P. had a patient on whom he performed colo- 
tomia iliaca, somewhat modifying the method of Madelung. 

Mrs. T. K., aet. 45, for four years was suffering from carcinoma col- 
loides in the rectum, which, starting from a point above the second 
sphincter had extended above the third sphincter and reached, the ad- 
jacent parts of flexura sigmoidea. In January, 1885, Dr. Podrez had 
performed on his patient extirpatio recti radicalis, preserving the 
the sphincter externus. The patient recovered and for about a year 
had normal passages ; she felt herself well and attended to her home 
duties. At the end of October, 1885, there appeared again all symp- 
toms of carcinoma, pain, constipation, insomnia, loss of appetite, and 
cachetic coloring of skin. On January 14, 1886, Dr. P. performed 
colotomia'iliaca, all necessary precautions being observed, including a 
properly disinfected operating room. A cut was made 8 cm. long, 
parallel to crista ilei sinistr., i inch above Poupart's ligament. The 
opening in the peritoneum was 5 ctm. long. The edges of peritoneum 
were attached to those of skin by sixteen deep and fourteen superficial 
silk sutures. Putting aside the omentum and some loops of the intes- 
tines, the descending colon was found and drawn out. It was fixed by 
silk ligature and then cut through. The lower end was washed in 5 



34^ INDEX OF SURGICAL PROGRESS. 

per cent, solution of boracic acid, and its walls were sewed by sixteen 
sutures according to Czemy, and then it was dropped into the abdom- 
inal cavity. Then the mesocolon was dressed and also put into the 
abdominal cavity. At last the upper end of the colon was fixed in the 
opening, in which operation there were made forty- eight sutures. A 
rubber drainage tube was introduced into the intestine and the wound 
was properly dressed. The operation was bloodless and lasted about 
three hours. Ice and opium were prescribed to the patient. On Jan- 
uary 1 8 and 20 she had small passages. For some days she was suf- 
fering from nausea and vomiting. But on January 19 she was already 
able to take scraped meat and eggs. On January 22 the patient was 
allowed to lie on the side, and all the sutures (accessible) were re- 
moved. January 26-30, the appetite and sleep were good, and daily 
passages. February 10 — the wound is perfectly cicatrized; the edges 
of intestine and skin are Avell united. March 5 — a cancerous infiltra- 
tion was found around the anus ; on March 10 a large mass of pus and 
cancerous fi-agments were remowed. per anum. March 20 the patient gets 
up trora her bed. Her general condition is rapidly improving. At the 
time this report was given, April 8, the patient was in a very good con- 
dition. Dr. Podrez beUeves that in case the rectum is affected with 
cancer, colotomia ihaca is properly indicated. — Chirurgichesky Vest- 
nik. May and June. 1886. 

P. J. POPOFF (Brooklyn). 

EXTREMITIES. 

I. Spontaneous Phlebacteriektasia of the Foot. By A. 

G. Gerster (New York). Robert Klaile, aet. 14, a well-developed 
boy, was admitted to the German Hospital, July 2, 1885, on account 
of a number of rebellious ulcers situated on the dorsum of the left foot. 
The condition was said to have existed since childhood ; no injury 
was remembered, physical examination of the internal organs re- 
vealed their normal state, with the exception of the heart, which was 
found to be enlarged, and evidenced a marked increase of the energy 
of its pulsations. The femoral arteries of both sides were found to 
beat with unusual strength, and, when somewhat compressed, gave rise 



EXTREMITIES. 347 

to a Strong whirr, both to be felt and heard by the stethoscope. On in" 
spection, an increased size of the left foot became manifest, the hyper- 
trophy pertaining to the soft parts as well as to the bones. The length 
of the right foot was 24 centimetres, that of the left 25 centimetres. 
Their circumference was 23 and 24 centimetres. The dorsum as well 
as the sole of the left foot was occupied by a doughy, soft, nodular 
swelling of irregular and not well-defined outlines. The skin of the 
plantar surface was normal, but on the dorsum, along the course of the 
saphenous nerve, a series of roundish, irregular, rather hard, dark blue, 
partly confluent nodes could be seen. They were partly covered with 
a thick layer of rough epidermic scales, partly by a closely adherent 
dry scab. Attempts at removing this were followed by rather copious 
capillary htemorrhage. Their general aspect was that of teleangiek- 
tatic nodes. A number of enlarged veins surrounded these nodes, and 
could be plainly seen through the skin. If pressure was exerted on the 
swellings, they could be made to disappear, or at least diminish in size, 
and also a deep-seated pulsation of the whole mass became at once 
evident. Compression of the femoral artery promptly suppressed the 
pulsation, and Avhile the compression of the main trunk lasted the swell- 
ing did not resume its former size. On the other hand, if the artery was 
compressed while the tumors were turgid, pulsation ceased, but there 
was no appreciable decrease of the size of the swelling to be observed. 
The stethoscope gave evidence of a strong arterial bruit all over the 
swellings. There was a marked difference in the temperature in favor 
of the left foot. 

It seemed clear that we had to deal with a mixed angioma, contain- 
ing the elements of both a cirsoid aneurism and of teleangiektasia with 
phlebektasia. As there was no history of a gross lesion of the blood- 
vesi-els, a chionic inflairmatory alteration of the entire vascular appa- 
ratus of the foot had to be assumed, which by this time had also re- 
acted upon the femoral arteries and the heart, inasmuch as they too 
were found to be hypertrophied. . "-^f^". '^^'^^^J'- 

Ar ablaticn of the diseased part was proposed, but declined , where- 
fore havmg explained the not inconsiderable danger of a deligation of 
the main artery, and having vainly tried elastic compression for a con- 



34^ INDEX OF SURGICAL PROGRESS. 

siderable time, the patient was anaesthetized on July 7, and the super- 
ficial femoral artery was tied in Scarpa's triangle. Pulsation ceased 
for a time, but became faintly but clearly noticeable about ten minutes 
after closure of the vessel, whereupon the external iliac artery was ex- 
posed and tied. Pulsation did not return after this. The Avounds were 
closed, not drained, and the limb was enveloped in a thick swathing of 
cotton batting. 

The course of the healing of the wounds was undisturbed and fever- 
less, but the circulation in the limb became 30 depressed that serious 
apprehensions were entertained in regard to its preservation. The toes, 
especially the first and second, were cold and Hvid, their sensibility 
was destroyed, and in the course of the first week necrosis of the in- 
tegument of the terminal phalanges became manifest. At the same 
time the skin on the outer and posterior aspect of the limb, exactly 
over the course of the peroneal muscles, sloughed, and on, being re- 
moved, necrosis of the entire belly of the peroneus longus was ascer- 
tained. A fortnight after the operation, the muscle was removed. It 
had the aspect of a pale, waxy, translucent substance. There was 
hardly any suppuration, and it was deemed advisable not to leave the 
sequestration of such a large mass of tissue to the rather uncertain and 
risky efforts of nature. The toes were also removed. The patient 
was discharged cured in October, and no pulsation or increase of the 
tumors were noted at the time. The size of the swellings was some- 
what smaller than before the dehgation, but there was no hardening or 
marked shrinking such as would follow obliteration ; on the contrary, 
the dough-like consistency had remained unaltered. 

Patient was readmitted to the hospital in January, 18S6. Pulsation 
had returned, and was just as evident as before the operation. The 
teleangiektatic spots were all supplanted by ill-conditioned ulcers. The 
metatarso-phalangeal joint of the great toe was open and suppurating, 
and the boy complained of much pain and discomfort due to the 
ulcers. 

Pirogoffs amputation was done January 29 1886, with the aid of Es 
march's band ; the sections of an unusual number of large vessels, 
twenty-seven, were taken up and tied before ; eleven more ligatures 



il 



GENITO- URINAR V OR CANS. 349 

were applied after the removal of the constriction. The segment of 
the calcaneum was nailed to the tibia, and the wound closed by an in- 
terrupted catgut suture. Drainage was effected through a counter- 
opening made alongside of the tendo AchiUis. The first dressing 
was removed twenty-one days after the operation, and the wound was 
firmly united, except along a small portion of the suture, where the 
rather fine catgut had been absorbed too soon. This narrow strip of 
granulation, together with the track of the nail, was found cicatrized 
over five days later, when the second dressing was changed. 

The patient has a good stump, and walks on it without support. 

A very excellent anatomical study of a case of considerable magni- 
tude, by W. Krause. will be found in the second volume of Langen- 
beck's Archiv, published in 1862. Nicoladoni has also reported three 
cases, two in vol. 18, pp. 252 and 711 ; the third one in vol. 20, p. 146, 
of the same periodical. All, with the exception of one reported by 
Nicoladoni, were affections of the upper extremity, which is said to be 
the favorite site of the disorder. Both cases seen by me involved the 
foot, one the left, the other the right. I may add, that the other case 
presented, especially as regards the local appearance and situation of 
the malady, an almost identical state of affairs as the case before you, 
only of less development. 

As regards the treatment, the case presented bears out the expe- 
rience of others, inasmuch as it demonstrates the futility, in the more 
extensive cases, of less radical measures than ablation. — Proceedings 
New York Surgical Society. March 8, 1886. 

GENITO-URINARY ORGANS. 

I. Supra-Pubic Lithotomy. By N. A. Sokoloff, M.D., (St. 
Petersburg). Stone in the bladder is a rare disease in the capital of 
Russia. Dr. S. had only four cases of that disease during two years in 
the Mary's Hospital. On his patients he performed supra-pubic lithot- 
omy. Bladder was distended with 4% solution of borax. 

Case I. Male, aet. 25, was suffering from calculus for twelve years. 
November 29, 1883, operation. December 15, urine is discharged 
through the urethra, and only a few drops through the wound. January 



350 INDEX OF S UR GICAL PR CRESS. 

lo to 29, 1884, slight symptoms of pyelitis. February 21, wound is 
closed, and the patient was discharged as cured. 

Case II. Male, aet. 18, was suffering from calculus since childhood. 
March 5, operation. April 18 was discharged as cured; the wound 
was perfectly cicatrized. 

Case III. Male, set. 9. July 20, 1885, operation ; stone was of size 
of pigeon's egg. July 22, urine passes through the wound which was 
sutured ; sutures removed and drainage tube introduced. Fever. Au- 
gust 14, urinates normally. September 21 to October 2, fistule now 
is closed and now open again ; closed permanendy November 7. In 
January, 1886, wound was cicatrized, and the patient left the hospital. 

Case IV. Male, set. 22, was suffering from calculus since childhood. 
On examination in the bladder were found two large stones and sev- 
eral small ones. June 25, 1885, operation; one stone 1^2 c^- re- 
moved, the other broken. The wall of the bladder attached to that of 
the wound. July 7, a stone is removed through the openings; cys- 
titis. Fistule continued up to September 2. September 16, wound is 
cicatrized and the patient was discharged as cured. — Chirurgichesky 
Vestnik. May and June, 1886. 

P. J. POPOFF (Brooklyn). 

II. Lesions Caused by the Presence of the Eggs and Em- 
bryos of " Bilharzia Haematobia " in the Bladder, the 
Prostate, the Rectum, the Mesenteric Glands, the Kidney 
and the Liver. Dr. Albert Ruault presented to the Anatomical So- 
ciety in March, 1885, microscopical preparations of the above organs, 
taken from two subjects who had succumbed to the complications of 
calculous cystitis. In the sections of the bladder a great number of 
the eggs of the distoma can be seen in the substance of the bladder 
wall which is considerably thickened. The eggs are particularly abun- 
dant in the mucous coat and immediately below it. The thickening of 
the organs seems to be due to an abundant formation of connective 
tissue. There is also some alteration of the muscular fibres, but it is 
not clear whether the degeneration is vitreous or amyloid. In the 
prostate also there is a certain quantity of the distoma eggs, and there 



ABSCESSES, TUMORS. 351 

is much connective tissue of new formation. The section of the rectum 
shows a large number of the eggs in the mucous membrane. The al- 
teration appears to be but little advanced, and there are no dysentery- 
like ulcerations to be seen. The section of the kidney exliibits some 
of the eggs and also free embryos. Around the eggs connective tissue 
of new formation is seen producing an interstitial nephritis of vascular 
origin. In the liver the ova are situated in the neighborhood of the 
portal spaces, or in those parts of the hepatic lobules nearest to the 
spaces. As M. Kartulis says, the retraction of the liver caused by the 
deposit of the distomum eggs seems to be due to a cirrhosis. The 
cirrhosis is evident in the preparation. — Progres Medicate. July, 1885. 

P. S. Abraham (London). 

ABSCESSES, TUMORS. 

I. On Draining Pelvic Abscesses by Trephining the 
Ilium. By Dr. Rinne (Greifswald). This is a report of two cases 
of very tedious pelvic abscess rapidly cured by G. Fischer's method of 
drainage through the ileum. The first case was that of a man aet. 26, 
who in childhood suffered from coxitis ending in ankylosis. In the 
earlier years of the coxitis he developed a pelvic abscess (by perfora- 
tion of the socket); this for fourteen years had kept up a fistula on the 
front of the thigh. Operated three and a half years ago ; cure in three 
months. The second case was that of an otherwise healthy girl who 
for eight years had suffered from suppuration of the flange of the left 
ilium, probably in consequence ot non-tubercular ostitis. After lying 
two years it broke spontaneously a hand's breadth below the spina an- 
terior sup. Repeated drainage of the abscess cavity through the long 
narrow resistant sinus secured temporary closure, but never cured the 
abscess. Operated in 1885 ; cure in nine weeks. Large subperios- 
teal abscess in the internal iliac fossa, filled with granulations and 
scant pus. 

R. makes an antero-posterior incision through the musculature three 
finger breadths above the large trochanter, and chisels through the os 
ilii so that a finger can be readily introduced. The procedure is 
not dangerous ; it is valuable where a cure is not effected through the 



352 INDEX OF SURGICAL PROGRESS. 

usual perforative opening. — Report of XV Congress of Germ. Surgs. 
m Centbl.f. Chirg. 1886. No. 24. 

Wm. Browning (Brooklyn.) 

II. The Role of Parasites in the Development of Certain 
Tumors. Fibroadenoma of the Rectum Produced by the 
Eggs of Distomum Haematobium. By Dr. V. Belleli (Alex- 
andria, Egypt). The hypothesis that many tumors have a parasitic or- 
igin every day acquires greater probability. Already it is beyond doubt 
that all granulation growths (tubercle, glanders, farcy, lupus) are the 
consequence of the development of 'a special parasite. The question 
is still open as regards the bulky " tumours " which are really worthy 
of the name. The discovery, however, of actinomyces in certain sar- 
comas opens a large field of study, and justifies researches directed 
with this view. Hence the interest in the development of certain 
tumors, typical in form and histological structure, under the action of a 
parasite very common in Egypt, the " distomum haematobium " or 
" Bilharzia hsematobia." 

It is known that the adult animal which lives in the portal vein and 
vesical veins, deposits its eggs chiefly in the little veins in the neigh- 
borhood of the intestines and of the bladder. The dimensions of the 
eggs, 160 !J- long and 60 //. broad, hinder them from reaching the capil- 
laries. They are stopped in the small veins which are subsequently lacer- 
ated by the efforts of the " vis a tergo." Some of the eggs are thus set 
free in the intestinal and vesical cavities, but others remain implanted 
in the tissues. In the whole length of the intestinal region the infiltra- 
tion of the Bilharzia eggs may produce different effects ; that which 
predominates, however, is the formation of certain tumors which have 
the appearance of polypi. It is in the rectum that the development 
of these tumors is particularly frequent, or rather it is in this region 
that they generally grow to a greater size. By their situation, at a dis- 
tance greater or less from the anus, they give rise to various phenom- 
ena, of which the principal are, hemorrhage, diarrhoea, tenesmus — in a 
word all the symptoms of dysentery. These tumors are often as big as a 
walnut or almond, but many Egyptian doctors have cited examples of 
rectal tumours consecutive to the Bilharzia, which have reached the size 



J BS CESSES, TUMORS. 353 

The following case occurred in the hospital of the Deaconesses of 
Alexandria, under the care of Dr. Mackie : 

A child, £et. 12, for nearly two years suffered from hematuria and 
dysenteric symptoms. It was observed that a tumor appeared at the 
anus during efforts of defecation. Recently the hsematuria had disap- 
peared and the rectal tenesmus had considerably diminished, but defe- 
cation was more and more impeded by the increased growth of the tu- 
mor. The child was ancemic ; the urine clear and transparent, but a 
repeated examination showed that it contained a notable quantity of 
Bilharzia ova. Rectal examination revealed, at a distance of 5 to 6 
centimetres, from the anus, a large tumor implanted by a broad base 
on the left side of the rectum. During the efforts of defecation a part 
of the tumor became visible through the orifice of the anus. This tu- 
mour was removed at the level of its base by aid of the ecraseur. 

Examination of the tumour. — The tumour of the approximate size 
of a small apple is flesh coloured and of soft consistence ; the surface 
regularly lobulated, with fibrous tracts limiting the principal lobules. 
Each lobule is formed ot a finely granular substance. On a cross sec- 
tion the aspect is identical Avith tliat of the surface, except that there 
are exposed a few cystic cavities filled with a gelatinous, yellow, trans- 
parent substance. In one of the cysts is remarked a blackish material 
of hard consistence — evidently toecal. The gelatinous substance was 
cursorily examined under a low power for the distoma eggs ; but as the 
result was negative the tumour was cut up in small pieces to be hard- 
ened in alcohol. On one of the fresh fragments of the tumour a con- 
siderable number of the ova could be distinguished with the micro- 
scope, containing living embryos, and one of them presented the 
various movements often observed some minutes before the rupture of 
the egg. 

Histological examination. — In the sections treated with picrocar- 
mine, large tracts, strongly colored, can be observed with the naked 
eye, limiting alveolar spaces more or less circular, formed of a trans- 
parent tissue of reticulate structure and feebly colored with the picro- 
carmine. Under the microscope the opaque bands are seen to be 
composed of connective tissue more or less compact ; the alveolar 



354 INDEX OF S UR GICAL PR CRESS. 

spaces being masses of tubular glands. Between each gland are thin- 
ner divisions of connective tissue. The inter-alveolar connective tis- 
sue is fibro-cellular, more or less compact ; in certain spots the fibres 
are so close together that the cellular elements are scarcely visible. In 
other parts they predominate. Moreover, there are limited places 
where the tissue, composed almost entirely of cells, assumes the aspect 
of embryonic tissue. Most of the cells are rounded, but manv are 
elongate and fusiform. Their protoplasm is uniform in appearance 
and more or less stained by the picrocarmine. In the sections treated 
with acetic acid the presence of a nucleus is manifested in some of the 
cells; others show only some granules strongly stained, probably the 
debris of a nucleus. In this same inter-alveolar tissue a considerable 
number of eggs and free embryos of the distoma are distinguished. They 
are found for the most part outside the vessels and are equally scat- 
tered in the fibrous and in the embryonic tissue. They are most often 
disposed in considerable groups — containing as many as twenty. 
Nearly all the eggs have the spine terminal, a few have it on the side. 
Some of them have the contents granular, others have the yolk more or 
less segmented, and others enclose the embryo already formed. Many 
of them, especially those in the compact tissue, have the contents ob- 
scure and blackish. The intra-alveolar connective tissue presents 
nearly the same characters as the above, but the fibrillar connective 
tissue with abundant prohferation of cells predominates. In this tissue 
the Bilharzia eggs are far from being as numerous as in the inter-aveo- 
lar, but a great number are to be seen, most often isolated, or rarely in 
groups of four or five. 

In the sections, the glands which make up the alveoli are cut in 
various directions. Some are simple tubes, others difurcate or have 
several branches. Their length varies from ^/, to i millimeter ; their 
diameter from 50 to 250 //. Some have a distinct membrane. They 
are lined by cyUndrical epithelium, the cells having no nuclei, but 
transparent and almost hyaline contents, and they vary in size. Some 
of the glands contain nothing, others an amorphous granular substance, 
and others are filled with hyaline spheres of cylindrical or polyhedral 
transparent cells. 



ABSCE:>SES, TUMORS. 355 

Independently of the glands large empty spaces are to be seen, 
which evidently form part of the cysts which are recognized with the 
naked eye. They have not all the same origin. In a few a great 
number of the glands open, indicating that they result from accumula 
tion of the glandular secretion ; others have no communication ^\dth 
the glands and they enclose several fibrous tracts ; they are probably 
formed by the destruction of a certain number of [glands. Indeed, in 
some places can be distinguished masses of glands with a part of the 
walls and of the cells, destroyed so as to form a single cavity. 

Diagnosis. — The above histological characters allow the tumour to 
be called a fibro-adenoma. The great augmentation in the number 
of the glands, and their deviation in type, show the growth to be a 
true adenoma, and not a simple hypertrophy of normal glandular tis- 
sue, and the large development of fibrous, compact connective tissue 
justifies the name of fibroma in addition. 

Observatio?is. — The cause which has determined the development is 
not doubtful, viz., the eggs of the Bilharzia, deposited in the mucous 
membrane of the rectum, having provoked an irritative process which 
has ended in the formation of an adenoma. These eggs have not acted 
solely as foreign bodies ; most of them are placed hving in the walls of 
the rectum, and many even have the embryo already formed. The 
movements of the embryo, and its exit from the egg, are also causes 
of the tissue irritation. 

The Bilharzia eggs not only explain the genesis of the tumour, but 
they are the cause of its successive development and its continued 
growth. In fact the large vessels which end in the tumor are contin- 
ually carr>'ing the Uving eggs throughout its extent, and the numerous 
foci of irritation provoke a continual development of the elements of 
the growth. Where a part of the tumour is newly formed its vascular 
system has a parallel development which allows of the introduction of 
eggs into new tissue. This is, therefore, a case in which, in place of 
the hackneyed irritations usually invoked to explain the origin and 
growth of tumours, it is possible to substitute the more definite and 
less hypothetical action of a special parasite. It is possible to go further, 
and to find in the peculiarities of the Ufe of th e parasite, an explana- 



3 5 6 lADEX OF S UR GICAL PR GRESS. 

tion of the nature of the tumour. It is generally admitted that for an 
adenoma to form the development of its histological elements should 
be so moderated that they have time to be disposed regularly and to 
reproduce the typical structure. The Bilharzia eggs produce a mod- 
erate irritation. The parasite is not fully developed in the human 
body — the ultimate transformations do not take place in the tissues. 
The embryo is only endowed with certain movements which soon 
cease, the irritation of the tissue being circumscribed and consequently 
moderate. If, on the contrary, the ova underwent a series of trans- 
formations ending in the perfect animal, it is probable that the more 
extended irritation of the tissues would hinder the regular disposition 
of the neoplastic histological elements. The abundant formation of 
epithelial cells would not give rise to new glands, but to irregular 
masses of cells imbedded in the connective tissue, we should then have 
all the elements of an epithelioma or true cancer. This is, of course, 
a pure hypothesis, but a likely one, which in similar cases to the above 
could be easily verified. Indeed, instead of a parasite like the Bilhar- 
zia there may be others which, from their size, escape a superficial ex- 
amination. The particulars of the life of these micro-organisms may 
also, as in the case of the distomum, give the key to the origin, growth 
and nature of ordinary tumours, malignant and benign. Modern 
science tends to these ideas, and it is probable that they will be sooner 
or later verified. — Pr ogres Med. July, 1885. 

