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Full text of "The rules of aseptic and antiseptic surgery; a practical treatise for the use of students and the general practitioner"

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UNE MEOm UBRARY 
STANFORD UNIVERSITY 
MEDICAL CENTER 
STANFORD. CALIF. 94305 



THE RULES 



OF 



ASEPTIC AND ANTISEPTIC 
SURaERY 



A PBACTICAL TREATISE FOR THE USE OP STUDENTS 
AND THE GENERAL PRACTITIONER 



BY*'* • 



ARPAD G. GERSTER, M.D. 



mOFESSOR OF SCRGERT AT THE NEW YORK POLTCUKIC ; TWITIICO Sl?ROBON TO MOUKT SINAI HO8PITAI1 
AMD THE QERMAM HaePITALt KBW YORK 



ILLUSTRATED WITH TWO HUNDRED aKD FORTY-EIOHT EXORAVINGS 
AND THREE CHROMO-UTHOORAPHW PLATES 



S E <• O M> K 1> 1 T I O X . 




NEW YORK 
D. APPLETON AND COMPANY 

1888 



,•*, I : •„: •C'OPTRIOHT^lfeWl •• 



C©MPANY. 




PREFACE. 



The object of this volume is a systematic yet practical presentation 
of the Listerian principle that has revolutionized surgery within the last 
fifteen years. Its adoption has wrought so many incisive changes in 
practice, has shifted the surgeon's standpoint regarding all the important 
disciplines of the art in such a radical manner, that most English text- 
books of surgery, even those recently published, have become partly or 
entirely inadequate to the wants of the modern physician. 

To a large number of medical men the aseptic and antiseptic methods 
present an incongruous chaos of seemingly contradictory and often in- 
comprehensible detail, arbitrary and varying, according to the predilections 
or whims of this or that teacher. 

Yet the principle involved is based on the correct observation of a 
common biological process — namely, that of the decomposition of organic 
substances. The well-known methods employed since the earliest dawn 
of civilization for the preservation of organic, especially animal, sub- 
stances, are based upon the empirical yet correct appreciation of the 
causes of putrefaction, and the practical adaptation of these methods to 
the healing of operative or accidental wounds contains the whole essence 
of the new surgery. 

Evils that fonner generations of surgeons deplored, but could not 
effectually combat, such as septicttmiia, pyiBmia, liospital gangrene, and 
erysipelas, have been much abated, as a direct consequence of a clear 
understanding of their esseiitial nature and causation. 

Prevention has become the watchword of modern practice, and it can 
be said that, by the successful employment of the preventive methods of 
the present day, surgery has become a conserimtive branch of the heal- 
ing art. 



iv PREFACE. 

Tlie elimination of tlio accidental disturbances of repair caused by 
wound infection has depressed the percentage of mortality following 
amputation of the extremities from an average of thirty-five per cent to 
alK)ut fifteen per cent. 

The dread of undertaking and submitting to a surgical operation has 
greatly diminished, and timely — that is, early — surgical interference has 
become more and more frequent, to the great advantage of both patient 
and physician. 

As a direct consequence of the implied obligation of rendering timely 
aid where possible, a laudable eagerness for an early diagnosis is develoj^ed, 
and, there being so much to be gained by diagnostic knowledge, thorough 
and practical study of the morbid processes requiring surgical aid has 
been greatly stimulated. 

The fear of suppuration with its dreadful consequences does not stay 
now the hand c>f the surgeon as of old, when an operation was always 
considered a forlorn hope and a last resort. Strangulated hemise, for 
instance, are not allowed to gangrene as often as formerly, and herniotomy 
is readily resorted to, as it is well known that the dangers of an aseptic 
herniotomy done on a healthy gut are diminutive in comparison to the 
certain and enormous danger of strangulation itself. 

By the conviction that a fault of omission may \\e followed by irre- 
mediable mischief, the sense of responsibility is stirred up to vigilance, 
which again breeds self-reliance and firmness of purpose in advising and 
carrying out incisive measures, made clearly necessary by a well-recognized 
danger to life or limb. And an additional degree of responsibility is 
ini(K)sed by the very safety of aseptic operations. 

It can not now be successfully denied that t/w tturyeon^s acts deter- 
mine the faie of a ft'esh loouiufy and t/tat !f« infection and /<uppuration 
are due to hi« teehnica/ /aults of omission or iwn mission. 

The principle underlying antiseptic surgery has ceased to be the 
subject of serious controversy. The autlior does not undertake to prove 
each of his statements to the satisfaction of those who look but see not. 
Ilis object is instniction rather than controversy. Every one will have 
to j>as8 his |>eriiHl of apprenticeship with its blunders and lessons. But 
he who lxHH>mes a master, to whom the primary healing of a fresh 
wound remains not a curiosity but becomes a matter of course, will not 
doubt the great change that has come over surgery. 