P. S. ABRAHA>nLondon). 

III. Notes Toward the Formation of Clinical Groups of 
Tumors. By J. Hutchinson, F. R. S., (London). Advances the hypo- 
thesis that the time has arrived when it is both possible and desirable 
to make for practical purposes a more detailed classification of tumors 
than has yet been attempted, and that this must depend more upon lo- 
caHty, cause, contour and general course of the growth than upon m^^re 
microscopical appearances. The plan proposed is to take any ex- 
ample of rare disease and keep it by itself until others similar to it are 
found, and thus construct groups, which in turn may become large 
enough to allow of determining without much risk of error what are 
the differential peculiarities of the malady. As a general law for guid- 



ABSCESSES, TUMORS. 357 

ance in clinical observations in this regard, repetitions of structural 
peculiarities may be expected whenever the morbid tendency displays 
its activity in precisely similar regions. Of this law the author submits 
several examples, such as rodent ulcer, which occurs with such prepon- 
derance in one special region that it gained the name of " peculiar 
ulcer of the eyelids." While the writer presents numerous instances in 
favor of his proposed method of classification, such as a characteristic 
fungous tumour of lympho-sarcomatous composition, occurring in the 
upper part of the neck, melanotic sarcoma of the sole of the foot, sym- 
metrically fatty outgrowths, a hard and bossy tumor of the palate, 
which, though presenting a deep ulcer, is devoid of irritability and 
pain, warty tumors in cicatrices, etc., he notes more at length three 
groups : 

T. Melanotic Whitlows. — This is one of the several peculiar forms 
which melanotic sarcoma presents under the law of modification by 
locality; the amount of pigment is very sHght in the vicinity of the 
nails, and it is often difficult to recognize the pigmented structure in 
this region, but along the unswoUen border of the tumor is to be 
seen a faint, melanotic line ; the disease spreads more slowly here 
than does melanosis in most other positions and destroys the nail. The 
fungating growth which it finally produces, fails altogether to obtain pig- 
ment and is quite colorless. There is much greater hope of delaying 
the progress of the disease by operation than in most other forms of 
melanosis. 

2. The Crater if ort?i Ulcer, a new form of epithelial cancer of the 
face. — This is a malignant growth of epithelial type, met with, as far 
as the author's experience goes, only on the upper part of the face and 
more especially in the precise localities of the common rodent ulcer. 
The first stage is a bossy, rounded lump which rapidly attains consid- 
erable size and presents a somewhat conical summit. At this summit 
ulceration occurs, and a deep cavity forms with exceedingly little sup- 
puration or obviously destructive inflammation, forming a crater, the 
walls of which are of much thickness and of great firmness ; the growth 
is much less vascular and less succulent than that of rodent, and, while 
it is easy to scrape the latter away, it is quite impossible to do so with 



358 INDEX OF SURGICAL PROGRESS. 

this. It usually begins in those past middle age, and without any ob- 
vious cause ; is rapid in its progress, growing as large in a few months 
as rodent would in many years. As far as the author has observed, it 
shows no tendency to fungate or become warty, and in this respect, as 
well as in hardness of structure, density and thickness, differs from 
what is observed in common epithelial cancer of other parts. 

3. Recurring Fibroid of the Skin (spindle-celled sarcoma). — Exam- 
ples of the recurrent cutaneous fibroid are very rare, but they are very 
pecuhar in the mode of development, the inveteracy and rapid' ty with 
which thev recur on extirpation and in the absence throughout of any 
tendency to gland disease. In each of the cases observed, the early 
stage of the new growth was insidious and for some time very slow, but 
if left alone, there was ultimately a tendency to fungate and to the 
formation of blood cysts. The deep fascia became involved if the 
growth were neglected, but in the first instance the skin alone was im- 
plicated ; in two out of three cases the groAvth was on the thigh, and 
in the third on the lower part of the abdomen. The author has never 
seen a recurring fibroid of the skin on the upper extremities, the head, 
nor, with one doubtful exception, on the upper part of the trunk. The 
tumors seemed to be softer in structure and grew more rapidly with 
each recurrence ; their elements were repeatedly and by different mi- 
croscopists assigned to the spindle-celled sarcomata. 

If recurring fibroids of the skin are grouped by themselves, similar 
groups should be formed of the tumors of similar structure but more 
fibrous and developing in deeper parts, which are much harder and 
often found attached to the periosteum or to the deep fascia, and of 
the hard fibrous tumors, developed deeply, of very slow growth and 
tending to unsymmetrical multiplicity (Annals of Surgery, vol. i, p. 
423). By these and by numerous other instances referred to less at 
length, the author shows that by careful case-collecting and the selec- 
tion and grouping of cases clinically alike, clinical families, much more 
minutely subdivided than is possible to the microscopist as yet, may 
be constructed on a natural basis. — Infernaf. four. Med. Sci. 1886. 
Jan., April, July. 



ABSCESSES, TUMORS. 359 

IV. Cancer of the Cartilage or Chondrosarcoma. By 
Desir de Fortunet, M.D., (Lyon). This study of cartilaginous tu- 
mors is based upon a case of tumor originating in the tibio-fibular ar- 
ticular cartilage and in fourteen months attaining the size of the fist, the 
growth being attended Avith so great pain that amputation in the lower 
third of thigh was performed for its relief The ' amputation was done 
according to the method of Molliere, complete hsemostasis being ob- 
tained by torsion of the vessels without the application of a single lig- 
ature. This case is submitted in opposition to the theory that chon- 
dromata arise only from abnormally placed cartilage, and to prove 
that normal cartilage tissue may give rise to tumors of a nature iden- 
tical with itself Further, it shows the possibility of malignant tumors 
of the cartilage, and the author proposes the name of chondrosarcoma 
for it in opposition to chondroma, used to designate benign growths. — 
Revue de Chi^-urgie. 1886. May. 

V. On Fatty and Sarcomatous Tumors of the Knee- 
joint. By R. F. Weir, M.D., (New York). Details three unpub- 
lished cases together with a review of the Hterature of the subject. The 
first was of a young man in whose knee-joint, on the inner side of the 
patella, was felt a mass of considerable firmness like a loose cartilage 
and the size of an almond ; it could be moved freely within the joint, 
but was evidently pedunculated as it could not be forced without it. 
Under antiseptic incision the supposed cartilage proved to be a por- 
tion of fatty tissue, harder than usual and attached by a rather broad 
thick pedicle, which stretched under the hgamentum patellae and across 
the joint. As the mass could be pulled out with moderate traction, 
an attempt was made, in addition to the removal of the button-shaped 
end, to cut off as much of the hpomatous growth as possible after liga- 
turing it. This required an unusual amount of manipulation, and in 
spite of antiseptic precautions and immobiUzation, a suppurative syno- 
vitis set in, which necessitated amputation. The second case was of 
a young woman who had suffered for a year from pain, swelling and 
stiffness of the knee, in which was detected, internal to the patella, a 
lump the size of a large bean and movable for about an inch parallel 
to the axis of the Hmb ; the joint was opened and, under carbolic 



360 . INDEX OF SURGICAL PROGRESS. 

spray, the tumor exposed and lifted out, and its slender pedicle liga- 
tured and divided, proving to be a giant-celled sarcoma; the patient 
made a good recovery. The third case was* similar to the others in 
history, and under antiseptic incision an irregular shaped, softish 
growth, yellowish pink in color and marked by sundry ecchymotic 
patches, the result of recent exertion in dancing, was exposed, the 
growth being 172 inches long by i broad and nearly ^j^ of an inch 
thick, and proving to be a fibro-sarcoma. This mass was held by a 
long, slender pedicle which was tied and subsequently divided. In spite 
of slipping of the ligature and consequent intra-articular haemorrhage, 
which was checked by pressure, by which the blood in the joint was 
also evacuated, the patient passed on to a satisfactory recovery. A 
search into the literature of the subject gives but a single case of sim- 
ilar sarcomatous growth and but eight of lipomata. 

The practical deduction to be drawn from the review of so few cases 
of a somewhat obscure affection is that too much effort should not be 
made, in the fatty gro\\1;hs, to effect their total extirpation, since the 
removal of the floating portion is [all that is called for ; and that, in 
cases where the suspicion of sarcoma is microscopically verified, the 
subsequent progress of the two cases reported leads to the belief that 
the same conclusion will be arrived at. — N. V. Med. Rec. 1886. 
June 26. 

James E. Pilcher (U. S. Army). 

VI. Melanotic Whitlow. By Jonathan Hutchinson. Under 
this name the author alludes to cases of sarcoma, usual by melanotic, 
which spring from the bed of the nail. The black color is sometimes 
limited to a narrow border near the nail. He points out that when 
melanotic sarcoma fungates, and when it affects the glands, the larger 
growths are often white. — Brit. Med. Jour. 1886. P. 491. 

VII. Traitement des Fibromes de la Paroi Abdominale . 

By Terillon, The author cites two cases respectively of fibroma and 
fibrous sarcoma of the abdominal wall in the inguinal region, both in 
women. He lays stress on the fact that these tumors are often ad- 
herent to the peritoneum, and ra removal of a portion of that mem- 



ABSCESSES, TUMORS. S'^I 

brane may be necessary^.] In one of the cases cited the adhesion of the 
tumour to the serous membrane was firm, but its division was avoided 
by removing the bulk of the tumour and then dissecting off the ad- 
herent portions. If any part of the tumour be left, recurrence is fre- 
quent, although the growth has the characters of a fibroma. — Bull. 
Gen. de Therap, 

F. S. Eve (London). 

VIII. The Immediate Closure and Rapid Cure of Fistula 
in Ano. By Stephen Smith, M.D., (New York). Referring to the 
fact that this method of operation seems to have occurred to a num- 
ber of surgeons independently and acknowledging his indebtedness to 
Emmet's operation for lacerated perineum, the ^\Titer describes his 
method as follows : 

The bowel being cleaned out, the patient anaesthetized, the parts ir- 
rigated antiseptically, and a sponge, wrung out in a bichloride solu- 
tion, introduced into the rectum above the fistula, the fistula and ab- 
scess cavity, if there be one, are opened freely, the pyogenic mem- 
brane thoroughly enucleated with the scalpel or scissors and all haem- 
orrhage arrested. The chief object of the operation is to secure per- 
fect apposition of these freshened surfaces ; to bring the whole wound 
into view, an assistant should introduce an index finger well into the 
rectum and, bending it as a hook, extrude the bowel. The first su- 
tures should be so applied as to bring the deep surfaces together and 
evert the margins of the mucous membrane. To accomphsh this, a 
carboHzed silk ligature with a needle slightly curved at the point is 
used. One of the needles is now passed just above the highest point 
of the incision and from a fourth to half an inch from the margins of 
the wound, and the thread is passed through the center ; the needles 
are then passed in opposite directions, at intervals of half an inch, in 
a continuous saddler's stitch so as to draw the two faces of the wound 
together and slightly evert the edges of the mucous membrane, but 
without any strain. The entire fistula track being now drawn outside 
by gentle traction on the ends of this suture, the edges of the wound 
are nicely adjusted by a continuous suture, commencing at the upper 
extremity of the wound. The operation is completed by passing two 



362 INDEX OF SURGICAL PROGRESS, 

or three large carbolized silk ligatures entirely under the fistula and 
tying them over an iodoform gauze pad, rolled fiimly and laid along 
the wound, the object being to draw the deep portion of the fistula 
into suitable apposition. The parts are then dressed antiseptically and 
precautions taken to prevent movement of the bowels. In case of a 
large or irregular abscess cavity he suggests two modes of procedure, 
(i) by employing the saddlers' stitch, taken still farther from the mar- 
gins of the wound, in order to bring the deep [parts together ; (2) by 
interrupted sutures passed as in lacerated perineum completely around 
the cavity — a method more difficult to employ but surer than the 
other. The cure is complete in a period varying from eight to four- 
teen days. The principles to be borne in mind in the operation are 
(i) complete removal of the lining membrane of the I'stula and of the 
abscess cavity which may exisi ; (2) accurate and permanent adjust- 
ment of the opposing surfaces, and (3) thorough antiseptic treatment 
of the wound. — N. V Med. Jour. 1886. June 12. 

James E. Pilcher (U. S. Army). 

BONES, JOINTS, ORTHOPAEDIC. 

I. Congenital Symmetrical Exostoses. By Dr. Reulos. 
Observations of mukiple symmetrical exostoses are far from being rare. 
If authors are in accord as to the mode of their development, they are 
not so with regard to their etiology. Amongst the cases published 
some have been attributed to rickets, some to a special and chronic in- 
flammatory process, others to a super-abundance of the germative ma- 
terial which should later contribute to the formation of osseous tissue, 
or to some trouble of nutrition of unknown cause. All these hypo- 
theses are supported by a certain number of facts. In many of the 
observations " heredity " plays a somewhat important part, but until 
now no such good example has been met with as in the following case: 

Mrs. X., died at 79 years, of good general health, had always had 
symmetrical exostoses in the neighborhood of the femoro-tibial articu- 
lations. 

M. R., her brother, died at 83 years; had from birth exostoses on 
the lower limbs. He had four sons, who all bore femoro-tibial exosto- 



BONES, JOINTS, ORTHOPEDIC. 3^3 

ses. In one of them they were so developed that he walked with dif- 
ficulty. 

Mme. L., only daughter of Mme. X., now set. 62, healthy, possesses 
since her birth two bulky exostoses on the inner tuberosities of the 
tibi^. She has had eight children, of which four are living. They all 
have exostoses situated on the lower limbs at different heights and 
nearly all symmetrical. 

The eldest of the sons, aet. 37, invaUded on account of the multiple 
and large exostoses of the legs, has two daughters who present exosto- 
ses of the bones near the femoro-tibial articulation. The second son, 
set. 34, has hke his brother been excused from miUtary service on ac- 
count of his exostoses. He is healthy, walked at 13 months; shows no 
incurvation of the long bones ; teeth regular and without erosions ; his 
muscular system very well developed, and articulations normal. No 
trace of rheumatic, syphilitic or other diathesis. His lower limbs are 
alone the seat of the abnormahties. 

L. F., son of the precedent, set. 7, of good general health, brought 
up at the breast, walked at 1 1 months, teeth well placed and without 
erosions, no incurvation of the long bones or trace of rickets, never 
had rheumatism or epiphysary pains; exhibits exostoses on the femora, 
tibiae and fibulse, and also on the chondro-sternal articulations of the 
fifth and ninth ribs, and on the scapulae. 

The third son of Mme. L., aet. 24, has exostoses Hke his brothers. 

The fourth child of Mme. L. is a daughter who married young and 
has had eleven children, of which the five Hving, carry, like her, con- 
genital symmetrical exotoses in the neighborhood of the knee-joint. 

The history of the family seems worthy of interest, because it estab- 
lishes incontestibly the transmission of the exostoses by virtue of hered- 
ity, because it puts in rehef the character of the congenital exostoses, 
and because it gives us a means of distinguishing this from the specific 
exostoses. This character is the symmetry which has not failed once 
in any of the members of the generation. — Progres. Med. Angust. 

1885. 

P. S. Abraham (London). 



3^4 INDEX OF S UR GICAL PR O GRESS 

II. Excision of the Knee-joint. By A. M. Phelps, M.D., 
(Chateaugay, N. Y.). Cases for this operation should be carefully se- 
lected ; it should never be resorted to in children under 8 years of age, 
except in cases of destruction of the entire joint and not until other 
means have failed. It is better at this age to excise through explora- 
tory openings, such portions of bone and tissue as are found diseased, 
using the gouge-scoop and chisel thoroughly, establishing perfect 
drainage, fixation and extension. Chroric diseases with deformity, 
either purulent or non-purulent, not yielding to ordinary methods of 
treatment, are suitable cases at any age. Extensive suppuration, bur- 
rowing of pus, with many sinuses distributed about the joint and ex- 
tensive necrosis, making it difficult, uncertain or impossible to remove 
all diseased tissue, are cases suitable for amputation. Deformities 
from long standing arthritis, with but little bone disease, limited to the 
articulations are very favorable cases for excision. Ankylosis in bad 
position, compound luxation and subluxation from long standing joint 
disease should be excised. Many cases of joint disease among the poor, 
which might by long treatment be cured, if the patients could spare 
time from their work, should be excised, because they are then soon 
restored to health ; while, if the operation were not performed, ampu- 
tation would quite likely be demanded in after years, owing to fre- 
quent relapses. The end sought in all operations of excision of the 
knee-joint should be (i) to remove all the diseased tissue, including the 
capsule of the joint ; (2) to make the incisions in such a manner as to 
furnish easy access to every part of the joint and supply perfect drain- 
age ; (3) to restore old tissues to their normal position without leaving 
cavities ; (4) to get perfect drainage ; (5) to insure absolute immo- 
bility of parts after the operation; and (6) in children, after resection of 
the flexor tendons, placing the limb straight and utilizing the patella, 
when practicable, to prevent relapses. The operations which best 
meet these indications are Volkmann's, Fenwick's and Neuber's. 

While tenotomy of the hamstring tendons has been frequently per- 
formed to allow straightening of the limb before the operation, to ob- 
viate the sacrifice of a greater amount of bone, the author beUeves re- 
section of all the flexor tendons, to prevent their subsequent action in 



GYNECOLOGICAL. 3^5 

producing relapse in children, to have originated \\ith himself, and con- 
siders that it adds greatly to the efficacy of the operation, while de- 
tracting nothing Trom its safety. The paper is accompanied by re- 
ports of nine cases, in four of which the flexor tendons were resected, 
and tables of 329 operations antiseptically performed. — N. Y. Med. 
Rec. 1886. July 21. 

T. E. PiLCHER (U. S. Army). 

GYNECOLOGICAL. 

^xander's Operation. Dr. Doleris contributes a lengthy 
article on this subject to the Nouvelles Archives d' Obstetrique et de 
Gynecologie (Jan. to May inclusive). After reviewing at length the 
history of the operation, which he clearly shows was first suggested by 
Alquie in 1840, he cites Alexander's cases in full, and adds to these 
100 others which he has collected in literature. To these should be 
added nine more operations by Dr. Polk of this city, three by Dr. J. B. 
Hunter (not reported) and two by Dr. F. B. Harrington, of Boston. 
Several others have been performed in this city, so that the number of 
actual operations is probably 175 at the lowest estimate. In spite of 
the evidence thus adduced, there is a singular feeling of uncertainty 
among gynecologists with regard to the ultimate value of the opera- 
tion. Its technique requires no further exposition. As regards \}s\q. per- 
manence of the results we are still left very much in the dark. 

II. Oophoraphy. Under this name Dr. Imlach described before 
the British Gynecological Society a novel operation for the permanent 
reposition of prolapsed ovaries, when their extirpation by laparotomy 
is tmdesirable. In multiparge, according to this gentleman, the ovaries 
are kept in place by the infundibulo-pelvic ligaments; whenever the 
latter become much relaxed, the ovary sinks downwards and becomes 
congested by reason of the interruption of the circulation in the vessels 
supplying the organ. Dr. Imlach seeks to restore the prolapsed ovary 
to its normal position in the pelvis and to maintain it there by shorten- 
ing the relaxed infundibulo-pelvic ligament and suturing it to the 
hilum. Fourteen successful cases were reported. In the discussion 



3^6 INDEX OF SURGICAL PROGRESS. 

which followed the paper Mr. Lawson Tait insisted that prolapsed 
ovaries were usually the seat of chronic inflammation, and therefore 
that the operation suggested by Dr. Imlach might relieve, but would 
never cure, the patient. 



III. A New Operation for Repair of Complete Lacera- 
tion of the Perineum. Dr. R. A. Jamieson reported to the same 
society the successful results obtained by the following method of op- 
erating, in cases of laceration of the perineum through the sphincter : 

Separate the recto-vaginal septuminto two layers for a distance of 
about half an inch [from the anus?], then divide the vaginal portion 
longitudinally in the median Hne dissecting up the mucous membrane, 
with a portion of the adjacent skin, forwards on either side to the level 
of the insertion of the labia mijiora. This is now separated in the 
form of a strip, but is simply lifted from its previous attachment to the 
depth of lYs inches, parallel to the long axis of the body, its free bor- 
der being the median longitudinal incision and a curved line drawn 
about half an inch '-below the junction of the partlyaltered vaginal mu- 
cous membrane with the skin of the thigh." Transfix the horizontal 
border of each flap with a piece of catgut, to the end of which is at- 
tached a piece of lead. A cutaneous flap 4 inches long, having the 
shape of an isosceles triangle, with its base corresponding to the line 
of junction of the skin and mucous membrane, is now made on each 
side. These, with the muco-cutaneous flaps, are dissected " upwards 
and outwards to a line parallel with their bases, but a quarter of an 
inch external to them, and a quarter of an inch deeper." The raw sur- 
faces of the muco-cutaneous flaps are stitched together with fine cat- 
gut along the median Une, to form the lower part of the new posterior 
vaginal wall. The new perineum is made by carrying a continuous 
catgut suture from side to side along the lines of denudation " a quar- 
ter of an inch internal to the inclination of the cutaneous flaps to the 
subjacent areolar tissue." The anterior ^ edge of the rectal wall is next 
drawn down and fastened behind the new perineum, and the cutaneous 
flaps^are "loosely replaced, leaving on each side i' /., inches between their 



GYNECOLOGICAL. 367 

apices and the apices of their former beds." In order to complete this 
complicated operation, its author directs that two sutures be carried on 
each side " deeply into the perineo- crural angle, so as to ensure the 
formation of a lold in this situation " while a line of sutures is carried 
along the edges of the flaps, and the borders of the gap which remains 
are drawn together. 

In the course of the discussion which followed this rather bhnd de- 
scription Dr. Fancourt Barnes referred to the operation performed by- 
Mr. Tait, the essential feature of which was the spUtting of the recto- 
vaginal septum. The advantages of Tait's method were rapidity, ab- 
sence of subsequent pain, the fact that the new perineum was more 
sohd, and that the bowels could be moved soon after the operation. 
The operation was equally application to any variety of perineal lacera- 
tion. 

Dr. Inilach described a method by which a flap was taken rom 
each labium, that on the left side being turned outward, while the right 
hand flap had its base in the median line of the posterior vaginal wall. 
A strip from the recto-vaginal septum was then to be dissected out- 
wards. The free edge of the right flap was drawn across to the left 
labium and attached to its raw surface by fine sutures ; the left flap 
was united in a similar manner to the right labium. "Then," in the 
words of the speaker, "pass a single stitch through the anterior edges 
to prevent infiltration of vaginal secretions, and then through the recto- 
vaginal strip behind." Dr. Imlach claimed that a solid perineal body 
was formed in this way, and not a mere median cicatrix, as after most 
operations. 



IV. Excision of the Diseased Portion of a Cancerous 
Uterus Preliminary to Total Extirpation. Pean claims pri- 
ority in the following modification of the ordinary operation of vaginal 
hysterectomy. The operator, being provided with two thermo-cautery 
knives at a white heat, proceeds to remove small fragments of the dis- 
eased tissue until nothing is left but the shell composing the healthy 
uterine wall. There is no serious haemorrhage during this procedure. 



368 INDEX OF SURGICAL PROGRESS. 

The cul-de-sac is now opened and the uterus removed in the usual 
manner, except that the vessels in the broad hgaments are at once 
seized en masse with long haemostatic forceps, ligatures being applied 
at leisure. — Gaz. des Hop. 1886. Jan. 21. 



V. Conservative Ovariotomy. Professor Schroeder has re- 
cently devised an ingenious operation, which consists of excising the 
diseased portion of an ovary and leaving the healthy tissue, with a view 
to the preservation of the function of the organ. After carefully dis- 
secting out the larger cysts. Prof. Schroeder unites the raw surfaces 
with fine sutures and then restores the ovary to the abdominal cavity. 
According to the experience of this celebrated surgeon, and of those 
who have practiced this operation, the results have been most gratify- 
ing. While menstruation continued, the former dysmenorrhcea was 
relieved in several instances. In one case the patient became preg- 
nant after excision of portions of both ovaries. 

V . The Use of Cocaine in Gynecology. Dr. George W. 
Johnston (A\'ashington). After discussing the value of the drug as a 
local anaesthetic in cases of vaginismus the writer dwells upon its use 
in operative work, acknowledging that its range is restricted. Cocaine 
does not produce that profound and permanent anaesthesia which it is 
necessary to maintain during operations upon such sensitive parts as 
those in the female genital tract. The operator must repeatedly re- 
sort to fresh injections of the drug, while practically it is found to be 
difficult to keep the patient in a constrained posture, even when she is 
free from actual pain. 

The author recommends the stronger solution (20%) used in Ger- 
many. The part to be anaesthetized should be thoroughly washed 
with an antiseptic solution, and then carefully dried before the appH- 
cations of cocaine are made. After thoroughly pencilling the part with 
the solution above mentioned a piece of absorbent cotton soaked in 
the fluid should be allowed to remain in contact with it. The anaesthetic 
effect is obtained in from four to six minutes. Deep injections may be 



G YN^ COLO GICAL. 369 

practiced in certain localities ; by beginning the denudation at the 
most dependent point in plastic operations on the vagina, each area 
may be cocainized as it is reached. The author summarizes with the 
opinion that "by surface-pencilling with strong solutions in nearly all 
the simpler and more frequent plastic operations about the vagina and 
cervix a sufficiently deep and prolonged anaesthesia may be pro- 
duced." 

Following the body of the paper are a number of reported cases, 
several of which occurred in the author's practice, in which coloprraphy, 
trachelorrhaphy, operations on the urethra, etc., were successfully per- 
formed without pain to the patient. The paper deserves no little com- 
mendation, as it presents in a concise form a collection of valuable 
surgical memoranda which were widely scattered throughout the lit- 
erature. — Medical Record. 18S6. July 17. 



VII. The Treatment of Retroflexion of the Uterus by a 
Recent Operative Method. Von Robenau. The author sug- 
gests the following novel operation for the relief of cases of retroflexion 
in which either a pessary cannot be retained, or, if worn, fails to keep 
the uterus in proper position. The anterior lip of the cervix is com- 
pletely excised to the height of 4 centimetres. " The immediate re- 
sult," in the words of a commentator in the Centralblat filr Gyndkolo- 
gie, " is a perfect reposition of the uterus, which is explained by the 
fact that the larger anterior convex surface is so reduced in size by this 
high excision that it becomes smaller than the'posterior concave." 

Through the resulting cicatrization the organ is drawn upward into 
its normal position. The author's observations and experiments were 
.interrupted by his untimely death, so that the number of recorded op- 
erations only amounts to six. In four of these the result is stated as 
nil, in the other two doubtful. In reviewing the reports of the cases 
in which it is naively acknowledged that the extensive cicatricial con- 
traction frequently led to stenosis of the cervical canal and resulting 
dysmenorrhoea, the reader will be led to wonder not so much at the 
heroism of the surgeon, as at hij faith in the efficacy of an operation 



370 INDEX OF SURGICAL PROGRESS. 

which savors more of the dark ages than of modern scientific gynae- 
cology. — Berliner klin. Wochensch. 1886. No. 18. 



VIII. Hofmeier's Statistics of Operations for Cancer of 
the Uterus. Discussing the question of the radical cure of malig- 
nant disease of the cervix uteri before the Berhn Obstetrical and Gyn- 
ecological Society, Hofmeier compares the result of operations after 
periods varying from one to five years. The reported cures after total 
extirpation amounted to 48% ; at the end of the third year only 14% 
of the patients remained free from the disease. He concludes that in 
45% of the suitable cases of supia-vaginal amputation no recurrence is 
observed, so that these patients may be fairly considered as cured. H. 
beheves that if the above operation has been thoroughly performed the 
disease rarely returns within a year, and then nearly always in the per- 
uterine tissues. When, he says emphatically, a year after operation 
there is no evidence of a local recurrence, it may be safely affirmed 
that there will never be any. To this rule he has seen only four ex- 
ceptions among forty-five cases. 



XI. Castration in the Treatment of Cavernous Myo- 

Fibromata of the Uterus. Dr. Goldenberg lays particular stress 
upon the application of the so-called " Hegar's operation " to cases of 
uterine fibroids in which the tumor is recognized as a soft interstitial 
growth, with a rich vascular supply. In this class of tumors the entire 
uterus is diseased, and haemorrhage is a prominent and dangerous 
symptom, because of the excessive congestion which attends each 
menstrual period. The writer believes that production of the prema- 
ture menopause as well as a marked decrease in the size of the tumor, 
are results more invariably obtained when the fibroid is of the soft or 
cavernous variety, than when it is hard and less intimately connected 
with the uterus. The size of the tumor as well as the age and general 
condition of the patient do not affect the value of the operation. — 
Centbl. f. Gynak. 



G YN.-^ COLO GICAL. 3/1 

X. Vaginal Hysterectomy for Cancer. Prof. Schultze 
(Jena). Schultze gives the results of three abdomhial and nine vaginal 
hysterectomies, and deduces from them certain practical lessons, viz.: 

If the cervix alone can be amputated at a point i centimetre above 
the upper limit of the disease, as felt by the finger, then amputation 
is to be preferred to total extirpation. If, however, the posterior cul 
de sac is opened during the former operation, then the surgeon should 
not hesitate to remove the entire organ. [This is opposed to the 
teaching that opening of the peritoneal cavity during operations on the 
cervix is a comparatively innocuous proceeding]. 

Before undertaking the operation, after the patient is anaesthetized, 
a thorough examination should be made by the rectum, vagina and bi- 
manually, in order to discover the extent to whfch the surrounding tis- 
sues have been invaded. It is impossible to decide positively on this 
point, since in some cases the distal portions of the broad ligaments 
may be affected, while the areas immediately adjacent to the uterus 
are not diseased. 

S. believes that the diagnosis of cancer of the corpus uteri can be 
made more positively by introducing the finger through the dilated os 
than by examining microscopically fragments removed by the curette. 
— Deutsch. Med. Zeit. 1886. No. 24. 

XI. Retention of a Fcetus in One Horn of an Uterus Bi- 
cornis; Extirpation of the Pregnant Horn. Dr. Wiener. The pa- 
tient was get. 29 and had borne two children, the last, seven years before. 
Her menses ceased in December, 1883, and the foetal movements were 
felt for the last time in September, 1884. The woman's health began to 
decline, and a month later she was seized with severe pains in the left 
side of the abdomen, accompained by uterine haemorrhage which per- 
sisted ior three weeks. When received into the hospital and examined 
under ether, it was found that the uterus was displaced to the left by a 
smooth, hard tumor, which filled the pelvis and the lower portion of 
the abdomen. 

In the posterior fornix was a mass resembling a foetal head ; the 
growth appeared to be attached to the uterus by a thick, short pedicle. 



372 INDEX Oh SURGICAL PROGRESS. 

The probable diagnosis of extra-uterine pregnancy was made, and 
laparotomy was performed. The tumor was found to be the right 
horn of a double uterus, containing a mature foetus in a state of begin- 
ning maceration. The mass was ligated and removed in the same 
manner as an ovarian cyst. There was profound shock for five days, 
with rapid, feeble pulse, vomiting and moderate rise of temperature. 
The patient then rallied and was discharged, cured, at the end of four 
weeks. 

An examination previous to her departure revealed the presence of 
a left horn 6 ctm. in length, with a vertical septum, which had formerly 
separated it from the right. Involution proceeded normally and three 
months later the uterus had returned to the normal size of the organ 
at that time. 

Commenting upon this case the writer believes that its result, if left 
to its natural course, would have been disastrous since the foetus would 
have become decomposed, and rupture of the sac with escape of its 
contents into the peritoneal cavity would have been a not unlikely oc- 
currence. Operative interference is clearly indicated, since the prognosis 
is iavorable. The stump should be treated intraperitoneally in every 
instance, unless there are evidences of advanced decomposition of the 
{c&\M%.—Archiv.f. Gynak. Bd. XXVI. Hft. 2. 

XII. Italian Statistics of Vesico-Vaginal Fistula. Dr. 
MoRiSANi. The author reports fifty cases of fistula. One hundred 
and eleven operations were performed, forty-one patients being cured 
and seven relieved. There were two deaths from septicemia. Sims' 
operation was the one performed in most instances, the silver suture 
being preferred. — Annali di Ostet. 

XII. Gradual Amputation of an Inverted Uterus by 
Means of a Ligature. Dr. Poncet. The inverted uterus was 
drawn downward as far as possible with a volsella and a stout silk lig- 
ature was passed around the pedicle of the tumor, and the ends at- 
tached to a serre-nceud. The cord was tightened until the patient 
(who was not anaesthetized) complained of feeling a slight pain. The 
vagina was thoroughly disinfected before and after the operation, and 



SYPHILIS. 373 

was packed with iodoform gauze. The ligature was tightened a httle 
each day, the patient experiencing but a moderate amount of discom- 
fort and having an insignificant rise of temperature A large slough 
came away on the eleventh day, and on the twenty- third a vaginal ex- 
amination revealed no trace of the uterus, but only a transverse linear 
cicatrix in the roof of the vagina. — Arch, de Tocologie. 1886. April. 

H. C. COE (New York). 



SYPHILIS. 

I. Necrosis of Clavicle of Syphilitic Origin. Sub-Perios- 
teal Resection. By M. Gillette (Paris). In this operation, which 
was performed on account of necrosis attributed to syphilis, all but the 
inner 3 cm. of the bone was removed. It is noteworthy for the repro- 
duction of a bridge of new bone connecting the sternum and the scap- 
ula, and for the complete restoration of all movements. 

The patient contracted syphilis at the age of 17, was treated for a 
few weeks, and suffered only fi-om shght reminders until July, 1884, 
when he was 25 years old. Then Avithout apparent cause a swelling 
formed over the middle of the R. clavicle, and in a short time several 
sinuses led down to dead bone. Keeping within the periosteum 
M. Gillette sawed through the bone at its inner healthy end, and ex- 
tracted, without any material hemorrhage, the remainder, which was 
found to contain three sequestra. The wound healed quickly. It 
may be doubtful whether the necrosis was really s)rphilitic, no special 
search was made as to tubercle. In the subsequent discussion a sim- 
lar case in which an equally successful operation was performed was 
mentioned, whilst M. Trelat maintained that the right treatment was to 
remove the sequestra and not to excise the whole bone ; he admitted, 
however, the complete success of the operation. M. Tillaux (Anat. 
Topograph. P. 479) describes the case of a Parisian writer who in 
spite of a pseudarthrosis in one clavicle suffered no inconvenience ex- 
cept when carrying heavy weights on that shoulder. — Bull, de la Soc. 
de Chirurgie. March. 1886. 



374 INDEX OF SURGICAL PROGRESS. 

II. Treatment of Chronic Gonorrhoea by Means of 
Grooved Bougies. By Dr. Leopold Casper (Berlin). The author 
asserts that he has, by the daily passage of large nickel-plated bougies 
(Nos. 1 8 to 23 Charriere), succeeded in curing about fifty inveterate 
cases of gleet. Each bougie has a series of six longitudinal grooves 
which are charged with an astringent salve. After various trials he 
found the best astringent to be nitrate of silver, which is mixed in the 
proportion of 1.5 grms. to too of cacao butter and two of balsam of 
copaiba. The cacao butter must be only just melted for fear of re- 
ducing the silver bv over-heating. Each bougie is left in the urethra 
for from a few minutes to an hour, depending on the patient's toler- 
ance. 

Casper agrees with the generally held opinion that gleet usually 
arises from chronic inflammation in the bulbous portion, and that it 
implies a threatening stricture, hence he insists upon the use of large 
bougies. The rare cases of " gonorrhoea posterior" (implicating the 
membranous and prostatic portions) he heals by pushing the bougie 
further into the urethra. In order to diagnose the latter condition he 
makes the patient pass his urine into two vessels consecutively, if both 
contain flakes and films of white deposit he infers its existence. If 
only " gonorrhoea anterior " (situated in front ot the triangular liga- 
ment) only the urine first passed will contain the deposit. Tenesmus 
is an uncertain sign in chronic gonorrhoea posterior. — Lancet. Feb. 
6, 1886. 

J. Hutchinson, Jr. (London). 



REVIEWS OF BOOKS. 



A Manual of Surgery. In Treatises by Various Authors. In three 
volumes edited by Frederick Treves, F.R.C.S., Surgeon to and 
Lecturer on Anatomy at the London Hospital. Vol. I., General 
Surgical Affections, The Blood-vessels, The Nerves, The Skin. Vol. 
II., The Thorax, The Organs of Digestion, The Genito-Urinary Or- 
gans. Vol. III., The Organs of Locomotion and of Special Sense, 
The Respiratory Passages, The Head, The Spine. Duodecimos, 
1866 pages, 213 engravings. Per volume, cloth, $2. Philadelphia, 
Lea Brothers & Co., 1886. 

It would be not only a pleasing but a profitable task to carefully re- 
view in detail the three handsome and shapely volumes issued by Mr. 
Treves and his collaborators. Without more time and space than can 
be allotted in these pages such an attempt would be both inadequate 
and invidious. The justice of this remark will be apparent when one 
reflects that the work contains no less than fifty-nine articles by thirty- 
three different writers, and that each article is a model of conciseness 
and brevity. To select a few from these for especial commendation 
would be not only a distasteful but a difficult undertaking, in view of 
the high standard of merit to which each attains. 

The hand of Mr. Treves is evident throughout the work, in the 
choice, arrangement and logical sequence of the subjects selected for 
presentation. It is still more evident, if we mistake not, in the traces 
of vigorous and relentless pruning which appear from time to time in 
turning its pages. It must not be inferred from the stress laid upon 
this characteristic of conciseness, that any given subject is slurred over 
or imperfectly represented. . This would be an incorrect impression. 
Every topic so far as observed is treated with a fulness of essential de- 
tail, which is somewhat surprising in view of the necessary Hmitations 
of space. This end is attained by a strenuous effort to express ideas 
in the fewest possible words, by the exclusion of polemic writing, by a 
systematic classification of each subject, and by the use of small but 
clear and readable type. It is also apparent that with a few exceptions 
litde room can be allotted to the thousand and one details of treat- 
ment. Such details belong to larger and more exhaustive special trea- 

(375) 



3/6 RE VIE WS OF BO OKS. 

rises. The principles and main lines of surgical therapeusis, however, 
are amply noted and enforced. The illustrations are comparatively 
few in number, but well chosen. 

Another characteristic of the work is the well-nigh universal accept- 
ance of modern and progressive views of pathology and treatment. 
This is seen especially in those portions treating of surgical tuberculo- 
sis, diseases of lymphatics, diseases of bone, and the treatment of 
wounds. As regards the latter, antiseptic theories and practice seem 
to be fully accepted. It is curious to observe in this connection that 
some of the authors represented still chng to the use of carbolic oil, 
and the antiseptic spray, both of which have been discarded by many 
operators as futile, and therefore mischievous in giving a false sense 
of security. It would also seem that the compHcated and cumbersome 
gauze dressings, recommended in one at least of the articles, could be 
replaced with advantage by the more easily prepared and adjusted 
pads of absorbent material. The ardcle on anaesthesia contains a use- 
ful hst of conditions in which ether should and should not be used. No 
mention is made of Esmarch's wire frame for giving chloroform, which, 
in the writer's experience, is safer and by far more convenient than the 
use of a folded napkin. 

The arguments for the use of Clover's and similar apparatus for 
giving chloroform and ether do not seem to counterbalance the great 
defect of such appHances. This defect consists in the fact that during 
their employment the effects of poisoning by rebreathed air are super- 
added to the narcosis/rom the anaesthetic. 

The binding is well done, loose backs being employed so that the 
volumes lie open easily and are convenient to handle. Some errors of 
proof-reading exist, but none that cannot be readily corrected by the 
context. Cross references are inserted with sufficient frequency and 
discrimination to bind the different articles into an organic whole. 

The entire work is conceived and executed in a scienrific spirit. It 
is conservative without bigotry, and contains the bone and marrow of 
modern surgery. Doubtless some imperfections may be discovered on 
close examination, but taking the manual in its entirety, it unquestion- 
ably falls a place in the surgeon's Ubrary which would otherwise be un- 
tenanted. 

G. R. Butler. 

The Science and Practice of Surgery. By Frederick James 
Gant, F.R.C.S. Third edition. London, Bailliere, Tyndall & Cox, 
1886. 
The present year has been rich in the production of large text books 



GANT ON THE SCIENCE AND PRACTICE OF SURGERY. 2)77 

on surgery, and encyclopedias and dictionaries. The third edition of 
Mr. Gant's work is to some extent a joint production, for we find sev- 
eral well known names attached to the more special subjects. Still the 
work is mainly Mr. Gant's for more than 2,000 pages are by him while 
the other contributors occupy about 240 pages. That his work has 
been appreciated by the pubHc is evidenced by this being the third 
edition, and in the present issue we find considerable additions both to 
the text and to the engravings. 

There is, and has always been, a special feature in this work, that it 
is not like most modern works upon the subject, which are noticeable 
for their conciseness, and err rather upon the side of abruptness. In 
this work there is an opposite tendency, and the author appears to be 
talking to you with plenty of time at his and the hearer's disposal. 
There is sometimes a charm in this, but it no doubt makes it of less 
value to the student whose time is only too short. But the practitioner 
who has the time will find the information given in a pleasant and gen- 
erally in a clearly expressed form. Authorities are fully given and it is 
refreshing to find the old masters so freely quoted. 

But in considering a modem text book on surgery, or one which 
claims to hold such a position, it is necessary to have more than a 
readable book. Surgery has no doubt made considerable advances in 
modern times, and these advances must be carefully borne in mind. 
Moreover, the explanations of pathological and physiological processes 
are subject to considerable modification trom time to time. And we look 
to see how these matters have been treated. Here we find that the author 
has not been unsuccessful, and especially with the advances in surgery 
proper. Clear accounts are given of recent operative improvements, 
and the illustrations are certainly good, while the references to other 
works will be valuable to the reader. Where the author can refer to 
cases under his own care they are mentioned, but do not occupy too 
much space — sometimes, indeed, not fully enough or clearly enough, 
perhaps. 

An endeavor has been made to interest the reader in the patholog- 
ical aspects of surgery, but we cannot help feeUng that it is with infer- 
ences and opinions that the work is deaUng rather than with facts, and 
in the general diseases we do not find that what is known of the pathol- 
ogy is clearly described or the more recent observations always taken 
notice of. 

The chapter on Pyaemia is thus not up to date, and the relation of 
this disease to organisms is not described, nor of septicaemia to the 
ptomaines, and yet the space given to its consideration is more than 



3/8 RE J 'IE JfS Ob BOOKS. 

enough to make one expect a full account of what is known. The ac- 
count of Tetanus in the same way is wordy. That of hydrophobia 
seems not well arranged, and no mention is made of Pasteur's obser- 
vations, but this may be accounted for by iheir being chiefly published 
very recently — perhaps since the type of this work was set up. We 
do not think the author wise in approving of delay in the treatment of 
cases of bites by possibly rabid dogs, nor do we think that excision 
when he recommends would be likely to be efficacious. Much that 
we have looked at in this work is extremely good, but the fault is 
wordiness, and this will make it less useful than it might be. The wood- 
cuts, numerous as they are, and often very good and original, are 
wanting in clearness to the reader because they have no description 
attached to them. 

W. W. Wagstaffe. 

A Guide to the Examination of the Nose with Remarks on the 
Diagnosis of Diseases of the Nasal Cavities. By E. Cress- 
well Baber, M.B., London. 

This little work is certainly a most excellent and concise guide for 
those who wish to make themselves conversant with the various meth- 
ods employed for the exploration of the nasal cavities. 

The description of the anatomy of the interior of the nose and naso- 
pharynx is the most complete of any we have seen in the English lan- 
guage, and will be found of value not only to the beginner, but also to 
those who are experts in rhinoscopy. 

The opening chapter deals with the anatomy and physiology of the 
nasal foss£e, Two excellent illustrations, after Zuckerkandl, of vertical 
transverse sections through the anterior and posterior thirds of the nasal 
cavities greatly assist the reader to grasp the details which are need- 
ful to all who wish to make the nose a special study. 