PREFACE. 



The purely practical tendency of the work iniide a rather free ar- 
rangement of tlie several partg of the Bubject-matter a necessity, or at 
least a convenience ; yet ii sufficiency of systematic order was preserved 
to give the collection of papers the character of a well-rounded, organic 
whole. 

The author begs to state explicitly that completeness — that is, the 
inclusion of all the disciplines of surgery — was not aimed at, else a com- 
plete text-lx»ok of surpjcry won Id have resulted. The leading idea, trace- 
able througli all the matter contained in the book, is to illustrate the 
incisive practical cli:mges that the adopti(«i of aseptic and antiseptic meth- 
ods has wrought in surgiwil therapy. llei*eby the changes in wound 
treatment are meant, as well as the notable extension of active surgery 
into fields formerly considered a noli me tajujere. 

As a consequence of the stiijMi-udous growth uf oj>erative surgery within 
the last decade, a fruitful development of operative technique is to Ix* 
noted also. In accordance with the desire of the author to pi'esont to the 
profession a vivid and true picture of contemporaneous methods, the terms 
used as the title of this work should be accepted in their widest signifi- 
cance. 

Confinement to the meager details of those manipulations which, 
strictly speaking, constitute aseptic and antiseptic measureSj would have 
yielded an inadequate and tedious compilation. I )n t!ie other hand, it is 
hoped that the pathologicitl and technical diveraious, intrcKiuced for tlie 
te of laying a rational foundation to the principles composing tlie 
'WBenee of ant'qHii'ntsltlc surgery, may be admitted as gerruane to the 
subject. 

The methods of wound treatment hei-eiu explained are to a certain 
extent still undergoing changes, hencje should not be accepted Eis tinal. 
Yet it is undem'able tliat, as the clearness of the comprehension of the 
6\\nf\ii jn'inc'tph- of asepticism applied to wound treatment has advanced, 
so the frequent changes and bewildering vacillation characteristic of the 
experimental stage of the new discipline have naturally given way to 
steadier methods. At present, changes are not so freipient its formerly, 
yet progress, especially the conquest of new iields for the legitimate prac- 
tice of active surgery, is not at a standstill. 

The author is well aware that the practical directions recommended 
by him are not the only ones that lead to success. Yet, in the main, he 



VI 



PREFACE. 



1 



lias refrained from quoting other anthorities. As reasons for this ma}' \te 
adduced, tii'st, the disiiiclinatidn to write a bulky text-book, and, further-^ 
the knowledge that the inteivst of the reader is proportionate to tln?*'-^ 
directness and immediate character of the facts and thoughts contained—^ 
in the work nnder perusal. 

As far as possible, all important statements will be found borne out by 
illustrative examples taken from the author's personal experience. 

The author is much indebted to the gentlemen composing the house 
stalls of the (xennati ami IVIouiit Sinai IlDspitali* for the ready ktndnei* 
and courtesy with vvlueb their help was protfered in traciiijLj and extract- 
ing histories of cases, and in making the very numerous photographic 
plates that form the bulk of the iilnstrntions. ■ 

Great technical difficulties, inherent to the unfavorable seascni, the 
small space and inadequate lightiuf^ of the operating-rooms of the men- 
tioned hospitals, had to be overcome in exposing the sensitive plates- 
The matter was rendered still more difficult by the circumstance that 
operating and photographing were done by one and the same set of per- 
sons, a!id that the welfare and interests of the patients? themselves had 
constantly t(» be sedulously cinisidered. ■ 

In view of the defective character <»f niiiny of the authors negatives^" 
the greatest praise l>elongB to Mi-. William Kurtz, to whose artistic taste, 
skill, and \'ersatility is due their excellent reproduction by pboti>typo- 
graph ie |irot*ess. 

ProjX'r credit is given for the lithographic plates copied from Rosen- 
bach, for the excellent microphotographs reproduced from Koch's clas^i- 
cal reports, and for a ft-w otiier ilhistrations borrowed from Esmarch, 
llenkf, and Bumm. 

In conclusion, the author may be permitted to express the hope that, 
by publishing his share of experience gathered from a modest public and 
private practice, he may suct-eed to somewhat propagate and popularize 
the principles and practice of antiparasitic surgery. 

Nbw York, Septnnlxr .% 1887. 




CONTENTS. 



Pabt I.— asepsis. 