Attention is drawn to the tuberculum septi, first described by Mor- 
gagni and which has been recently figured by Zuckerkandl. This 
elevation of the mucous membrane of the septum due to an accumu- 
lation of glandular elements, lies opposite to the anterior end of each 
middle turbinated bone, and may be said to roughly mark the limits 
of the superior or olfactory region of the nose from the inferior or res- 
piratory. As the author justly says, it plays an important part in the 
examination of the nares from the front, and he has certainly done well 
in insisting on the importance of this structure, and he is so far as we 
are aware, the first English writer who has done so. 

The physiology of the nose is dealt with in a few pages. A distinc- 



BABER ON EXAMINATION OF THE NOSE, ETC. 379 

tion is made between the taste of substances appreciated by the tongue 
and their smell when in the mouth perceived by the olfactory ner\e. 

The somewhat conflicting opinions held as to the effect of the nasal 
cavities on the voice are alluded to. That they have a very impor- 
tant effect on the volume of sound admits of no doubt, and anyone can 
easily demonstrate this for himself by suddenly compressing his nose 
while sounding a note when the diminution in volume becomes very 
evident. 

The symptoms of nasal disease are treated of in chapter ii, and the 
general practitioner will get some useful hints from the concise de- 
scriptions given. 

Much attention has been paid by rhinologists during the last few 
years to various reflex phenomena such as attacks of asthma, spas- 
modic cough, migraine, etc., which are, according to Hack and other 
continental observers, at times connected with the presence of nasal 
polypi or hypertrophy of the inferior turbinated body. Dr. Baber adds 
some interesting instances of such cases, from his personal experience, 
in an appendix. There is no doubt that such cases do occur, but we 
would add as a word of caution, that we fear too much has been made 
of them as regards frequency, and as a result many unnecessary opera- 
tions have been performed. 

A few pages are devoted to the physical examination of the nose, 
and there is a good sketch of the typical physiognomy presented by a 
child suffering from nasal obstruction. 

Dr. Baber calls attention to the value of sunhght in examining the 
nose, and prefers it to any other in the elucidation of difficult cases. 
He is also in favor of Trouve's Electric Photophore as being less cum- 
bersome and expensive than the oxyhydrogen hght. Trouve's ap- 
paratus gives a light of about ten candle power, whilst the oxyhydro- 
gen light is considerably over five hundred, and we cannot but think 
that in its present form it is far preferable to the photophore, although 
a little more costly, and it compensates the surgeon for the trouble of 
manufacturing oxygen, which, however, in large to\vns can be often ob- 
tained in the compressed form. 

Beginners will find much assistance from some diagrams which show 
in a very clear manner the different parts of the nasal cavities brought 
into view by bending the head of the patient backwards or forwards, 
and the sketches showing what is usually seen on looking into the nose 
fi-om the front are also of value. 

Clear instructions are given how best to perform anterior and pos- 
terior Rhinoscopy. 



380 REVIEWS OF BOOKS. 

We agree with the author in preferring the simplest of appliances in 
examining the posterior nares, and beHeve with him that palate hooks 
and other Hke instruments of torture are hardly ever necessary. There 
are wood-cuts representing the best forms of nasal instruments, as 
well as some, such as "Zaufal's Tubes," which are painful to use and 
of very Httle advantage. 

A short chapter on palpation of the post-nasal space, and another 
on the diagnosis of the commoner diseases of the nose are both use- 
ful. Anyone who follows out the very elaborate outline for a nasal 
examination suggested by Dr. Baber will certainly not be likely to fall 
into errors of omission. 

In conclusion we know of no book which in a small number of pages 
gives such admirably clear and concise instructions on all the essen- 
tial points connected with the examination of the nose. 

Manuel De Technique des Autopsies. Par Bourneville and P. 
Bricon. 1885. Paris. Librairie du Progres Medical. (Handbook 
of Post-Mortem Examinations). 

This is a useful little book which deals with the subject of which it 
treats in a thoroughly practical manner. The first part discusses briefly 
the various conditions under which post-mortem work is legally con- 
ducted in France, and by way of comparison, in other countries. Un- 
der the heading of Edinburgh the authors state "that post-mortems 
are generally opposed by Cathohcs, but this opposition can be set 
aside by the priest at the instance of the physician." Again it would 
appear that post-mortems upon Jews'are prohibited in Paris, owing to 
the bodies being claimed by the Jewish consistory, a condition of things 
which the authors state is perfectly unjustifiable. The second part of 
the book describes the practical details of post-mortem work, and 
concludes with an exceedingly useful chapter upon the means to be 
adopted for preserving pathological specimens for the museum. As 
in most French works upon technical subjects, so in this, a careful 
and exhaustive bibliographical index is added. 

H. Percy Dunn. 



THE SERVO-BULGARIAN WAR FROM A SURGICAL 
POINT OF VIEW. 

By R. lake, L. R. C. P, M. R. C. S. 

AT the commencement of hostilities early in November, 
1885, the position of the forces at different times en- 
gaged was about as follows : 

The main Servian army lay at Nisch and Pirot, and con- 
sisted of some 120,000 men. Opposing the Servians was a 
Bulgarian force at Zaribrod of about 20,000. 

The main bulk of the Bulgarian army lay at Philipopolis, 
ready to meet the Turks, at least four days march from Sofia. 

The Zaribrod force was gradually driven back to Slivnitza. 
This took one week, but the Servians were unable to proceed 
further on account of the break-down of the commissariat, 
thus allowing time for the main Bulgarian army to arrive. On 
its arrival in the second week of the month the battle of 
Slivnitza was fought, followed by the Servian retreat and the 
Bulgarian advance. The Dragoman Pass was forced, and the 
battle of Pirot fought. By the end of November the war was 
practically over. 

Bulgaria. — At the outbreak of the war, what there was of 
an army medical department on this side, had made its ar- 
rangements for a campaign with Turkey. When war was sud- 
denly declared with Servia their transport beasts were mostly 
required for more immediate uses, as the main force had to 
march about 360 kilometres to the seat of war. Consequently, 
even if the Army Medical Department had been capable of 
meeting the requirements of the forces, it was crippled, and 
when the strain came it collapsed. There were no trained 
orderlies to do the work; in fact, their Army Medical Depart- 
ment was in much the same condition as was the British when 
the Crimean war broke out, with the exception of the posses- 
sion of most excellent ambulance wagons. These latter were 
able to carry two lying and two sitting. 



3^2 J^. LAKE. 

Now it was not at the outset that the wounded were numer- 
ous enough to cause an utter break-down of all transport ar- 
rangements. During the first half of this short war of hard 
fighting the Bulgars were able, to a large extent, to remove 
those of their wounded who escaped capture, as they were 
continually faUing back on their base in Sofia. 

The transport of the wounded was accomplished by the few 
ambulances, but especially by the country carts, rough, long, 
narrow, open vehicles drawn by oxen, entirely without springs 
and with merely some brushwood or straw in them to lessen 
the jarring. However short the distance, therefore, the time 
between the "'first aid dressing," which was rarely an antisep- 
tic one, and that at the hospital, was necessarily very long. 

Fortunately the weather was not very trying and the men 
were not worn out by long marches and privations. 

At the middle of the campaign with the Servians atSlivnitza 
came a pause, all the capital was in a panic, but there were 
volunteers who helped to form hospitals — twenty-six in all — 
ambulances and a nursing staff. After the defeat of the Ser 
vians at Slivnitza there was good provision for the reception 
of wounded. Those already fit for transfer were sent home, 
or where there were either temporary or permanent hospitals. 
After the severe fighting following Slivnitza those beasts pre- 
viously spared to the Army Medical Department were with- 
drawn, as the army simply pressed forward by forced marches 
fighting more or less all day. Each day added its comple- 
ment of wounded to the rapidly increasing total, which formed 
at the time Pirot was reached at least 5,000. All that could 
be done was done, but skilled medical assistance was absent, 
or only represented by a few Bulgarian doctors who had 
probably never done an operation since they quitted the uni- 
versities, and were only too ready to cloak their timidity and 
ignorance under the disguise of conservative surgery. 

After the last fight at Pirot a new and serious complication 
arose in the camps, for typhoid and dysentery appeared. Be- 
fore, however, many had succumbed to these diseases, the 
weather changed suddenly to bitter cold with a temperature 
as low as 27° Fahr, which seemed to check them. 



SERVO-BULGARIAN WAR HOSPITAL SERVICE. 383 

The troops who were on the mountains were mostly without 
great coats and hundreds perished from cold. The wounded, 
with short rations, were still worse off, as they had only the 
open wagons to convey them back to the base. All up the 
Dragoman Pass the wounded were exposed to all the varia- 
tions of the weather. Often at night they were not able to 
reach a shelter. Their limbs on splints were numbed for want 
of movement. They suffered terribly from the cold, and the 
number of frost-bites was enormous. It was no uncommon 
sight to see on removal of the dressings that the whole limb 
was gangrenous, such cases being, of course, most fatal. With 
the first frost came a heavy fall of snow, which necessitated 
all the wagons being put on runners. This rendered the in- 
convenience less, as the wagons traveled more easily. 

The total distance from front to rear was about 90 kilome- 
tres, a journey of about twelve hours posting, but which occupied 
even as long as four days by these wagons which were thus 
obliged to spend from one to three nights on the road, and the 
accommodation at the rest stations was not one hundreth part 
enough. At the midway halting place, for instance at the top 
of the Dragoman Pass, not more than ten beds were to be got, 
and the demand for men at the front left no means of enlarg- 
ing these buildings. At all of them there was a doctor, who 
did what he could for those requiring his assistance, although 
at one station I went over, the doctor in charge had only two 
instruments, a pair of tooth forceps and a scalpel. 

Now at the end of November, however, relief was at hand. 
The German, Austrian, Hungarian, English and Roumanian 
Red Cross Societies sent out their ambulances all provided 
with surgeons, assistants, nurses and equipments. 

The Austrian and Hungarian ambulances had most excel- 
lent wagons, and brought their own horses. They were thus 
able to set to work at once. They divided the work between 
them in such a way that the Austrian wagons, which were con- 
structed for the conveyance of wounded on more or less level 
ground, took that portion commencing at the summit of the 
Dragoman Pass, the Hungarian wagons being of lighter build, 
and on very strong springs, doing that to which their ambu- 
lances were more suited, /. e., the mountain roads and passes 



384 



R. LAKE. 



from Pirot to Dragoman, Now there was no longer necessity 
for increased accommodation. The journey took from 24 to 
36 hours under these more favorable circumstances, thereby 
greatly diminishing both the mortality and suffering. 

Early in December the Red Cross surgeons were working 
hard, having completed their arrangements ; most of the cases 
had been in hospital some weeks by this time, and much valua- 
ble time has been absorbed in rendering the various hospitals 
less septic. 

When operating commenced it was found that the patients 
would as often as not refuse permission to the surgeon to am- 
putate, whereon the surgeons went to the council for help. A 
law was passed to suit the case, which said that if three medi- 
cal men agreed that it was necessary for a patient to undergo 
a capital operation, and refused his consent, that the opera- 
tion might be done without or rather against his consent. 

With regard to the temporary hospitals there is really but 
little to say, as they were all large, fairly well ventilated, pub- 
lic buildings, and with the exception of the water supply and 
drainage were as good as could be expected. The cold ren- 
dered an important service in preventing any decomposition in 
those things capable of putrefaction left about by the Bulgars, 
who have not much idea of cleanliness. 

Overcrowding in hospitals, except at the front and at short 
intervals, was not common, and often then on account of the 
laziness of the chief of the hospital. In my hospital of 60 
beds the assistance in the nursing line was fairly typical of 
what one would expect of untrained though kind women; they 
attempted what they were asked, but without intelligence or 
understanding the reason of what they did. 

Pyemia and its allied diseases were, so far as I could learn, 
rare. This may have been from the fact that the more weakly 
and worse injured died en route. Still blue pus and foul smelling 
wounds were the rule when I started work. 

There was scarcely a single primary operation of any magni- 
tude done during the campaign, only a few minor primary be- 
ing done at all. 



SERVO-BULGARIAN WAR HOSPITAL SERVICE. 



385 



Servia. 

On account of the reverses they had suffered the Servians 
refused permission to the Red Cross surgeons to go beyond 
Belgrade, effectually preventing any knowledge of the real 
state of the wounded at the front and at Nisch. There is good 
reason to believe the state of affairs was worse even than in 
Bulgaria, during and after the battles of Slivnitza, Dragoman 
and Pirot. 

Here, however, the Red Cross was earlier on the field, on 
account of the greater facilities of getting to Servia; an Aus- 
trian train belonging to and worked by the Knights of Malta 
under Baron Mundi came also at this time. 

MAP OF THE SEAT OF WAR. 




Showing Hospital Accommodations. 

This train is constructed on the most improved and 'perfect 
system of railway ambulances. Capable of being run on all 
continental hnes, as the gauge is everywhere similar. It was 
complete in all its minutest details, and by aid of ordinary car- 
riages they conveyed as many as 300 wounded, who were sup- 
pHed with three cooked meals a day, that being about the time 
occupied by the journey from Nisch to Belgrade. 

The train consisted of wagons to carry the wounded, each 
with its heating apparatus, and also kitchen wagons, a store 
wagon and a dispensary. 



386 /?, LAKE. 

The medical men in charge of the train found a large num- 
ber of wounded with a ligature round the wounded limb, no 
other means having been tried to stop the haemorrhage, and 
this had often been on for days. It was often too late to save 
the limb when they came under his care. The hospitals and 
the hospital organizations were good ; for many reasons better 
than at Sofia, for the town itself was larger and the war had 
never been so close. Therefore more time was available, and 
the public buildings and schools were often larger and more 
suitable than those at Sofia. There was also a very useful sup- 
plement to the nursing department in the form of a staff of 
dressers. It consisted of two parts, one of a certain number 
of medical students and the other of school boys. This was a 
very great improvement on the Bulgarian dressers. Amongst 
the Servian wounded it was most noticeable that a large per- 
centage were wounded in a peculiar way. It is a well-known 
fact that when hand wounds occur behind entrenchments the 
left hand, and especially the index finger and thumb of that 
hand, suffer most frequently. These men were shot so that 
the bullet wounded the index finger on the right hand (the 
trigger finger) or passed between it and the next, or through 
the palm. This was the class of wounded most frequently at- 
tacked by tetanus. I had two cases; one was rapidly fatal, but 
the other recovered without any operative treatment. Prof. 
Mosetig treated his cases by amputation above the joint on 
the proximal side of the lesion and stretched all nerve trunks. 
He also treated three cases of traumatic aneurism most suc- 
cessfully, one subclavian and one brachial, by incision of the 
sac and evacuation of its contents, and then plugging the sac 
by iodoform tampons, which were allowed to separate of them- 
selves, in no case was any ligature applied to the main trunk. 



AN h\I PROVED TROCAR. 387 

AN IMPROVED TROCAR FOR PARACENTESIS AB- 
DOMINIS. 

By JOHN S. MILLER, M.D., 

OF PHILADELPHIA. 

ASSISTANT TO THE SURGICAL CLINIC, JEFFERSON MEDICAL COLLEGE HOSPITAI^ 

THE frequent occlusion of the canula by intestine or omentum in 
the operation of tapping has suggested the devise shown in 
the accompanying cut. The stoppage generally occurs when about 
a pint of fluid has been withdrawn, and various manoeuvres are resorted 
to, such as the endeavor to float away the obstruction by changing 
the patient's position, or the dangerous one of introducing a probe 
through the canula — and generally Avithout success. 




The device to which reference has been made, is a smaller and lon- 
ger canula introduced into that already in position in case there is a 
cessation of flow. 

It is blunt and provided with two long fenestra. In the latter are 
springs which expand and push away the obstruction on emerging 
from the original canula, and which are so solidly soldered as to offer 
no danger of breaking off in the abdominal cavity. In reply to the 
query whether or not the gut can become incarcerated and wounded 
in the springs it may be stated that in several operations no such acci- 
dent has occurred, nor were efforts successful to bring such about upon 
the recent cadaver. The instrument can be used with any trocar and 
canula above calibre sixteen — French. The instrument is manufac- 
tured by Chas. Lentz & Sons, 18 N. Eleventh St., Philadelphia. 



EDITORIAL ARTICLES. 



SURGICAL TREATMENT OF MALIGNANT TUMORS OF THE FAUCES. 

Castex contributes to the Revue de Chirurgie a series of articles on 
this subject which amounts to an elaborate treatise of such value as to 
merit an extended review. Professional opinion has undergone a 
marked change regarding the surgery of this perilous region within a 
few years, and doubdess, as the experience of operators increases and 
the practicability of extirpation of the neoplasms of the fauces becomes 
generally accepted, many lives will be saved, or, at least; considerably 
prolonged, which now are lost through the ignorance and timidity of 
surgeons. Blandin condemned the stupid rashness of any attempt at 
removal of the malignant tonsil, and a few years later invented a pro- 
cedure for this very purpose. Many surgeons have essayed the oper- 
ation, and Castex has, within two years, collected reports of thirty-five 
cases of the disease, eleven of which were under his own observation. 
His opportunities have been large, and his study of the hterature of 
the subject thorough. 

The beginning of these growths is generally insidious, and the phy- 
sician is quite hkely to prescribe chlorate of potassium ; the patient is 
fortunate if he escapes cauterization with nitrate of silver. 

Curiously the difficulty and pain in swallowing disappear in many cases 
and the patient forgets his trouble, until four or five months afterward, 
he notices a swollen gland at the angle of the jaw, and the case may 
have progressed beyond the point of justifiable operation. 

All the parts of the fauces do not display an equal tendency to the 
development of malignant tumors. The tonsil is the point of least re- 
sistance in this respect. Of thirty-one cases in which the starting- 
point was observed, in twenty-one the tonsil was the part invaded first. 
Involvement of both tonsils is very rare. When the case is not seen 



SURGICAL TREATMENT OF MALIGNANT TUMORS. 3^9 

early, the tonsil is usually found to be more extensively destroyed than 
any other part. Next to the tonsil the anterior pillar is most suscepti- 
ble to attack. 

Necropsies are rarely made, and very few histological observations 
have been recorded. Castex has made a particular study of the nor- 
mal anatomy of the parts. The tonsil is very nearly opposite the an- 
gle of the jaw. He regards it as an agglomerate gland, and calls at- 
tention to the fact that there are minature tonsils in the faucial depres- 
sion, which satellites are probably the seat of the nodular growths around 
the principal tumor. Luschka discovered the pharyngeal tonsil in 
1856 ; Gerlach has recently found a similar structure around the orifice 
of the Eustachian tube. There is also a series of isolated glands behind 
the circumvallate papillae of the tongue, connecting the two principal 
tonsils, and meriting the name of the lingual tonsil. Between these 
various glands there is lymphoid tissue, but no distinct eminence of it, 
and on the inferior and middle turbinated bones and the posterior 
wall of the pharynx there are islets of the same, which are comparable 
to Peyer's patches. Thus is formed what Waldeyer has designated the 
lymphatic ring of the throat. The lymphatic vessels of the tonsils are 
numerous and large, and, according to Cruveilhier, empty into the 
glands at the angle of the jaw. 

The malignant tumors of this region vary in character. Most au- 
thors consider encephaloid as the most common, obviously because 
they include under this head all tumors which have a cerebriform ap- 
pearance, such as lymphadenomata and lymphosarcomata Unfor- 
tunately microscopic examinations have been so infrequendy made 
that it is impossible to state positively the relative frequency of the 
different varieties. In the observation of Castex, epitheliomata are by 
far the most frequent. 

Heredity is believed to have httle, if any, influence on the develop- 
ment of these growths. They have been seen in persons of various 
ages from 7 to 82 years. Epithelioma and carcinoma are more fre- 
quent in adults, sarcoma in the young. But a small proportion of the 
victims are females. The alleged influence of tobacco-smoking may 
well be doubted. The coincidence of buccal epithelioma and diabetes 
has been noticed. 



590 EDITOR J AL ARTICLES. 

These tumors manifest themselves by various symptoms- In the 
throat there may be abnormal sensations — distress in swallowing 
sohds, especially in the second stage of deglutition ; in some cases 
there is no pain, but a distressing dryness ; in others there is excessive 
formation of saHva. Pain is not often excited by swallowing sahva, 
but is caused by pressure at the angle of the jaw. Frequently there is 
less pain after the surface of the tumor has been removed by ulcera- 
tion. Meantime pulsating or lancinating pains occur in the head, 
neck and face, and especially in the ear, The aural pain, occurring in 
different diseases, often diverts the attention of the physician from the 
throat. The voice is altered, the degree of change depending on the 
size of the tonsil, the amount of salivary secretion, and the involvement 
of the veil. One of the saddest complications is the ptyalism, which 
at first is an inconvenience only after eating, but later is constant and 
may be prodigious, seriously impairing speech. Difficulty in swallow- 
ing is marked, and, unless care is exercised, liquids may be ejected 
from the nose. As some patients have no pain during deglutition 
though great trouble in the performance, Castex proposes the word 
odynophagia to designate painful swallowing, as distinguished from 
dysphagia or difficult swallowing. Haemorrhages are infrequent, at 
least before the last stages, and are commonly insignificant. The 
breath is rarely fetid, excei)t in the advanced condition of the disease. 

Great care is necessary in the examination of the fauces and neigh- 
boring parts of the pharynx. (Would that we had an English word 
exactly corresponding with the French arriere bouche) '. Natural light 
is the best. When the patient opens his mouth, he should be asked 
to show his teeth so that the lips may be fully separated. The left fore- 
fingei should then press back the right labial commissure in order to 
expose the throat to oblique illumination, thus permitting the examiner 
to place himself in front without intercepting the light. Frequent ob- 
servations are desirable. Depression of the tongue is sometimes im- 
possible, because its vertical portion has already become hardened, 
and sometimes because it is exquisitely tender. 

The tonsil may be greatly enlarged. It is sometimes cracked, and 
then it is difficult to distinguish the disease from syphilis. It may be 



SURGICAL TREATMENT OF MALIGNANT TUMORS. 39 ^ 

lobulated or it may have disappeared by ulceration. If the tumor has 
invaded the surrounding parts, it is elevated as it hardens, and leaves 
the tonsil in a pit. The anterior pillar becomes thick, short, shriveled 
and hard. Then the tongue and the veil of the palate are invaded. 

Having acquired a certain volume, the neoplasm begins to break 
down. It resembles a mush-room, its borders spreading out under the 
veil, the pedicle being concealed. It often becomes lobulated, owing 
probably to the movements of the tongue, and assumes a grayish hue. 
The ulceration looks Hke that in cancer of the tongue ; there is rarely 
a granulated surface ; the edges are red ; the sore is covered with a 
gray, pulpy glaze, which gets onto the teeth and tongue. The disease 
is not entirely confined to the principal tumor. Around it at 
various points may appear spots of the same character, though sepa- 
rated by areas of seemmgly healthy tissue, which, however, are soon 
involved and become part of the main cancerous mass, and others 
come into view outside the increased Umits. 

It is very important to examine every part with the pulp of the fin- 
ger. Pain is produced by the digital touch, but all the region has lost 
its reflex sensibility, and occasionally is analgesic, as if it had been 
treated with cocaine. It is difficult to ascertain the degree of density 
of growths on the veil on account of its motion. 

The most common seat of lymphatic involvement is at the angle of 
the jaw. The discovery of a hard gland at this spot should lead im- 
mediately to an examination of the fauces. These glands only excep- 
tionally suppurate. Sometimes nodules are found in the submaxillary 
region; they are hard, movable and painful. At this time excision 
offers a chance of success. Gradually almost all the other lymphatics 
in the neighborhood are invaded. 

The general health may not be affected for a long time, but some 
patients decline rapidly, because they deny themselves food in order to 
avoid odynophagia. 

The progress is usually steady, but there are periods of arrest, es- 
pecially between the appearance of the tumor at the angle of the jaw 
and the enlargement of the cervical glands. The veil is particularly 
liable to involvement, and the disease extends from it down the an- 



392 EDITORIAL ARTICLES. 

terior pillar and involves the tongue. The posterior nares and the 
larynx are rarely affected. After a long time the hypertrophied glands 
may become sarcomatous. The dangerous period begins when the 
gland capsule breaks down ; then removal is imperatively demanded. 
The duration of the disease is extremely variable. It may be five 
years or only a few months, according to the nature of the tumor and 
the constitution of the individual. The mode of death is equally un- 
certain. Haemorrhage quite often ends the scene, coming from' the 
branches of the external carotid. The internal carotid is not as near 
the tonsil as certain unfortunate accidents of tonsillotomy suggest ; it 
is two centimetres from the outer surface of the gland. 

In making a diagnosis, we should be suspicious of unilateral hyper- 
trophies of the tonsil in mature patients, especially as atrophy is the 
rule at this time of life. Pain and soreness in the throat should never 
be disregarded. Infecting chancre, which Diday considers not rare on 
the tonsil and soft palate, may be recognized by its subacute progress, 
the pre-auricular adenitis, its singleness, its regular, oval or circular 
form, the evenness of its bottom and edges, its occurrence in young 
women, and its rapid cicatrization. The diagnosis is far less easy in 
some of the secondary manifestations of syphilis. Mucous patches es- 
pecially are liable to be mistaken for epithehoma. In a general way, 
when the ulcer has a grayish bottom, is indolent, and is not accom- 
panied by lymphatic enlargement syphilis is to be suspected. Tuber- 
culosis of the pharynx is distinguished by absence of induration and of 
large lymphatic tumors Tuberculous ulcers generally do not bleed, 
and the surface is granulated, as that of cancer is not. Scrofulides 
display irregular, granulating plates with cicatricial points, or an un- 
even, serpentine ulceration, or several small, jagged ulcers, eating be- 
neath the surface ; marks of scrofula will be present elsewhere. The 
microscope does not furnish means for perfect diagnosis between sim- 
ple and maHgnant hypertrophies of the tonsil. 

Epithehoma is characterized by early ulceration on an indurated 
base, and by the slowness of its extension and of its involvement of 
lymphatic glands. Lymphadenoma and lymphosarcoma are cerebri- 
form, of large volume, quickly adhere to the vessels, grayish, and but 
sHghtly 'ender. True carcinoma is very rare. 



SURGICAL TREATMENT OF MALIGNANT TUMORS' 393 

When the growth is circumscribed, the lymphatics are not involved, 
and the general condition is good, all surgeons are agreed that the tu- 
mor should be removed : but when the disease has invaded the walls 
of the pharynx and the neighboring glands, there is room for a ques- 
tion as to the propriety of an operation. Each case must be treated 
on its own merits, as in mammary cancer. If the tonsil and a part of 
the soft palate are involved, ablation is called for, especially if the 
growth has been slow. Operation is permissible even if the lymph- 
glands at the maxillary angle are impHcated, provided they are mova- 
ble. But when their mobility is lost, when the lymphatics in the caro- 
tid and subclavian triangles are affected, operation is contraindicated, 
because it only hastens the growth of the tumor. Cachexia and rapid 
growth absolutely prohibit the use of the knife. Even if the surgical 
procedure does not cure where it is permissible, it relieves the pitiful 
condition of the patient, saving him the pain in the ear, odynophagia, 
haemorrhage, dyspnoea, and the swallowing of putrid discharges from 
the ulcer. 

Many different methods of operating have been tried. Chloroformi- 
zation is often difficult on account of the tendency to suffocation. Pre- 
liminary tracheotomy expedites the process and saves much trouble, 
closing the windpipe against the entrance of blood, especially when 
the instrument of Trendelenburg is used. Antecedent ligation of the 
carotid is considered indispensable by Polaillon, as it greatly lessens 
haemorrhage, and sometimes diminishes pain. 

In the removal of the tumor, there have been used the ecraseur, 
thermo-cautery, galvano-cautery, and cutting instruments, but the last 
two are best. When the growth is not very large, is movable, and the 
glands are not involved, the operation should be done through the 
mouth. The knife can be used. LeFort removed a cancer which in- 
volved the tonsil and part of the base of the tongue by passing curved 
needles under the tumor and applying the loop of a galvano-cautery 
beneath them. Ordinary means will control the bleeding. There is 
not much danger of wounding the internal carotid. When the opera- 
tion can not be performed through the mouth, an artificial opening 
must be made. Jeeger practised incision of the cheek on the affected 



394 EDITORIAL ARTICLES. 

side in direct continuation of the line of the mouth. Polaillon hgated 
the external carotid, and then joined the upper end of this incision to 
the angle of the mouth by a horizontal cut, making a flap which he 
turned downward and forward towards the hyoid. With the chain saw 
he divided the lower maxillary at the right of the symphysis and across 
th i of the ramus. This portion of bone being raised, he could 

reach the tumor. He passed a platinum wire through the tongue from 
a little above the great horn of the hyoid to the apex of the lingual V ; 
a second loop was placed below the tonsil from the base of the tongue 
to the pharjmx ; and a third behind the tonsil cut the wall of the 
pharynx. The tumor was removed ; the haemorrhage was great ; the 
cheek was sutured ; no drain was used. One carbolized sponge was 
placed inside, and one outside, fastened together by a thread passing 
through the wound ; the inner one was taken out the next day. The 
wound healed admirably, and the patient left in twenty days, able to 
swallow liquids and semi-sohds perfectly. Polaillon has also practiced 
a semi-circular incision over the posterior and lower borders of to the 
lower jaw-bone, to circumscribe the tonsillary fossa. A modification 
of this consists of two horizontal incisions united by a vertical which 
follows the parotid border of the jaw. Cheever extirpated the tonsil. 
He made a horizontal incision on the lower edge of the jaw, cut the 
bone in front of the masseter, drew out the tonsil with his finger, all 
without hurting a nerve or important vessel, then sutured the pieces of 
bone, and left an opening for discharge. In another case, he carried 
his incision from the end of this first along the anterior border of the 
sterno-mastoid. The incision along the base of the jaw allows one to 
pass under the parotid, between the submaxillary and the carotid ves- 
sels. Maunoury, in a case of epithelioma of the veil, anterior pillar 
and back part of the gum, made a vertical incision from the corner of 
mouth down to the lower edge of the jaw, and a horizontal cut to its 
angle. Israel, in a case of epithelioma of the third part of the pharynx, 
which was attached to the back of the pharynx, made a preliminary 
tracheotomy, and, three days afterwards, made an incision from the 
base of the jaw, two fingers' breadth in front of the angle, to the upper 
part of the trachea. The larynx was turned around on its axis, and 



SURGICAL TREATMENT OF MALIGNANT TUMORS. 395 

made to present its posterior face, which was then freed from the tu- 
mor. Death occurred in seven days from gangrenous retro-laryngeal 
abscess. Bilh-oth performs pharyngotomy by a cut along the anterior 
border of the sterno-mastoid. Blandin and Dumarquay, when the 
tumor is too large to be removed through the mouth, open in at the 
same point, an assistant drawing back the important vessels. Duplay 
recommends Malgaigne's subhyoid pharyngotomy, in which an incision 
five centimeters long is made along the lower border of the hyoid, thus 
escaping the superior laryngeal vessels and nerves. 

The following examples of large operations are given because they 
were brilliantly successful. In 1882 Labbe reported a case of epithe- 
lioma of tonsil, veil, neighboring pharynx, part of tongue and floor of 
of mouth. He made a preliminary resection of the inferior maxillary, 
and totally ablated the growth with the thermo-cautery. Two objec- 
tions may be raised to this mode of proceeding : (i) the absorption 
of septic products which form on the eschars, which, however, may be 
remedied by frequent antiseptic washing and leaving an aperture to 
the outside for a drainage tube ; (2) the difficulty of alimentation, 
which Labbe overcame with the tube of Faucher. In 1884, Navaro, 
Turin, removed from a female, aet. 45, the lower part of the pharynx 
and upper part of the gullet. Five months afterwards she could take 
sohd food, was m good condition, and the disease had not returned. 
One of the most extensive operations attended with good results was 
made in 1879 by Caseli, of Genes, on a girl stx.. 19, who had epithe- 
lioma of pharynx, uvula, tonsils, base of tongue and part of larynx. 
There was no lymphatic enlargement, and the general condition was 
good. Preliminary tracheotomy was practised with the galvano-cautery 
and the tube of Trendelenburg was inserted. Tthe incision extended 
from the symphysis to the sternum. The larynx and pharynx were de- 
tached at the level of the cricoid cartilage, the hyoid was cut in the 
middle, the base of the tongue was extirpated, the pharynx entered, 
all the soft palate detached, the pharjmx amputated above, and the 
tonsils removed. An oesophageal tube was inserted, and three-quar- 
ters of the wound closed. Less than two ounces of blood was lost. 
The operation lasted over three hours. The points of chief difficulty 



396 EDITORIAL ARTICLES. 

were the isolation of the larynx, so as not to injure the carotids and 
vagi, and the extirpation of the tonsils. Union was complete in 
one month, and in anctther the patient could swallow solids and H- 
quids. 

These operations are merely palHative, but in such tumors as sar- 
comata they prolong life and make it fairly comfortable. When the 
recurrence takes place, the patient suffers less than at first, because 
the parts invaded are less sensitive than the mucous parts at first at- 
tacked, and the tumor no longer presents retracted or bulging surfaces 
tor the bolus of food to irritate. If the disease returns in the glands, 
the pain is less acute. Cachexia reduces the painful excitement of the 
nervous system. As Gosselin says, it is better to substitute a wound 
which the patient sees healing, than to allow him to observe constantly 
a growing disease. It is easier, also, to deceive the patient about the 
return of the disease, than about the character of the disease at first. 
If death by haemorrhage threatens, the ligation of the common carotid, 
after Weiss, should be practised. 

As regards medication, syphilitic treatment should be given in 
doubtful cases. Arsenic is employed by Verneuil and Bourdon, but is 
principally useful through its moral effect. Applications of cocaine 
are serviceable. 

Castex sums up as follows : 

MaHgnant tumors of the tonsillar region are most frequently epithe- 
liomatous, and the tonsil is their usual point of departure. They gen- 
erally attack adults rather than children. The chief functional symp- 
toms are ear-pain, salivation, dysphagia and odynophagia. The 
objective characteristics are tendency of the ulceration to spread 
rather than to go deeply, grayish and pulpy deposit covering the ulcer; 
crushed forms or scattered spots sometimes covering the growth ; an- 
aesthesia to touch ; angular glandular enlargement. The general 
symptoms appear late. The progress is not steady. Some epitheli- 
omata bore through the base of the skull. Adenomata of the veil, 
at first encapsulated, may break out and become sarcomata. Early 
diagnosis is very important, and in elderly people unilateral tonsillai 
hypertrophy is suspicious. The principal disease with which it 



EXCISION OF THE LAR YNX. 397 

liable to be confounded is syphilis, especially chancre of the tonsil. 
The rules for surgical interference are (i) when the neoplasm is cir- 
cumscribed, and the lymphatics are not involved, operate ; (2) when 
the tumor, more extended, but still circumscribed and movable, is ac- 
companied by secondary lymphatic disease, operation is justifiable, 
intervention being useful more generally than harmful ; (3) when the 
involvement is greater, interference, though only palliative, is permis- 
sible, if certain conditions obtain, intolerable pain, intention of suicide, 
etc. The operation has a preliminary and a fundamental stage. It 
may be done through the natural or artificial passages. An opening 
for drainage should always be provided. Generally if the operation is 
early and thorough, the prolongation of life is satisfactory. 

F. H. Gerrish. 



EXCISION OF THE LARYNX. 



Le Progres Medicale of March 27 and April 10 of the present year, 
contains an exhaustive memoir by M. Baratoux, on the subject of "Ex- 
cision of the Larynx." This may be considered as supplementing the 
contribution on this subject by Hahn (see Annals of Surgery, Vol. 
III., No. I., P. 67, January, 1886) and should be studied in connec- 
tion with it. Hahn published a Ust of ninety-one cases, together 
with eleven hitherto unpublished cases of his own. Baratoux has as- 
sembled 104 cases for the purpose of his study. The contributions 
of Gerster, Park and Lange, in the number of the Annals of Sur- 
gery, above referred to, should also be considered in this connection. 
The substance of Baratoux's memoir is as follows : 
History. — Until Levret, tumours of the larynx were left to nature. 
Desault was the first to propose the removal of laryngeal neoplasms . 
he described laryngotomy, but never practiced it. The first attempt 
of the kind was made by Braiiers, of Louvain, in 1833, and since that 
time the operation has been many times repeated. In 1829, Albers, 
of Bonn, in experimenting to establish at what point the larynx par- 
ticipated in respiration, removed a part, and even the whole of the lar- 
ynx of dogs ; but his two experiments were not encouraging, for one 



39^ EDITORIAL ARTICLES. 

of the animals died of haemorrhage during the operation, and the 
other sank from inanition nine days afterwards. In 1854, Langenbeck 
having been consulted by a patient with malignant tumour of the lar- 
ynx, discussed in one of his clinical lectures, the operative procedure 
of extirpation of the larynx, but the invaUd refused the operation. 
Later Koeberle stated that he would not hesitate to excise the vocal 
organ in a case of cancer, " because," said he, " it would be more 
serviceable to have recourse to the operation, rather than not to inter- 
vene at all." Hueter also attributes to himself priority in the opera- 
tion, which he intended to employ in the case of a woman with cancer . 
of the arytenoid mucous membrane. He was going to do a prelimi- 
nary tracheotomy, when the patient died. In 1866, Patrick Heron 
Watson, of Edinburgh, having to treat a patient with tertiary syphilis, 
and destruction of the lar3mgeal cavity, determined to excise the lar- 
ynx. The patient died of pneumonia three weeks after the removal of 
his vocal organ. 

Ignorant of this a*:tempt, Czerny, of Heidelberg, wished to assure 
himself that removal of the larynx did not imperil the life of animals. 
His first experiments were not fortunate, for one of his dogs died at 
the end of two days, two others after fifteen days, and the last at the 
end of the fourth week from asphyxia due to displacement of the can- 
ula. In a later experiment, Czerny performed a preliminary tracheot- 
omy, and when the trachea had become adherent to the skin, he did 
the excision. Making use of canulae of larger calibre, he had nothing 
more to fear from displacement of the tube, which had been the cause 
of his first failures. Czerny's method of operating is the following : 
The animal being anaesthetized, he incises the skin in the median line 
from the hyoid bone to the tracheal fistula; then with a blunt instru- 
ment he detaches the soft parts ; he only uses the bistoury to divide 
the thyro-hyoid and sterno-thyroid muscles at their insertion to the thy- 
roid. He then cuts the trachea below the cricoid, and introduces into 
it a smooth caoutchouc tube with thick walls, in order to hinder the 
entrance of blood, and also to allow of the continuance of the anaes- 
thetic inhalation. By drawing up the larynx he separates it from the 
oesophagus in order to dissect its posterior surface as far as the point 



EXCISION OF THE LAR YNX. 399 

of the arytenoids ; cuts the large cornua of the hyoid bone, and di- 
vides the larynx parallel to the upper border of the thyroid. In his 
five operations, Czerny left the epiglottis in place ^\dth the aid of a 
suture. In his other experiments he removed it, and from the follow- 
ing day the dog could easily swallow food. This operator does not 
doubt that the excision may succeed in the case of man — provided the 
patient be nourished by means of an oesophageal tube for a few days. 
Later speech can be restored by emplojring an artificial larynx, per- 
mitting the air to pass through the mouth and nose. In putting this 
last idea in practice in dogs, Czerny proved that he could thus re- 
estabhsh the function of the vocal organ. A short time afterwards, on 
the 31st of December, 1873, thanks to Bilhoth, of Vienna, excision of 
the larynx was admitted to surgical practice. The following table 
gives a resume of the excisions which have been performed since the 
first operation. 

Up to the present time there have been 102 excisions — 73 for can- 
cers or epithehomas, 10 for sarcomas, 10 for stenosis, necrosis, poly- 
pus, and 9 for affections, the nature of which we do not know — proba- 
bly, however, epitheliomatous or sarcomatous tumours. Of these 
nine the operative procedure and results are not given in 5 cases. 
There remain, therefore, 97 cases which we may analyze. The ex- 
cision was total in 83, and partial in 14. 

The total excisions were : 











Result 






Cures. 


Deaths. 


Unknown, 


For epitheliomas or cancers, 


69 


21 


47 


I 


sarcomas. 


9 


2 


7 





contractions, necrosis, etc., 


4 


I 


3 





diseases unknown. 


I 





I 






Total, - - - 83 24 58 I 

In these statistics we include as cured 5 cancerous cases of which 
the results were reported less than two months after operation, and 
two ot them were only operated on quite recently. 



400 



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EXCISION OF THE LATYNX. 



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EXCISION OF THE LAR YNX. 



409 












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410 EDITORIAL ARTiCLES. 

The partial excisions were: 









Cures. 


Deaths. 


For epitheliomas, 


- 


4 


2 


2 


sarcomas, 


- 


I 


I 


o 


contractions, necrosis, etc., 


- 


6 


2 


4 


unknown affections, 


- 


3 


3 


o 



Total, - - - - 14 8 6 

Excision of the larynx has thus given us 32 cures and 64 deaths. Of 
49 deaths following the operation for cancers, 2 succumbed on the 
second day (collapse, shock), 3, of which i was a partial excision, on 
the third day (collapse, pnaumonia) ; 6 on the fourth day (collapse, 
pneumonia, haemorrhage, asphyxia) ; 4 on the fifth day (pneumonia, 
pleurisy, haemorrhage), 6 at the end of a week (pneumonia, embohsm, 
exhaustion), 7 at the end of a fortnight (pneumonia, gangrene, phthi- 
sis, haemorrhage), one on the twenty-fifth day (pneumonia), one at the 
end of a month (pneumonia), 3 in the second month (pneumonia, re- 
currence, slip|)ing of the tube), one in the third month (pneilmonia), 
4 in the fourth month (pneumonia), 3 in the fifth, 2 in the sixth, in the 
seventh and in the ninth, one at the end of a year, and one lastly 
after two years. This one had been operated on partially for carci- 
noma, which returned about the sixth month. Of the 7 sarcomas op- 
erated on by total excision, one died on the seventeenth day, the 
second in the third month (pneumonia), the third in the seventh 
month (recurrence), the fourth in the eighth (pneumonia), the fifth at 
the end of a year (accidental pleurisy), the sixth in the fifteenth month 
(recurrence), and the last at the eighteenth month (pulmonary tuber- 
culosis. Of the 7 deaths among cases of the contractions, necroses, etc., 
the 3 operated on by total extirpation succumbed — one on the fifth day, 
the second at the end of a month, and the last at the fifteenth month of 
marasmus, pneumonia and tuberculosis respectively. As regards the 
partial operations, one died on the third day, the second at the second 
month (diabetic slough), the third after two and one-half months (ex- 
haustion), and the last in the eleventh month (progress of the disease), 
We only know of one death on the fourth day in a patient from whom 
the larynx was totally excised for an afleciion not stated (cancer or sar- 
coma). 



EXCISION 01 THE LARYNX. 4II 

The 32 cures are thus composed : Twenty-three lor epithehomas, 
ot which 21 were total excisions and 2 partial, dating irom 4 years, 2 
years, 19, 18, 17, 16, 14 (2, of which one was a partial extirpation); 
12 (one;, 11, 8, 5, 4 and 2 months (2 cases); (in the 7 remaining ep- 
itheliomatous cases we only know the result for a few weeks) ; 3, for 
sai comas, with two total and one partial excision — going back to six 
years, five years and three years (the partial) ; 3 for contractions, ne- 
croses, etc., of which one was total (polyp) and 2 partial (papilloma 
and stenosis consecutive to typhoid fever), and 3 for affections of which 
we do not know the nature (cancer or sarcoma). These were partial 
excisions — performed the one two years ago, the others only a few 
months. 

In comparing the proportion of deaths and cures we see that for epi- 
thelioma — without regarding the five latest excisions, of which our in- 
formation does not extend for more than two months, and one case, 
the end of which is unknown to us, there were 47 deaths and 15 cures, 
that isito say that cures only resulted in a quarter of the cases, if we 
may consider those operated on for two months to a year. A third 
of the patients operated on died in the first week' from shock, exhaus- 
tion, pleurisy, pulmonary embohsm, haemorrhage (twice), collapse (3 
times), pneumonia (11 times). In the first month there were 8 
deaths — that is to say, that a fifth of the survivors succumbed — 6 from 
pneumonia, and in the five following months the mortality was 12, 
from pneumonia, recurrence, etc., /. e., more than a third of the 
remaining survivors. 

The results in the sarcoma cases were more favorable, since in the 
seven fatal cases five patients lived from seven to eighteen months. 
Here cures resulted in nearly half of the cases. But of the six cases 
operated on for contractions, stenoses, etc., five Hved for less than three 
months, one less than for six months, and the last less than a year. 