CHAPTER I. MOK 

Wzix m SkpsB AHD AsiFsn ? 8 

CHAPTER IL 

'^ttme WouHos-^AsBPTio Thkatmkmt ... ..'..'.. 6 

L Genenl remarks 5 

n. Bnles of sarf^oal cleanlineBB 7 

1. Hands 7 

2. The instruments ? 

8. Woond irrigation 7 

4. Sponges 8 

ft. Materials for ligatures and sutures 8 

8. Drainage-tubes and elastic ligatures 9 

7. Disinfecting lotions 10 

8. Dressings - 11 

(1) Types of dressings . . .11 

a. Simple exsiccation. Bismuth, iodoform 11 

l>. Chemical sterilization combined with exsiccation. Dry dressings 12 
e. Scbede's modification of the drj dressing, favoring the organization of 

the moist blood-clot . . . .12 

d. Simple chemical sterilization. Moist dressings . '!''. ... 18 

(2) Preparation of dressings 14 

a. Gauze 14 

(a) Corrosive-sublimate gauze 16 

(6) lodoformized gauze 16 

b. Absortient cotton, or common cotton batting 15 

e. Sawdust 16 

d. Moss 17 

m. Practical application of rules 17 

1. In operating 17 

2. Change of dressings 20 

lY. Aseptic measures in emergencies 23 

Operating bag and kit 25 

CHAPTER III. 

^n.gD WODNDS. — AKTISEPTIC TREATMENT. — DiFFERENCK BETWCEN ASEPTIC AND ANTISEPTIC 

Methods. — ^Illustration of Antiseptic Method 27 



viii CONTENTS. 



CHAPTER IV. 

Pi 
Special Rulks rboardino thr Treatment of Accidental Woonds .... 

I. Temporary measures 

II. Definitive relief 

1 . Contaminated wounds 

2. Aseptic wounds 

8. Gunshot wounds 



CHAPTER V. 

Special Application of the Aseptic Method 

A. General principles 

I. Technique of surgical dissection 

II. Sutures 

III. Drainage 

b. Application of aseptic method to diverse organs and regions 

I. Ligatures of arteries in their continuity 

II. Extirpation of tumors 

Presenration of asepsis 

Safe removal 

Complete removal 

ni. Amputation of limbs 

1. Aseptics and antiseptics of amputation 

a. Clean cases 

b. Mildly septic cases 

e. Septic cases of greater intensity 

2. Haemorrhage 

a. Artificial ansemia 

b. Ligatures and final htemostasis 

8. Securing of a good stump 

lY. Operations about non-suppurating joints 

1. Puncture and irrigation 

2. Arthrotomy 

a. Hydrops genu 

b. Vegetations 

e. Floating bodies of the knee-joint 

d. Suturing of the fractured patella 

3. Arthrotomy for irreducible or habitual dislocation, and for deformity due to 

fracture 

V. Operations for deformities 

1 . Knock-knee and bow.leg 

2. Bony anchylosis in a vicious position 

3. Deformed callus 

4. Club-foot and pes valgus 

VI. Plastic operations 

VII. Aseptics of the oral cavity 

VIII. laryngeal operations 

1. Tracheotomy 

a. Superior tracheotomy 

b. Inferior tracheotomy 1 

2. L8r}-ngofi8sure 1 

8. Extirpation of the larynx ... 1 



CONTENTS. ix 

' PAOB 

IX. Goitre 107 

X. Ampatation of the breast 109 

XI. A1.M]()iuitia1 opt>miiiis;4 115 

1. G<iiti^riil rvtaarke 116 

2. IIorLiiDtomy 117 

a. Demiotomy for BtranguUtion 119 

b. Radical operation for bemia 128 

S. Laparotomy 188 

a. Sxploratory indaion 188 

b. Abdoniiual Uiiiiur:^ . 188 

(a) Gonoral rcmnrks . . 138 

(6) ^dfll obsiirvaUons 140 

(a) f)v&rLaii tumors . 140 

(/3) Supra-Taginal hysterectomy 148 

(y) Nephrectomy 145 

c. Gastrostomy 146 

d. Ckdotomy . . 147 

(a) Lombar colotoray 147 

(b) Inguinal colotomy . 148 

Xn. Hydrocele, Tarioooele, and castration 149 

1. Hydrops of tlie tunica va^nalis 149 

2. Varioooele 161 

8. Castration 162 

^IL Asepdc operations on the rectum 164 

1. General observations 164 

2. Hemorrhoids 164 

8. Rectal tumorfl 167 

XrV. Aseptics of the bladder 159 

1. Catheterism 169 

2 Utholapaxy 161 

3. Cystotomy 162 

a. Perineal section 162 

6. Suprapubic section 168 



Part II.— ANTISEPSIS. 