Hence in the excisions of the larynx death has supervened before 
the sixth month in more than two-thirds of the cases — if we except, 
however, the sarcoma cases, in which only twice a similar rapidity of 
mortality has been noted. 

In partial excision success has been obtained twice in three times, 



412 EDITORIAL ARTICLES. 

whilst in total excision death has taken place in more than two-thirds 
of the cases, half of the patients not hving beyond the fourth month. 

Indications. — Total excision of the larynx appears to be indi- 
cated in the case of maHgnant neoplasms which, having invaded more 
than half of the organ, have spared the neighboring parts. Patients 
too advanced in age should not be operated upon. One of Hahn's 
patients, however, set. 67, was cured without any accident, surviving 
three and one-half years after operation. 

Excision is contra- indicated in all cases of benign growths, papil- 
lomas, perichondritis, or necrosis of the cartilages, and in cases where 
mahgnant tumours have invaded the neighboring tissues or organs at 
a distance. The operation should also be refused when the patient 
is the subject of a serious disease. 

Partial excision is preferable to total, in so much the more that re- 
currence is not more frequent in the first than in the second. It must 
also be considered that with partial excision the patient can dispense 
with the canula. He can then speak with a bass pharyngeal voice, 
and in certain cases, even-a new glottis is formed. On the one side 
is a vocal cord and on the other a cicatricial tissue replaces the cord, 
producing a laryngeal voice far superior to that of all the artificial lar- 
ynges. Partial excision will be employed in all the cases of malignant 
growths which do not extend beyond half the larynx, in certain con- 
tractions due to a fibrous transformation of the tissues, and to hyper- 
trophy or ossification of the cartilages, hindering the use of the ordinary 
methods of dilatation. But this operation should not be resorted to 
for the cure of simple contractions, papillomas, perichondritis and ne- 
crosis of the cartilages. 

Operative Procedure. Preliminary Tracheotomy. — In the greater 
number of the cases, tracheotomy was preliminarily performed, either 
on account of dyspnoea, or specially in view of the excision of the lar- 
ynx, as Czerny advised, or again in order to remove a laryngeal tu- 
mour without extirpating the organ itself. It has been maintained 
that tracheotomy performed about two weeks before the excision, per- 
mitted the patient to regain strength, that it habituates the mucous 
membrane of the air passages to the direct action of the air, and to 



EXCISION OF THE LARYNX. 4^3 

the tickling produced by the canula, that it had the advantage of fixing 
the trachea solidly to the integuments, and of preventing a too great 
sinking of the aerial tube, and a flow of blood and pus into the tra- 
chea during and after the operation. By means of it also anaesthesia 
can be maintained during the whole operation. 

Aiiathesia. — Surgeons have generally anaesthetised the patients with 
chloroform, with the mixture of alcohol, ether and chloroform or by 
means of bichloride of methylene (Heine). A certain number have 
used, besides, subcutaneous injections of morphine. Bottini has pro- 
posed to employ ether spray on the skin, but he was incommoded by 
the resistence and movements of his patient, whom he had not put to 
sleep. If prehminary tracheotomy has not been already performed, it 
must be done as low down as possible, and then the plugging of the 
trachea must be effected. 

Fhigging. — After removirg the canula and enlarging, if necessary, 
the tracheal opening, the canula-plug of Trendelenbourg is in- 
troduced. This is composed of a caoutchouc cylinder fixed below to 
an ordinary canula which carries a tube terminating above in the interior 
of the cylinder and below in a caoutchouc bag which allows inflation 
when the canula is in place. Trendelenbourg's plug,applied to the in- 
ternal wall of the trachea, prevents the blood from penetrating into the 
air passages, while it leaves the respiration free through the tracheal 
canula. A cHp, fixed on the india-rubber tube through which the plug 
is inflated, prevents the latter from contracting. It is well to have sev- 
eral of Trendelenbourg's canulre at hand, in case one or other of them 
does not act conveniently. 

This method of plugging has been recommended by Heine, Langen- 
beck, Bruns, Caselli, Schoenborn,etc. Billroth states that he has been 
rather hindered than well served by this plugging apparatus, and Bottini 
asserts that it has no advantage : "If the bag be distended as it must 
be, it may also distend the lumen of the trachea too much, and the 
patient can no longer bear the instrument. If, on the other hand, it be 
reduced in size enough to be tolerated, blood insinuates itself between 
the plug and the tracheal wall, thus augmenting the dangers one is try- 
ing to avoid." The complete distention of the cyUnder should not be 



4^4 EDITORIAL ARTICLES. 

effected until the narcosis is confirmed. In addition to the use of 
Trendelenbourg's canula, with the view to avoid the introduction of 
blood into the lungs, Caselli and Lange advise the head to be placed 
in a dependent position — as Rose recommended. Certain operators 
even, instead of plugging the trachea, content themselves with placing 
their patients in Rose's position. Hahn prefers to Trendelenbourg's 
apparatus a canula with the lower end surrounded by prepared sponge. 
Bottini places a piece of elastic tube in the canula, after performing 
preliminary tracheotomy, while Albert only introduces the india rubber 
tube after he has separated the trachea from the larynx — thus avoiding 
tracheotomy. 

If Trendelenbourg's arrangement be employed,the tube of the chloro- 
forming apparatus is passed through it. This consists of a metallic 
tube which is adapted on the one hand to the extremity of the tracheal 
canula. and on the other to a caoutchous tube, which is attached to a 
funnel-shaped metallic piece, closed by a piece of taffeta upon which 
the chloroform is poured. The metallic parts bent at a right angle can 
be completely rotated around the axis. By means of this tube chloro- 
form can be given from a distance. 

Operation. — In order to lay bare the larynx a single incision can be 
made along the median line of the neck, and at each extremity one or 
two perpendicular incisions, so as to have two lateral flaps. The me- 
dian incision should commence about one centimetre above the hyoid 
bone and extend as far as the tracheal fistula, if possible, without ar- 
riving, however, at the superior border of the cicatrix. In making a 
second incision transversely across the upper end of the first, Irom the 
internal border of the right sterno-mastoid muscle to the same muscle 
of the other side, the T incision is obtained which Langenbeck has 
recommended. Bottini, moreover, makes an incision perpendicular to 
the lower end of the median one. 

2d Stage. Before going further Schoenborn has advised the per- 
formance of lar}'ngotomy, in order to view the interior of the larynx. 
This opinion is not shared by a great number of operators, who at- 
tempt to isolate the larynx by means of a forceps, a grooved sound and 
a galvano-cautery knife (Bottini). The muscular insertions are thus 



EXCISION OF THE LARYNX. 4^5 

detached and the lateral surfaces of the larynx denuded — avoiding 
with care the vessels and nerves. According to Bottini, compression 
of the pneumogasrric might produce syncope. 

jd Stage. — The extirpation may be effected from below upwards, fol- 
lowing the example of Czerny, Billroth, Heine, Schoenborn, etc., or 
from above downwards, like Maas and Langenbeck. In the method 
from below upwards the larynx is dra^vn forwards by means of a hook, 
and the trachea is divided immediately below the cricoid, either with 
the bistoury or with the galvano-cautery (Caselli). If plugging has not 
been done, there must be placed immediately in the trachea, a canula 
prepared beforehand, or an India rubber tube, the calibre of which will 
completely obstruct the lumen of the air passage. The posterior wall 
of the larynx is then divided without wounding the oesophagus, the 
larynx is drawn forwards so as to isolate it from the anterior wall of 
the alimentary canal, as far as its superior border and then the thyro- 
hyoid membrane is incised. The larynx is thus removed without the 
epiglottis, which is excised afterwards if that be necessary. 

In the method from above downwards, the thyro-hyoid and thyro- 
epiglottidean ligaments are first incised, then the larynx is drawn for- 
wards, and after having cut the lateral attachments of the lar)'nx and 
oesophagus, the vocal organ is divided below the cricoid cartilage, or, 
better, the latter is divided with the help of Liston's forceps, so as to 
leave at the superior opening of the trachea a ring which will prevent re- 
traction. It is evident that to act in this way, the cricoid must be free 
from the neoplasm. 

For the extirpation, Bottini recommends the introduction of a sound 
into the trachea, to serve as a guide for the incision of the latter. After 
making a T incision, and opening the thyroid, Hahn advises an exam- 
ination of the interior of the larynx to determine whether a total or uni- 
lateral excision should be done. In the latter case, he detaches the 
thyroid, and slits the cricoid which he partly removes. In the case of 
total extirpation, after dividing the cricoid, he plugs the cavity with 
gauze, detaches the soft parts of the opposite side, and separates this 
cartilage from the trachea, then he removes the larynx commencing 
from its lower part. 



41 6 EDITORIAL ARTICLES. 

The removal being accomplished, the posterior wall of the pharynx 
and the superior opening of the trachea are exposed to view. The ves- 
sels are tied, Tredelenbourg's apparatus is replaced by a tracheal can- 
ula, or by a canula in the form of "^" ending above in a thick caout- 
chouc tube closed at the upper end on account of the abundant mu- 
cous secretion. The stopper may be afterwards removed so as to al- 
low the patient to breathe through the mouth, the tracheal opening of 
the canula being closed (Bruns). An oesophageal catheter is then 
placed in position, and the necessary sutures are employed to bring to- 
gether the edges of the wound. A phenic acid or iodoform dressing is 
then applied. CarboHc gauze or gauze steeped in dilute alcohol, or in 
a solution of chloride of zinc has also been used. Hahn has advised 
uniting the oesophagus to the thyroid membrane, so as to establish a 
provisional occlusion, permitting the patient to swallow. The sutures 
are removed on the fourth or fifth day. 

During the first few days the patient is exclusively fed through the 
oesophageal catheter, but in most cases he may commence to take him- 
self soft food, at about the fifteenth day or even on the eighth day 
(Billroth). From about the twentieth day the patient may habitually 
do without the catheter. A few days later an attempt to apply an ar- 
tificial larynx may be made. 

After the operation secondary hgemorrhage is to be feared, and 
above all pneumonia. To guard against this, it is well to employ per- 
manent plugging of the trachea, and to cover the tracheal canula with 
a drainage tube of calibre equal to that of the trachea. Moreover in- 
halations and solutions of carboHc, and soda benzoate etc., may be 
used : it is not necessary that these substances be inhaled directly, it is 
sufficient for the inspired air to be charged with the vapours. To pre- 
vent the pus from penetrating to the mediastinum, and to avert the 
risk of pneumonia, it has been recommended to keep the patient's 
head bent back for the first six or seven days, so that the tracheal 
opening might be the most elevated part of the wound. 

Artificial Larynx. In order to remedy the loss of voice, an artificial 
larynx is employed. The larynx of Gussenbauer is composed 
of two bent canulse of hardened caoutchouc. One of them is to be in- 



OSTEOCLASIS. 4^7 

troduced into the trachea to allow of respiration ; the other, adapted by 
its lower end to the former, conducts the current of air to the back of 
the buccal cavity. i\fter introducing these two canulas, they are . 
fixed by a ribbon around the neck ; and to them is adapted a third 
canula of silver, destined for the phonation. It contains a metallic 
tongue which is vibrated by the expired current of air. The \ bra- 
tions are transmitted to the air in the upper canula, and the resulting 
sound is articulated m the [)haryngeal and cricoid cavities. On the 
thickness and length of the metalUc tongue depends the depth of the 
voice. Bruns' larynx is formed of an elastic tube, flattened and angu- 
lar at the upper part 'which supports two India-rubber membranes 
touching at their free borders. These membranes vibrate, like the 
tongue of the preceding apparatus, when the external orifice of the 
tracheal canula is closed by means of a valve. Heine and Schmidt 
have applied the artificial larynx immediately after the operation ; other 
surgeons have waited three to five weeks. Leisrink has employed 
Gussenbauer's larynx on the twenty-second day in a patient who could 
not bear it, although he spoke very well with the apparatus. A silver 
Bruns' larynx was then applied, but although it was better borne, the 
patient could not speak. Leisiink therefore used a Bruns' larynx \vith 
a Gussenbauer's phonetic canula. 

P. S. Abraham. 



OSTEOCLASIS. 



A recent work by Pousson, of France, furnishes the most complete 
and instructive account of osteoclasis yet published. The author, a 
distinguished young French surgeon, has received considerable aid 
from Robin and other compatriots to whom the present position of os- 
teoclasis is mainly due. 

He justly remarks that it is perhaps wrong to regard osteotomy 
and osteoclasis as rivals. To-day both equally merit confidence, and 
are alike precise and safe. 

^Osteoclasis, by Dr. Alfred Pousson. Illustrated. Paris. J. B. Bailliere et fils 
1886. Pp. 262. 



41 8 EDITORIAL ARTICLES. 

The object of the first part of the monograph is to trace the history, 
the principles and the methods of osteoclasis. 

The General History. — Four periods may be distinguished. The first 
or "period of hesitation." It dealt exclusively with mal-united frac- 
tures. According to Fabrice de Hilden, quoted by Laugier, neither 
Hippocrates nor Galen refer either to these or to the means of remedy- 
ing them. Celsus advised, but timidly, the rupture of the callus. For 
many centuries this advice was repeated by scarcely any other sur- 
geons except Oribasius, Rhazes, Avicenna, Fabricius d' Aquapendente, 
and Heister. They used those old machines with wonderful names, 
such as the " scammum" of Hippocrates and the " glosocomium" of 
Nymphodorus. Ambrose Pare was a type of many surgeons who 
shrank from osteoclasis from the fear of breaking the bone in the wrong 
place. 

The 2d period {thaX oi '•'• application raisotinee'''') commences in 1699 
with the excellent case in which De La Motte (of Valognes) corrected 
a mal-united fracture of the femur. Purmann was the first to construct 
a special osteoclastic machine. It was a sort of wooden screw which 
pressed a pad against the projecting angle of a mal-united fracture. 
Bosch (of Wurtemberg) in 1782 invented and used several times an 
apphance like a book-binder's press. CEsterlen used Bosch's machine 
a good deal, and published, which Bosch did not. GEsterlen described 
a machine of his own, the "Dysmorphosteo-palinclaste!" 

The jd period (that of " generaHsation of osteoclasis and study of 
its procedures"). In 1848 RizzoU invented his "machinetta ossifraga." 
It is worth while to mention incidentally the object of its author in 
contriving this machine. It was to shorten the sound leg of one of his 
patients and make it match a deformed limb on the other side ! He 
called his book "A new Method of Curing Lameness (Boiterie)." 

During this period osteoclasis for anchylosis of the hip became not 
unfrequent. Pousson mentions various French surgeons in this con- 
nection, and our readers will readily recall the names of Americans and 
Englishmen. But their collective efforts did far less for osteoclasis 
than did the labours of Delore, of Lyons. This surgeon occupied him- 
self chiefly with the manual "brisement force" for the cure of genu val 
gum. 



OSTEOCLASIS. 



419 



Now appeared the osteoclast of M. Collin, a clever surgical instru- 
ment maker. It was brought forward by M. Terrillon. Though sci- 
entific it was not perfectly satisfactory. 

4th period, that "de perfectionnement et d' appUcation." Our au- 
thor writes that MacEwen's osteotomy would have given the death 
blow to osteoclasis, if improvements in osteoclasts had not come to 
the rescue. Under the patronage of two eminent masters, M. le prof. 
Oilier and M. Daniel Molliere, M. Robin, a young Lyonnais surgeon, 
has invented "a veritably new method" of osteoclasis which, either by 
means of M. Robin's own instrument or of that of M. Collin modified 
according to new principles, has proved its merits in all kinds of suita- 
ble cases, including fractures, ankyloses, and deformities. 

In the next chapter, dealing with fundamental principles, procedures 
and methods of osteoclasis in general. M. Pousson gives the following 
table : 

Procedures and methods. 



Operation 
principles. 



Vertical p 1 
sure. 



Flexion. 



Traction (in the 
long axis of 
the limb). 



Instrumental 



Manual 
clasis. 



Instrumental 
osteoclasis: 



f Manual osteo- ( With the surgeon's hands alone, or helped by 
■ ■ \ one or more assistants: Delore's method, 

f Weights 
Pulleys, exercising traction on the summit of the 

angle. 
Purmann's Machine. 
Bosch's " 

, QEsterlen's " 

osteoclasis, j Blasius's " 

Maisonneuve's machine "Diaclaste." 
Rizzoli's osteoclaste. 
Bruns' " 

Maurique's " 
^ Esmarch's " 

f vVith the hands grasping the limb and trying to 

break it either by straightening or bending. 

The manceuvre by which one breaks a stick 

across the knee. * 

Tillaux's method. 
[ f Weights. 

Apparatus employing I Pulley's, 
the long arm of a- Volkmann's. 
lever, | Collin's first apparatus. 

[Taylor's apparatus. 
Apparatus using only (' Robin's apparatus, 
a very short armed \ Collin's 2d apparatus, 
lever. ( 

Manual osteo- 'With the surgeon's own hands or with those of 
clasis. \ one or more assistants. 

r Pulleys. 
, , . , Schneider-Mennel's machine. 

Instrumental 

osteoclasis. 



Torsion. 



J Manual 
( clasis. 



osteo- ( 



Jarvis's 

Diefifenbach's 

Hennequm's 

Larger's procedure. 



420 EDITORIAL ARTICLES. 

Manual traction and torsion are mainly, if not solely used as adju- 
vants of force applied in other directions. 

As a type of the method of ?>ianual vertical pressure, is given 
Delore's own account of his operation for genu valgum. The pa- 
tient (anaesthetized) is placed on the edge of the bed. Beneath the 
external malleolus is put a cushion, which an assistant fixes firmly, in 
order to raise the knee above the plane of the bed. In this situation 
the angle of the genu valgum points directly upwards, and the surgeon 
presses upon it with his hands upon which he brings, to bear the 
weight of his body, giving, at the same time, Httle shakes (secousses). 
Too much force must not be used. The pad beneath the outer mal- 
leolus must not be too thick, for obvious reasons. When the surgeon 
feels tired he gives way to an assistant, whose manoeuvres he directs. 
The operator should proceed slowly, progressively and without being 
discouraged. At the end of a time varying with the resistance of the 
subject, he will see redressement take place. This time may be five 
minutes or even one-half an hour. Children of 2 or 3 years old, still 
actively rachitic, demand very little force. But great force is required 
for persons of say 1 8 to 20 years of age. Crackings are frequently 
heard during the operation. 

Osteoclasis for genu valgum can be performed also by breaking the 
bone across the surgeon's knee, hke a stick, or across the edge of the 
table (Tillaux's plan). The thigh is fixed by an assistant, and the leg 
and ankle are used as a lever by the surgeon. 

It is difficult to fix the pelvis when dealing with an ankylosed hip. 
Terrillon has invented an instrument for this purpose. It is a kind of 
large double vice. 

All the old instruments were, according to Pousson, difficult to man- 
age and, moreover, did not allow the point of iracture to be exactly 
predetermined. Therefore Rizzoh, in 1845, invented his " machin- 
etta ossifraga." This consisted of a steel bar provided at its centre 
with a screw carrying at its end a metallic arc which pressed against 
the limb at the point where the bone was to be fractured, and re- 
mained motionless whilst the screw turned in its socket, thrusting the 
arc awav from the steel bar. At each end of the latter were two 



OSTEOCLASIS. 421 

leather rings in which the Umb was fixed. The Hmb being secured in 
these rings it was enough to turn the screw in order to press, by means 
of the metallic arc, against the intermediate part of the limb thus held. 
This instrument worked with considerable precision, Maurigue, of 
Madrid, substituted two screws which acted on pads pretty close to- 
gether and broke the bone at a place between the two. 

C. B. Keetley. 
[to be continued.] 



INDEX OF SURGICAL PROGRESS. 



GENERAL SURGERY. 



I. On the Etiology of Tetanus in Man. By Rosenbach 
(Gottingen). Former theories as to the nature of this trouble are sim- 
ply referred to but not discussed. Amongst modern authorities the 
zymotic theory has many advocates. The earlier attempts at inocu- 
lating animals all miscarried, largely owing to the fact that dogs, the 
animals used, are proof against tetanus infection. Carle and Rattoue 
were the first to get positive results, and succeeded in passing it from 
animal to animal. Nicolaier's experiments with earth tetanus are 
known. 

Early this year R. took material from a fatal case of tetanus from 
frozen feet, about one hour post mortem. This came from below the 
line of demarcation, where necrotic skin adjoined non necrotic bone. 
It was introduced at evening under the crural skin of a guinea pig. 
Tetanus developed by the next morning and the animal died during 
the day. Further inoculation was only successful when the material 
was taken directly from the spot inoculated. It was successful in four 
gumea pigs and eleven mice in succession. This inoculated tetanus 
was completely identical with Nicolaier's earth-tetanus. It began ac- 
cording to the spot inoculated ; if in the lumbar region, e. g., the tail 
stood erect after nine to twelve hours incubation, though inclined to 
wards the point of inoculation, if in an extremity then this became 
stiff in all its motions and soon stretched out completely tetanized, the 
sole upwards and the toes spread; soon the same thing began in the 
other extremity and the contracture spread to the back muscles ; the 
animal could only move along with its forepaws. By the end of eigh- 
teen hours the latter also get stiff, trismus and opisthotonus develop, 
and at every contact, even with the glass coop, tetanic convulsions set 

(422) 



GENERAL S UR GER Y. 42 3 

in. After this the animal lies exhausted, with great difficulty in respi- 
ration. Later Ufe is only indicated by the rapid superficial breathing 
and slight twitching, death usually resulting in twenty-four hours. If 
a mouse is inoculated on the fore extremity then this becomes immo- 
bile first and soon prone in rigid extension. Some hours later the ear 
of the same side lies down, the otherwise prominerit eye is retracted, 
and the fids are half closed. Absolute lock-jaw. After eighteen hours 
the whole body is bent towards the affected side, the other paw is stiff, 
the hind paws still movable. Tetanic convulsions on being grasped. 
Death in twenty-four hours. In the young guinea pigs used by R. the 
disease runs a very uniform course. In rabbits, though the course is 
essentially the same, general tetanic convulsions are much more prom- 
inent. Incubation lasts from twenty-four to forty-eight hours, usually 
thirty-six. A local muscle- tonus spreads from the inoculated point. 

In man tetanus varies greatly according to the location of the 
wound. Not so very rarely the tetanic cramps seize the wounded ex- 
tremity, as in animals. Head tetanus is one form. Besides other 
microbes R. found a bristle-shaped bacillus, like that described by 
Nicolaier as the cause of earth-tetanus. This R. carried as impure 
cultures in solidified serum through four generations without loss of 
virulence. Flugge's co-workers have succeeded in obtaining pure cul- 
ture of the earth-tetanus bacillus, though difficulty was found in 
transferring them to other like media. Whether they can only live 
with other microbes or the other microbes by absorbing O. favor the 
life of the tetanus-bacillus, the fact is interesting since wounds contain- 
ing matters favorable to putrefaction specially dispose to tetanus. 

How this bacillus produces tetanus is a question yet to be answered. 
Nicolaier found the bacillus once in the sciatic and twice in the cord. 
R. also found them twice in the cord, though scattered. He finally in- 
clines to the view that some substance like strychnine must be pro- 
duced to cause the peculiar symptoms. 

In the discussion Konig conjoined the identity of Rosenbach's and 
Nicolaier's experimental tetanus, with that of man and the not infre- 
quent form of horses after castration. In the latter case it frequently 
begins in the extremities or back. In man tetanus does not. by any 



424 INDEX OF SURGICAL PROGRESS. 

means, always begin with trismus, but at times appears first in the 
muscles at the point injured. 

Socin (Basle) referred to his experimental results with garden earth 
as genuine tetanus. 

After Ebermann (St. Petersburg) had suggested the possibility of 
ptomaines, Trabludowsky (Berlin) referred to a case in Gerhardt's 
clinic where the tetanic phenomena disappeared each time on pump- 
ing out the stomach (for pyloric stenosis). — Author's report of XV 
German Surgical Congress, in Centrbl. f. Chirg. 1886. No. 24. 

II. Case of Inoculation-Tuberculosis After Amputation 
of the Forearm. By M. Wahl (Essen), In consequence of a 
bruise a one-year-old boy developed an inflammation and finally 
gangrene destroying the whole left hand. The forearm was taken off. 
In the preparation Gaffky found the coccobacteria septica of Billroth 
besides a variety of baciUi and cocci. Primary union, the boy being 
discharged with the small drain-opening still granulating. He passed 
into the exclusive care of a 13 year old girl with lupus of the nose. By 
her he was most probably infected with tuberculosis, since other 
sources of infection, especially impaired heredity, were not apparent. 

The granulating spot on the stump began to enlarge and degenerated 
fungously. Soon the axillary glands became infiltrated, and the gen- 
eral condition much worse. The glands were extirpated, and showed 
macroscopically and microscopically exquisite tuberculosis. The boy 
is now quite well. He suggests that Koch himself was the first to ob- 
serve tubercular inoculation. From a private communication it ap- 
pears that K., in 1874, amputated a finger for tedious ulceration in an 
otherwise healthy person. Some years later the man died of tubercu- 
losis. On examining the alcohol preparation of the finger in 1882 tu- 
bercular bacilli were found. 

With regard to infection from milk W. suggests that the custom in 
some country districts of washing skin eruptions with fresh milk may 
explain some cases. 

In the discussion Konig mentioned a case of large tubercular ab- 
scess of the rectus abdominis muscle, from which tubercular peritonitis 



GENERAL S UR GER \ . 425 

directly developed. In all probability it resulted from hypodermic in- 
jection with a syringe which a doctor, careless as regards cleanliness, 
had frequently used on a very tubercular individual. In the above 
case of peritonitis the remaining organs were free from tuberculosis. 

Volkmann told of a patient in whom, after the cure of a tubercular 
fistula of the rectum, a lupus exfoHativus developed at the point of the 
former wound. — Author's Rept. of Congress of Germ. Surgs., in 
Cenfd/./. Chirg. 1886. No. 24. 

W. Browning (Brooklyn). 

III. Three Cases of Malignant Pustule. By Dr. Giuseppe 
MoGGi. The author describes three cases of malignant pustule which 
had come under his own observation, and draws attention to the mode 
of treatment which he adopted in each case. The first case was that 
of a healthy, fine young lad, set. 16, who was working with a butcher. 
The disease appeared on the back ot the neck, in the usual situation 
of carbuncles, and the symptoms presented were unequivocally those 
of mahgnant pustule. The treatment consisted of cauterizing the part 
with the galvanic cautery, injecting some carbolic acid solution, of the 
strength of 2%, at four different points, into the diseased parts, and 
douching the part with the same solution. — T. 40.5°, R. 26, P. 120. A 
small dose of sulphate of iron was given at intervals during the night. 
The next morning the patient was quieter, but the swelling had ex- 
tended over the face and the neck, and had even reached the shoulder 
and the chest. T. 39.4°, R. 22,? . no. The patient was afterwards 
removed to the hospital, where he died on the sixth day. The next 
case was that of a man of about 40 years of age, a vender of skins by 
occupation. Three days before he came under observation the patient 
noticed a boil on his left zygoma, which was accompanied with pain 
and much malaise. On examination the disease proved to be a ma- 
lignant pustule. There was enlargement of the glands in the axilla, 
above the clavicle and beneath the lower jaw, on the left side. There 
were also general weakness, giddiness and pain in]the joints. T. 40.2°, 
R. 24, P. no. The local treatment was almost identical with that de- 
scribed — with the exception of the application of the cautery — above, 
and sulphate of quinine was given internally every half hour. The 



426 INDEX OF SURGICAL PROGRESS. 

next morning the swelling was found to have extended over the chest ; 
the pain, however, was less. The hypodermic injections were re- 
peated. T. 39.2°, P. 94, R. 20. Subsequently the galvanic cautery was 
used, owdng to the vicinity of the disease to the eye. On the follow- 
ing day some improvement was noted ; this was maintained, the en- 
largement of the glands subsided, and, after being under treatment for 
a month the patient was discharged, cured. The third case also ter- 
minated favorably. It was that of a man aet. 25, married, whose oc- 
cupation w^as the same as that of the preceding patient. At first the 
symptoms \vere indefinite, being limited to a swelling of the left side of 
face, and general malaise. T. 41°, R. 29, P. 120. In a day or two the 
disease became fully pronounced, the cardinal symptoms of malignant 
pustule appearing over the left zygoma. The part was cauterized with 
the galvanic cautery, and the injections hypodermically of carbolic acid 
solution of the strength above referred to were employed. Improve- 
ment commenced in ten days' time, in fifteen days the slough sep- 
arated, on the twentieth day the patient was quite convalescent. The 
author adds, in conclusion, that in a large number of cases of this dis- 
ease which have been treated after the manner described above good 
results have been obtained. — Lo Sperimentale, March, 1886. 

H. Percy Dunn (London). 

IV. A Case of Emotional Icterus, Accompanied by a 
General Eruption of Lichen. By Dr. Negel (Jassy, Roumania). 
A young man, get. 23, who had a urethral discharge and a herpetic 
eruption on the mucous membrane of the prepuce, himself cauter- 
ized the latter ^nth nitrate of silver. This led to an acute balanitis, 
going on to gangrenous ulceration. He was terribly alarmed, lest the 
whole organ should slough away. His urine became dark in color, 
the faeces pale, and a general and intense icterus was manifest. An 
eruption of Uchen then superv-ened. Under treatment the balanitis 
and the biliary derangement disappeared in three weeks, but the 
eruption remained for some time longer. This observation appears to 
the author interesting from the point of view of the nature of icterus 
and lichen. The liver and other organs were healthy, there had been 
no gastric excess or history of cold — one can only put down the cause 



NERVOUS AND VASCULAR SYSTEMS. 42? 

to a Strong moral emotion, induced by fear. At the same time the 
patient was of a herpetic nature, and the moral perturbation has acted 
only as an accidental agent in making appear the manifestation of a 
constitutional diathesis. — Le Progres Med., 21 Aug., 1886. 

P. S. Abraham \^London). 

OPERATIVE SURGERY. 

I. On Extirpation of Synovial Membrane Behind the 
Knee Joint. By Dr. D. G. Zesas. This short communication is 
on avoiding the popliteal vessels in arthrectomy for tubercular joint 
affections. The removal of all the fungous material is of prime im- 
portance. When the synovial membrane back of the joint is also af- 
fected he recommends that the vessels be prepared out as far as the 
granulation masses extend ; they can then be held aside until all the 
morbid tissue has been cleaned off. In very bad cases the vessels are 
to be approached from the popliteal space and then drawn back out of 
the \\2c^.— Centbl.f. Chirg. 1886. No. 28. 

Wm. Browning (Brooklyn.) 
« 

VASCULAR SYSTEM. 

I. A Case of Ligature of Subclavian Artery and Vein 
Under the Clavicle. By Dr. M. A. Vasilieff (of Warsaw, Russia). 
There are recorded sixty-five cases of Hgature of subclavian artery 
under the clavicle, of which in twenty-two there was a favorable re- 
sult, thirty-eight resulted in death, and in five cases the result is un- 
known. But there is not on record a single case of the simultaneous 
Hgature of the subclavian artery and vein under the clavicle. There- 
fore, the case of Dr. Vasiheff deserves special attention, 

Marianna Liatanska, set. 20, servant, was admitted into the surgical 
clinic of Prof. J. A. Efremovsky on November 21, 1884, in which clinic 
Dr. V. is an assistant. The patient could not move her right shoul- 
der, complaining of a severe pain in the axilla, where a hard, small tu- 
mor was felt. The tumor was rapidly increasing in size. On Novem- 
ber 29 it was distinctly fluctuating and filling up the axillary and sub- 
clavian space. The patient was feverish. On Decembe i, under 



428 INDEX OF SURGICAL PROGRESS. 

chloroform, the tumor was opened in the axillary line. There was dis- 
charged a considerable quantity of pus. Dr. V. introduced his finger 
into the cavity, and passing it upward to the clavicle he found that 
there was a passage too narrow for a thick drainage tube; therefore he 
cut some tissues with a dull pointed knife. A profuse bleeding fol- 
lowed, which, after several vain attempts, was stopped by seizing the 
vessels en masse with hemostatic forceps. As the cavity was very deep, 
it was impossible to put a ligature on the bleeding vessels; therefore, 
Dr. V. left the forceps in situ in the cavity. On December 3 the 
dressing was changed. In the evening there appeared haemorrhage of 
a venous character, and it was repeated in the night. 

December 4. Temperature, 997-2°; pulse, 104. Prof. Efremovsky 
enlarged the opening, trying to find the bleeding vessels. When the 
forceps were removed a very profuse haemorrhage set in, which was 
stopped only by placing a ligature on the subclavian artery. But im- 
mediately after that a venous bleeding began which was also stopped 
by ligature being placed on the subclavian vein. The cavity was 
cleaned of clots, washed and dressed. The right arm was kept warm. 
The patient perspired freely; pulse in the left arm was 100. 

December 5. The right arm was warm, but cedematous; sensation 
in the thumb and the index finger was lost. From December 6 to 
20 the dressing was changed every day ; the wound was very pain- 
ful. There was no pulse in the right arm. The arm was cedematous 
all the time. On December 14 the ligature of the artery was removed 
during the dressing of the wound. On December 20 the ligature was 
removed from the vein. Since then the dressing was done every other 
day. The wound was filled with healthy granulations. CEdema was 
disappearing. But on toward the end of January inflammation set in at 
the shoulder and elbow joints, resulting in abscesses. On February 24, 
under chloroform, the tumors were opened, yielding a large amount of 
pus. The '^humerus was exposed, and in several places affected with 
caries. Acute osteomyelitis. Treatment with drainage. Suppuration was 
very profuse and Dr. V. feared that exarticulation was unavoidable. 
On March i erysipelas attacked the arm, affecting also the right side 
of the chest. In a fortnight the erysipelas disappeared, and the 



L\MPHATIC SYSTEM. 429 

wound, in all its extent, was covered with healthy granulations. Bone 
and other tissues healed in the beginning of April. The patient could 
not move her right arm and fingers. Massage and electricity. On 
June 16 the patient left the clinic in the following condition. The arm 
at the shoulder and elbow joint could be moved; the flexion of fin- 
gers was yet difficult; sensibility in the fingers was restored; pulse in 
the radial artery could not be felt. In the fall ot 1885 Dr. V. visited 
his patient and found her arm still more improved, yet there was no 
radial pulse. She was in condition to attend to her duties. 

Dr. V. believes that he cut one of the thoracic arteries together 
with an adjacent vein ; he believes also that erysipelas had a rather 
beneficial influence on the patient, having checked the osteomyelitis. — 
The Chirjirgitchesky Vestnik, July, 1886. 

P. J. POPOFF (Brooklyn). 

LYMPHATIC SYSTEM. 

I. Lymphangeitis and Sublimate. Dr. W. Skinner. The 
following two cases show the prompt efficacy of mercuric perchloride 
in lymphangeitis following septic wounds : 

(i). X., cook of a steamer, on the 28th of March cut the dorsal sur- 
face of the left index finger with a kitchen knife which divided the nail 
transversely. The wound was bathed with carbolized water and cov- 
ered with diachyton plaster. On the 30th, inflammation of the lym- 
phatics had set in, with painful glands at the elbow and in the axilla. 
The finger was red, swollen and the least touch caused great pain. 
Tiie wound had a bad appearance and showed no tendency to close 
up. The treatment was changed, the wound well bathed with cam- 
phorated spirit, and compresses applied which had been steeped in 
a solution of sublimate, 2 parts in i.ooo. They were left on for twen- 
ty-four hours. On the following day all the symptoms had diminished, 
the lymphatic glands scarcely painful, the finger much less swollen 
aiid red or tender. On the 7th of April the lymphangeitis was cured, 
and the wound rapidly cicatrized. 

(2). Mile. V. presented a well marked and extensive lymphangeitis 
of the dorsal surface of the foot and lower half of the leg, with the in- 



43° INDEX OF SURGICAL PROGRESS. 

guinal glands enlarged and painful. She had previously scalded her 
foot and had pricked with a dirty pin one of the blisters caused by the 
burn. At the first examination the foot seemed to be the seat of 
phlegmonous inflammation which threatened suppuration, and it be- 
came a question whether the knife should not be used. The treat- 
ment, however, was limited to raising the limb, applying Neopolitain 
ointment and poultices to the foot. For three days this was continued, 
but no improvement ensued, and on the 30th the poultices were left off 
and the foot was dressed with compresses dipped in a 2 per i ,000 so- 
lution of sublimate. On the 2nd of May the amelioration was notable, 
the inguinal glands were nearly in a normal condition and all the 
pathological phenomena haa diminished in intensity. On the follow- 
ing day the lymphangeitis was quite cured and the wound commenced 
to heal. 

The rapid success of this mode of treatment in these cases leads to 
believe a priori in the efficacy of sublimate in cases of erysipelas 
which notably resembles " reticular angioleucitis " in its septic and 
other objective characters. It will be indispensable, however, to watch 
carefully the absorption of the sublimate by the inflamed skin, which 
by its great pathological vascularity might introduce in the system 
toxic quantities of the agent. — Le Progres Med. Aug. 7, 1886. 

P. S. Abraham (London). 

HEAD AND NECK. 

I. Direct Fracture of the Vault of the Cranium Consecu- 
tive to a Fall on the Parietal in an Infant of Four Months. 
Integrity of the Scalp. Traumatic Meningitis. Death. 
M. NoTTA. An infant fell out of a bed on the floor through a height 
of 75 centimetres. Five days afterwards he suddenly began to vomit, 
to cry violently and to be convulsed, especially in the right arm. At 
the autopsy, a yellow purulent layer was seen to extend over the left 
hemisphere of the brain, and with care a fracture of the left parietal 
without displacement of the fragments could be made out obliquely 
directed upwards and backwards to the sagittal suture. 

The rarity of similar cases is due to the elasticity of the cranial bones 



HEAD AND NECK. 43 1 

in infancy. The younger the child the more difficult the diagno- 
sis of such lesions. Fracture of the vault, often giving rise at first to 
no serious symptoms, may after some days end in acute and rapidly fatal 
meningitis. — Soc. Anat. Oct., 1885. Le Prog. Med. 13. Feb., 1886. 

II. Contribution to the Study of Gaseous Tumors of the 
Anterior part of the Neck. By Dr. Paul Fabre (Commentry). 
Aerial tumours of the neck are sufficiently rare for the following two 
cases to be interesting : 

Case I. Unilateral aerial goitre. — Spontaneous emphysema on the 
right side of the neck arising during the course of bronchitis. A. T., 
born December 28, 1884, suckled by her mother, attacked by cough, 
of simple bronchitis March 13, 1885. On the i6th a swelling was no- 
ticed in the right supra- and sub-clavicular region ; on palpation, the 
characteristic crepitation of traumatic emphysema ; no trace of trau- 
matism. The mother stated that the swelling began in the fold of the 
groin and mounted rapidly up to the neck. There was constant cough, 
each effort augmenting the tumour, which seemed to stretch also when 
the infant cried. Auscultation revealed loud and sibilant rales in the 
left lung. It was evident that the efforts of coughing had produced 
a rupture of the aerial canal followed by emphysema. No fracture 
of the ribs or of the laryngeal cartilages could be detected. The pulse 
beat over 116 per minute. Linseed poultices and Desessartz' syrup 
were ordered. The next day the cough was less, the supra-clavicular 
swelling a little less marked, and the emphysema had almost all dis- 
appeared below the clavicle. On the 1 8th the tumefaction was lim- 
ited to the neck, and the cough was almost gone ; the crepitation on 
the 19th scarcely existed. A teaspoonful of equal parts of the syrups 
of tolu and of ether was ordered every two hours. On the 21st all 
fever had disappeared, and pressure seemed to make the tumour van- 
ish. Two days after there was neither fever nor cough, and the neck 
was not more bulging on the right side than on the left. From that 
time, more than a year ago, nothing of the kind has reappeared, and 
the little girl has been quite well. 

Reflections, (i) From what he could estabHsh, the author is in- 



432 INDEX OF SURGICAL PROGRESS. 

clined to think that in this case there was a rupture of the thyrohyoid 
membrane. 

(2) In considering the succession of symptoms it seems difficult to 
assimilate this case to that of Mord-Lavaillee\ in which there was a 
hernia of the lung, of which the orifice was hmited by the border of the 
first rib — being, according to S. Duplay^ only an exaggeration of the 
normal protrusion of the apex of the lung above the level of the supe- 
rior opening of the thorax. 

Case II. Congenital absence of the first piece of the sternum. — 
Aerial diverticulum in front of the neck and in the upper median 
part of the thorax. 

A male infant, one month old, presented in front of the neck a tu- 
mour which subsided quickly and completely at each inspiration. 
There was total absence of the manubrium of the sternum, and none 
of the rings of the trachea could be felt ; there seemed, indeed, to be 
no solid tissues between the cricoid cartilage and the anterior ex- 
tremity of the fourth rib. The bi-acromial distance was 15 c. m., 
the distance between the internal articular surfaces of the clavicles 4.5 
c, m., and the length of the sternum 3.5 c. m. The size of the pro- 
tuberance, distended at each expiration, was about that of a goose's 
egg. By touch the internal articular surfaces of the ends of the clavicles 
could be easily made out ; the first ribs seemed to be joined together 
at their anterior extremities, and only at the level of the fifth rib could 
the sternum be felt. Curiously enough, a longitudinal fold or raphe ex- 
tended from the xiphoid cartilage along the median line as far as the 
umbilicus. The child's cries caused the tumour to project, and at 
each inspiration to disappear and form an oblong cavity. The skin 
of the part was very thin. Six months later the condition was just the 
same. An apparatus was devised, not to prevent the projection of the 
aerial hernia, but simply to hinder any augmentation of volume which 
might lead to rupture. 

Reflections. This case appears to the author unique, although many 

'Mem. d lea Soc. de Chirurgerie. 1847. Vol. i, p. 104. 
^Traite de Padiol. Externe, vol. v. 



HEAD AND NECK. 433 

deformities of the sternum are known — even cases of total absence of 
the bone. In October, 1852, Prof. Abbott, of Bahia, related to the 
Soc. de Biologic the case of a negress aged 30, whose rib cartilages 
came together in the manner of false ribs. At each inspiration they 
separated two inches from each other in the median line, approaching 
again at the expiration. If she laug.ied they separated so much that 
the heart could be laid hold of. She was quite strong and healthy. 
M. Servier, in his article on the sternum in " Dechambre's Dictionary 
of Medical Sciences," i860, says that "in many cliniques an individual 
may be seen whose heart, deprived of protection in front through ab- 
sence of the sternum, beats immediately below the skin, which is raised 
at each pulsation. A plaster cast of the condition is preserved in the 
museum of the Val-de-Grace." In another case, that of a soldier dying 
of phthisis at the age of 21, reported by Dr. Tenieres, the diaphragm 
was very much raised in consequence of the small length of the ster- 
num, which, instead of being formed of three well-developed pieces, 
only presented an equal number of small, spongy nodules united by 
cartilages, the whole length being about five inches. The xiphoid ap- 
pendix descended very low, and this contributed to the small height of 
the chest not being recognized. Wiedmann has cited a case in which 
the sternum was only represented by its upper part. 

Passing over the far more common cases of asymmetry of the ster- 
num, only those will be mentioned where the sternum was traversed by 
one or more openings from arrest of developments. Of the three 
pieces of the sternum, the xiphoid appendage is the seat of the great- 
est number of deformities, often of surgical importance, such as the 
pushing backwards of the xiphoid point, or its exaggerated projection 
in front, under the skin. Dr. Tino-Ramirez (Mexico) reported in the 
Gazette Med. 1868, p. 66, the case of a man get. 75, who had never 
had any serious illness and had always been lightly employed. Along 
the middle of the sternum an irregular canal with convex borders di- 
vided the bone. It measured four centimetres in diameter at the upper 
end, then narrowed a Httle, and at the level of the third and fourth ribs, 
the httle finger could not be inserted. From this point it again en- 
larged as far as the fifih and sixtli ribs, where there was a kind of 



434 INDEX OF SURGICAL PROGRESS. 

sinus, which became lost in the epigastric region. During respiration 
the canal alternately contracted and expanded, and the movements of 
the heart were quite evident. The case also may be recalled which 
was observed by J. Hamersky, and made the subject of a memoir 
read by M. Behier in October, 1855, before the Soc. Med. des Hopi- 
taux de Paris. There were no sterno-clavicular articulations, but the 
internal end of each clavicle rested on the upper part of the corre- 
sponding half of the sternum, which was in the form of a V, the halves 
uniting below in a cartilaginous piece which supported the xiphoid. 
Jahn has also reported a case of congenital fissure of the sternum in 
the Archiv fur klin. Med. vol. XV. p. 200. Finally, Sabatier has 
often observed a certain congenital mobility of the second piece of the 
sternum on the first, and he cites the case of a girl «t. 7 or 8 years, 
who presented this condition. 

M. Servier, in his article in the Diet. Encyc. des Sc. Med., gives no 
instance of total absence of the first bone of the sternum and of this 
only ; and on this account especially the example given above merits 
attention. Moreover, in this case the heart beats in its proper place, 
and none of the large vessels can be felt in the open space at the up- 
per part of the sternum. The principal point, however, is the presence 
of the aerial diverticulum which reaches to the superior part of the 
neck, projecting several centimetres, suddenly expanding at each ex- 
piration and disappearing equally suddenly at each inspiration. 

In bringing forward the two cases together, the author is quite 
aware of the differences which they present. In the one case the tu- 
mour is acquired, temporary, and unilateral ; in the other it is congeni- 
tal, permanent and median in position. They have the common 
character that the tumours are situated in the neck and upper part of 
the thorax, that their contents are gaseous, and that they were ob- 
served in very young infants. — Gaz. Med. de Paris. Aug. 7, 1886. 
P- 373- 

III. Two Cases of Excision of the Larynx. By Dr. Peak, 
Surgeon of the St. Louis Hospital, Paris. Excision of the larynx is of 
recent date. Like so many other operations, the success of which is 
to-day assured, it is opposed by many surgeons, particularly by those 



HEAD AND NECK. 435 

who have never had to employ it. Performed for the first time abroad, 
several years ago, it has been lately practiced in France by M. Labbe, 
who last year pubHshed a good case. This attempt encouraged the 
operation recently in the case of two patients who were affected with 
epithelioma of the larynx and who were nearly succumbing. One of 
them, aet. 35, is now full of health ; the other, set. 65, has seen the 
wound cicatrize, and the operation would have been equally successful 
if it had not been for a pneumonia complication, which would not have 
set in had we possessed more experience in this kind of operation. 

Case I. Louis B., aet. 35, restaurant keeper, entered February 3, 
1886, operated on February 13. No heredity — neither alcoholic nor 
syphilitic. Fifteen months ago, without known cause, he first became 
hoarse and dyspnoea followed. These phenomena gradually increased 
and since a year they have become urgent. At the present time there 
is aphonia, and attacks of pain. The expectoration is mixed 
with blood. By laryngoscopic examination Dr. Poyet established that 
the epiglottis was normal, that the right half of the larynx was dark 
red. that the arytenoid cartilages were swollen, and that the inferior 
vocal cord was covered with suspicious vegetations. The patient has 
much fallen off in flesh, although there are no cervical glands, nor anv 
disorders of the principal viscera. Oh the 13th of February tracheot- 
omy was performed, and on the 27 th the ordinary canula was replaced 
by Trendelenburg's plug canula, to prevent the entrance of blood into 
the air passages, the patient was chloroformed through the tube, and a 
vertical incision was made with the bistoury in the middle line, extend- 
ing from the middle of the sub-hyoid space to one centimetre from the 
tracheal wound. This incision exposed the cartilages of the larynx ; 
the thyroid cartilage was then divided in the middle line, and by means 
of the scalpel the perichondrium was detached from its external sur- 
face. Seizing the right half of the thyroid with a flat blade forceps, 
the perichondrium was dissected off from its inner surface as far as the 
posterior edge. Thus freed on its two surfaces, it was easily removed 
by a movement of torsion. The other half of the cartilage was treated 
in the same way. During this manasuvre the anterior membrane of 
the larynx was found to be divided, and it was discovered to be in- 



4:6 INDEX OF SURGICAL PROGRESS 

vaded above and at the level of the vocal cords in nearly its whole ex- 
tent, especially on the right side. It was establisned also that the 
malignant ulceration occupied the part of the mucous membrane which 
covers the internal surface of the thyroid cartilage and the laryngeal 
surface of the two arytenoid cartilages. To facilitate the removal of 
these infective tissues, the cricoid cartilage was cut in front in the mid- 
dle hne and removed, its perichondrium being detached from both 
surfaces. The whole cavity of the larynx was presented to view, and 
all the mucous and subjacent tissues which degenerated were widely 
removed — including the arytenoid cartilages which were also invaded 
by the neoplasm. The epiglottis, being healthy, was retained. Five 
haemostatic forceps controlled haemorrhage during the operation. Then 
nine separate silk sutures superficial and deep. The points of suture 
were passed on each side as near as possible to the mucous membrane 
which was left on the posterior region of the larynx, so that after cica- 
trization the space occupied by the larynx would be reduced to a nar- 
row channel. Thanks to the dressing with iodoform and sublimate ; 
union took place by first intention, and the threads of the suture were 
removed on the sixth day. During this time the patient was easily fed 
by an oesophageal caoutchouc tube passed by the nasal fossae. On the 
fifteenth day the tube was withdrawn and the patient was able to swal- 
low without difficulty liquids and solid food. Now, by means of a 
special canula he speaks, and he is able to attend to his work. 

Case II. Jules C. set. 35, the subject of epithelioma of the larynx, 
causing paroxyms of suffocation so alarming that tracheotomy had to 
be performed on the 13th of February, 1886. This operation was ren- 
dered very difficult by reason of the shortness and obesity of the neck 
and the retraction of the larynx, which was situated behind the upper 
border of the sternum. Without the author's haemostatic forceps and 
canula holder it would not have been successfully performed. On the 
6th of March the tracheal wound was healed, but the patient still suf- 
fered such pain in the larynx and haemoptyses that he wished for its 
excision.. The general condition was so bad. and the relations of the 
larynx so disagreeable, that the operation was attempted with much 
hesitation. 



HEAD AND NECK. 437 

After introducing into the trachea a plug canula, a vertical incision 
was made in the middle line from the chin to the canula. The thy- 
roid cartilage was thus exposed, its perichondrium detached from both 
surfaces and the two halves separated as in the preceding case. This 
time the operation was more difficult from the calcification of the car- 
tilage. The mucous membrane was seen to be invaded by the cancer, 
and in parts thickened to the extent of i centimetre. It was widely 
removed. The cricoid portion of the larynx was not involved, and it 
was left untouched. On the other hand, the posterior and lateral parts 
of the larynx were so much implicated that they were completely re- 
moved, together with the arytenoid cartilages, and the anterior wall 
of the oesophagus as far down as the cricoid and the base of the epi- 
glottis. An immense gaping wound was the result, exposing to view 
the pharynx and oesophagus. The results of the operation were less sat- 
isfactory than m the other case. The patient on the first day removed 
the oesophageal catheter which was badly adjusted, and which in the 
author's absence had been introduced into the cavity left by the larynx. 
In consequence milk injected through the tube had passed into the 
bronchi, and the next day it was necessary to re-open the wound and 
readjust the catheter in the oesophagus. The entrance of milk into 
lungs caused inflammatory action, which without preventing union by 
first intention in the wound, terminated in broncho-pneumonia, to 
which the patient succumbed. This accident would not have hap- 
pened if its possibihty had been foreseen. 

The histological examination of the parts removed in these two 
cases was made by M. Cornil, who diagnosed in the first pavement 
epithehoma, and in the second a lobulated epithehoma 

In spite of the author's Htde experience in such cases, the operations 
were successful performed. In the first the patient was anaesthetized ; 
in the second exhaustion was too great to allow of it. In the first, 
where the trachea was small, the plug canula was sufficient to plug 
the passage ; in the second the closure was incomplete. This did not, 
thanks to the author's haemostatic forceps, inconvenience the opera- 
tion, but it was of consequence in feeding the patient. 

As regards the operation, its pecuHar feature is in the excision by 



438 INDEX OF SURGICAL PROGRESS. 

pieces. It consists of, first the median incision of the soft parts from 
near the chin down to the canula ; second, the section of the thyroid 
cartilage throgh the middle of its anterior part, the detachment of the 
perichondrium by means of a scraper, and the separate withdrawal of 
the pieces by means of a flat-bladed forceps. If necessary the same 
procedure may be adopted for the cricoid. When the cartilages are 
removed, the internal membrane, which forms the anterior wall of the 
larynx, is exposed to view, and the diseased portions excised. Then 
by means of retractors placed on each side, the lateral and posterior 
walls of the larynx are examined, and the affected parts removed as 
widely as possible. Care being taken to preserve the external peri- 
chondrium, the operation may be accomplished without fear ot wound- 
ing the vessels or important nerves which are near the surface of the 
larynx. 

The operation over,the full view of the interior of the pharynx enables 
us to arrange in position a caoutchouc oesophageal catheter passed by 
the nasal passage. The haemostatic forceps are then replaced by lig- 
atures, and the wound completely closed by separate silk oUtures, su- 
perficial and deep. The .latter should be passed as closely as possible 
to the external perichondrium, to facilitate the union of its bleeding 
surfaces and to control the haemorrhage. The dressing should be 
done with iodoform and sublimate gauze and wadding bandage. On 
the sixth day the latter is removed and the sutures withdrawn. On 
about the fifteenth day the patient can feed without the oesophageal 
tube which may be taken away ; and the loss of the voice can be rem- 
edied by substituting for the tracheal canula another one furnished 
with an artificial larynx, such as Mathieu has constructed for the au- 
thor's case, after M. Frauvel's instructions — similar to Gussenbauer's. 

This operation has been objected to because it is liable to haemor- 
rhage and pneumonia. If the above rules are closely followed there 
will be no fear of loss of blood; and as for the pneumonia, it is not 
evident, if the immediate causes which produce it be guarded against, 
why a patient operated on should be more liable to it, rather than one 
who has in his larynx a painful maUgnant growth. 

It may be said that the present statistics are not yet favorable to the 



HEAD AND NECK. 439 

opeiation, hut the reply is that such is always the case with big opera- 
tions such as this, which, properly performed, will be one of the tri- 
umphs of modern surgery. — Gaz. Med. de Paris. April 17, t886. 

P. S. Abraham (London). 

IV. Four Cases of Tracheotomy, with Extraordinary- 
Features. By Dr. K. K. Reyer (St. Petersburg, Russia). Dr. R., 
senior surgeon of the surgical department of St, Mary's Hospital, St. 
Petersburg, has performed tracheotomy in the following four rare 
cases : 

Case I. Milan K., Servian soldier, during the Servo-Turkish cam- 
paign had his trachea shot through by a bullet. He was subjected to 
crico-tracheotomy and recovered, but for some unknown reason he had 
the tube in situ for over a year. Once while cleaning the internal 
tube, he found that the extra-tracheal part ot the other tube had sep- 
arated from the intra- tracheal one, which dropped down into the tra- 
chea, causing a severe paroxysm of cough. Surgeons of Belgrad failed 
to extract the canula from the trachea, and the patient was sent to St. 
Petersburg. February 25, 188+, he entered the Mary's Hospital. He 
was suffering from bronchitis and dyspnoea. No foreign body could 
be found through the tracheal opening, and its very presence was 
doubted. March 23, laryngitis. May i, dyspncea, severe cough and 
chills. The patient prayed for an operation. No examination showed 
the presence of a foreign body in the trachea. In the beginning of 
August dyspnoea increased, fever set in, and bad smell from the tra- 
chea was perceptible. On August 17 Dr. R. performed thermotomia 
trachealis longitudinalis ad maxifnum. Not a single drop of blood 
lost. Dr. R. introduced his finger into the trachea down to the bifur- 
cation, but could not find any foreign body. The patient was placed 
in the perpendicular position, head down, and was shaken. Then Dr. 
R., with his finger, felt'something hard in the right bronchial tube, but 
that was only for a moment, for with inspiration the foreign body was 
drawn in deeper. After repeated shakings of the patient, with head 
down, at last Dr. R. succeeded in extracting the canula with the 
curved polypus forceps. The canula was of hard rubber. For six 



440 INDEX Oh SURGICAL PROGRESS. 

months after the operation the patient was suffering from cough and 
dyspnoea. The tracheal fistula could be closed only after repeated 
plastic operations. On February 17, 1885, the patient left the hospital 
quite cured. 

Case II. Civil officer A. M., aet. 46, entered the hospital June 2, 
1884. He had carcino?na lingucz. On July 26 the left part of the 
tongue was removed. On July 28, asphyxia from unknown cause. 
Electiicity, oxygen and artificial respiration had no beneficial effect. 
Dr. Reyer performed the usual tracheotomy, but it was to no purpose ; 
cyanosis was setting in. Then Dr. R. performed tracheo-incisio longi- 
tudinalis ad maximum. The trachea was explored thoroughly, but no 
foreign body found. Dr. R. introduced his finger down to bifurcation 
and found that the trachea below the jugulum was closed by an aneur- 
ism. Pressing with his finger against the back part of the trachea Dr. 
R. opened a free passage to the bronchial tubes, and respiration was 
restored. Then Dr. R. introduced the spring canula of Koenig, which 
thus saved the Hfe of the patient. The patient was improving and 
could breathe freely with canula removed. On September 7 the open- 
ing m the trachea was closed, and on September 22, the patient left 
the hospital. However on the next day asphyxia took place. A new 
tracheotomy was performed and Koenig's canula again introduced. 
On October 20, in the morning, haemorrhage ; in the evening, asphyxia. 
Dr. Levitsky, in whose charge the patient was, wanted to examine the 
canula, but in his hand was left only the external part, while the in- 
ternal, having somehow separated, dropped into the trachea. Dr. L. 
cut three rings of trachea, but could not reach the canula. Dr. Reyer 
arrived, extracted the canula and fixed it. Next day the aneurism 
burst. 

Case III. Female, of a syphilitic family, since childhood was suffer- 
ing from syphilitic laryngitis. After marriage she had syphilitic ulcers 
in the throat. She had dyspnoea for several years. In January, 1885, 
she caught cold — -pneumonia dextra crouposa and stenosis laryngis 
luetica. On February 3, being in a dangerous condition, she was 
brought into hospital where tracheotomy was performed at once. On 
March 3 she left the hospital cured of pneumonia. She could not 



HEAD AND NECK. 441 

breathe without the tube more than half an hour. On August 26 the 
patient again was brought into hospital, suffering from a severe dysp- 
noea. She was in the fourth month of pregnancy. On September i, 
asphyxia, which was relieved by introducing the Koenig tube. Sep- 
tember 3, thermotomia tracheahs longitudinalis ; trachea below the 
opening was found reduced to the size of a quill. The Koeriig's tube 
was introduced into the narrowed portion of the trachea, September 
6 a tube ^j^ cm. was introduced instead of the Koenig's, and gradually 
tubes of a larger diameter were introduced. On December 25 the pa- 
tient left the hospital; the tracheal canal was enlarged four times. In 
the end of March was expected the delivery. It was thought danger- 
ous or at least very inconvenient to leave the Koenig's tube in the 
throat during the labor. Therefore a tube of soft ruober with an end 
of the vulcanized rubber was introduced instead, and the patient was 
safely delivered. The patient was examined on May 13, 1886; she 
wears a silver canula all the time. On having closed its opening she 
can talk distinctly and loud. 

Case IV. Ivan T., peasant, 2tl. 21, suffering from dyspnoea, was ad- 
mitted to the hospital April 28, 1886. Two years ago he was subjected 
to tracheotomy and since then he had the tube which, on April 27, has 
split into two, the lower end having dropped into the trachea. On 
April 29 Dr. Reyer has performed thermotomia trachealis longitudi- 
nalis. No foreign body could be found. The patient was placed in 
the perpendicular position, head down : then Dr. R., on having intro- 
duced his finger, felt the canula at the bifurcation. Due to its gravity, 
the tube gradually approached the opening and was extracted. 

The three former cases were reported by Dr. A. Kroetsky, and the 
last one by Dr. R. Weber. Dr. K., who witnessed the operations de- 
scribed by him,- comes to the conclusion that the presence of a foreign 
body in the trachea and bronchi cannot be always proved by physical 
examination, that turning man^head down must be resorted to in cer- 
tain cases, and that Koenig's tube is invaluable in some cases of tra- 
cheotomy. — Chirurgichesky Vestnik. July. 1886. 

P. J. POPOFF (Brooklyn). 



442 INDEX OF SURGICAL PROGRESS. 

ABDOMEN. 

I. Strangulated Umbilical Hernia in a Pregnant ^A^oman. 
Operation. Death. P. Berthod. On December 23, 1885, the 
patient, set. 40, was admitted to Saint Louis Hospital under M. Le 
Uentu, suffering from strangulated umbilical hernia. She was three 
months gone in her fourth pregnancy, and since the first one had suf- 
fered from an umbilical hernia, which a bandage had hitherto con- 
trolled without inconvenience. Eight days before admission the hernia 
had caused pain so that the bandage had to be left off, and six days 
later, when attempting to hft a weight, she felt the pain became sud- 
denly worse, and symptoms of strangulation appeared. Taxis ,failed 
so the sac was opened, a mass of fat ligatured and cut off, and a 
knuckle of bowel having been freed of one or two adhesions was re- 
duced. The sac was sewed up with catgut and the skin with horse- 
hair — Listerian dressing. Symptoms of peritonitis appeared on the 25th. 
Vomiting and severe hiccups came on and she died on the morning 
of the 26th of December. No post mortem examination was obtained. 
The author draws attention to the frequent association of peritonitis 
Avith umbilical hernia when strangulated. This case gives little support 
to the view that the peritonitis is apt to spread below the diaphragm 
and paralyze it, as there was no dyspnoea, although aggravated hiccup. 
He states that the shock of the operation had no further effect on the 
pregnancy than to cause some uterine haemorrhage on the two nights 
following the operation. The first stopped spontaneously, the second 
was checked with an injection of hot water, but there was no threaten- 
ing miscarriage. — Gaz. Med. de Paris. May 22, 1886. 

II. A Case of Strangulated Internal Hernia into the For- 
amen of Winslow. J. E. Square. A clerk, set. 25, dined in ap- 
parent health at noon on May 7, walked about a quarter of a mile to 
his office and at 2 p. m. was seized with excruciating pain in the epi- 
gastrium. He returned home at once with difficulty, was given brandy 
and water and a dose of castor oil, and at 4 p. m. began to vomit. 
Pain and vomiting continued, with two sleepless nights, until the 9th 
when he was easier and sat out by the fire. In the evening the symp- 



CHEST AND ABDOMEN. 443 

toms returned as before. On the following evening — loth of May — 
Mr. Square saw him for the first time at 7 p. m. The patient was then 
in a most excited and restless state, with difficulty kept in bed ; face 
anxious and somewhat pinched, axillary temperature 103.4°, pulse 122, 
regular and small. He had not vomited for an hour or two. The 
former pain over the ensiform cartilage, which had been excruciating, 
had subsided. The legs were not drawn up, and the abdomen seemed 
natural. There was marked tenderness around umbilicus and at epi- 
gastrium, but nowhere else. Resonance all over abdomen, except at 
flank ; bowels bound since morning of 6th, no albumen in urine. In- 
testinal obstruction was diagnosed, and an enema of warm water and 
soap administered without effect. A larger enema in three hours 
caused a fluid stool with two solid faecal masses. The vomit was now 
faecal. At 3 a. m., on the nth, Mr. Square was hurriedly sent for; 
the patient was now in a most childish condition, so restless that he 
could neither be kept in bed nor be prevented from throwing off the 
bed clothes. Hands and feet cold and clammy ; pulse feeble, though 
quite conscious. After hypodermic injections of morphine he was left 
moderately quiet at 4:30 a. m. He became quieter and sank at 7 
o'clock after an illness of three days and seventeen hours. At the post 
mortem only a small amount of peritonitis was seen on first opening 
the abdomen. Great omentum drawn in among the small intestines to 
left of middle line, and moderately congested. Intestines distended 
with gas, but with little faeces. Fully eight inches of the ileum about 
two feet from its coecal end were firmly incarcerated in the foramen of 
Winslow, and were with some difficulty withdrawn. Its mesenterv was 
much congested, the intestine much more so. No perforation or ulcer- 
ation through the coats of the intestine. Margins of the foramen 
rounded and thickened — two fingers easily admitted. Coecum freely 
movable and furnished with a meso-coecum. Mr. Square believes that 
an early operation would have been successful. — Brit. Med. Jour. 
June 19, 1886. 

Charles W. Cathcart (Edinburgu). 



444 INDEX OF SURGICAL PROGRESS. 

EXTREMITIES. 

I. Primary Tuberculous Synovitis of the Tendinous 
Sheaths of the Wrist and Hand. MM. Jardet and Notta. 
A farm laborer, set. 59, strong and always healthy, no phthisical his- 
tory, personal or family, developed a fluctuating swelling on the 
palmar surface of the lower arm and wrist, painful, impeding the 
movements of the fingers, and giving the characteristic sensation of 
crepitation of the rice-grain cysts. The tumour removed from the 
arm contained no Hquid nor vice bodies, but was filled with loose false 
membranes, its wall very thick and forming a kind of cylinder, becom- 
ing thin at and extending beneath the annular ligament. When cut 
into a very little Hquid similar to synovial fluid could be squeezed out. 
It was dissected out and a 5 % phenilic solution injected. The pa- 
tient w-as discharged cured in twelve days, and was soon able to re- 
sume his work. 

The histological examination showed that the false membrane con- 
sisted entirely of fibrin, and that the wall contained tubercles composed 
of embrvomal cells and giant cells. No bacilH were found. — Soc. 
Anat. Oct. 1885. Le Prog. Med. Feb. 6. 1886. 

^. S. Abraham (London). 

II. On the Mechanism of Trigger- Finger. By. Dr. Stein- 
THAL (Heidelberg). S. had the opportunity of examining the right 
middle finger which had been exarticulated at the meta-carpophalangeal 
joint for post-inflammatory ankylosis (interphalangeal joint at a right 
angle). He first cut through the flexor-tendon over the ankylosis, 
whereupon motion became again free, but had the trigger lorm. This 
affected both flexion and extension ; it was most marked in the first 
interphalangeal joint. Its cause was found in the action of the lateral 
ligaments their insertion at the base of the second phalanx being some- 
what displaced towards the palm. 

The fibres of the lateral bands became more and more tense on 
slowly flexing the finger up to an angle of about 45° when on further 
flexion the two insertion points began to approach and the previous 
tension passed into the trigger motion. The same thing occurred dur- 



I 



GENITO- URINAR Y OR CANS. 4 1 5 

ing extension, only that here the volar fibres of the lateral bands be- 
came tense the dorsal lax — the opposite occurring on flexing. Konig 
had made a similar observation on the amputated phalanx of a toe. 
Only in his case an unequal elevation on the cartilaginous part of the 
basal phalanx made the lateral hgaments in a certain position very 
tense ; then on further flexion or extension the articular sarfaces came 
so into apposition that this prominent spot no longer had to bear the