CHAPTER VI. 

■*-*"*yiui. History op Idiopathic Soppuration. — ^Treatment of Scppcratiom . . . 169 

I. The cause of suppuration, or phlegmon 169 

II. Portals of infection 171 

1. Infection through lesions of the skin 171 

2. Infection through lesion:; of the mucous membranes 172 

III. Entrance. pro|;ressi, nnU lot'alizjilion of the infection 173 

M{K.>lmnical irritiitiutt 175 

Chemiial ami t^aloriu irritation 176 

IV, Dt^Tdnpimmt of plilcj^iiiuTi ........... 177 

V. Spread of uuppuratiun 179 

VL Diagnosis and treatment of phlegmon 184 



X CONTENTS. 

PAOB 

1. General principles 184 

a. Superficial suppuration, or septic ulcer 185 

6. Cutaneous and subcutaneous phlegmon 185 

e. Deep-seated or subfascial phlegmon. Lymph-gland abscess . . .189 

(/. Acute infectious osteomyelitis 191 

e. Chronic suppuration due to bone necrosis. Necrotomy . . . .104 

2. Phlegmonous affections of some special regions 2U8 

a. Face. Floor of the mouth. Neck. Temporal and mastoid r^ons . 208 

(a) Face 209 

{b) Neck 211 

(a) Fauces and pharynx 211 

(/3) Submaxillary and parotid cynanche 217 

(y) Acute glandular abscesses of the anterior and lateral cervical regions 220 

(8) Glandular abscesses of the temporal, mastoid, and occipital regions 221 

6. Mammary and retro-mammary abscess 223 

c. Empyema 226 

d. Phlegmon of the palmar nspect of the hand, of the arm, and axilla . . 280 

e. Suppurative affections of the lower extremity 289 

(a) Ingrown toe-nail 239 

(6) Chronic ulc«rs of the leg 241 

(e) Acute suppuration of the prepatcUary bursa 242 

{d} Acute suppuration of the knee-joint 242 

(e) Suppuration of the inguinal glands 245 

/. Perityphlitic abscesses 246 

ff. Abscess of the liver 251 

/t. Lumbar abscesses 2.'>1 

i. Anal abscess. Fistula in ano 254 

CHAPTER VIL 

Ebtsipblas and Psrudo-Erysipklas 259 



Part III. -TUBERCULOSIS: 
ITS ASEPTIC AND ANTISEPTIC TREATMENT. 

CHAPTER VIIL 

Natural History a.nd Treatment op Tuberculosis 263 

L Etiology of tuberculosis. Tubercle bacillus 263 

II. Complication of tuberculosis with pyogenic or suppurative infection . . 267 

III. Treatment of tuberculosis 267 

(reneral principles 267 

Local treatment of tuberculosis . 268 

1. (.^utaneous tuberculosis. Lupus 268 

2. Tuberculosis of the mucous membranes 269 

8. Tuberculosis of the lymphatic glands, or scrofula 269 

4. Tuberculosis of tendinous sheaths 271 

6. Tuberculosis of bone. Caries. Cold abscess 273 

6. Tuberculosis of joints. White swelling 276 



CONTENTS. xi 

PAQB 

General part 276 

a. Technique of joint exsection 27S 

(a) Septic injection from without 276 

(6) Complete removal of tuberculous tissues 276 

(c) Ck>ntrol of haemorrhage 276 

{d) Preservation of function 276 

b. After-treatment 277 

Special part 278 

a. Shoulder-joiut 278 

b. Elbow 280 

e. Wrist and hand . 284 

d. Hip>joint 286 

e. Knee-joint ..... ...... 287 

/. Ankle and foot 298 



Part IV.— GONORRIICEA : 
ITS ANTISEPTIC TREATMENT. 

CHAPTER IX. 

RAL HiSTORT AND TrEATHENT OF GONORRHSA 299 

I. Etiology of gonorrhoea. Gonococcus 299 

II. Treatment of gonorrhoea 801 

1. Acute gonorrhoea. Clap 801 

a. Anterior gonorrhoeal urethritis 802 

b. Deep-seated gonorrhoeal urethritis 804 

2. Chronic gonorrhoea. Gleet 307 

a. Inflammatory stenosis (incipient stricture) and permanent or cicatricial 

stricture of the urethra 307 

(a) Anterior urethra 307 

(6) Deep urethral strictures 313 

b. Vegetations of the urethra 316 

c. Granular urethritis 316 

d. Chronic catarrh of the posterior part of the urethra, and chronic cystitis . 316 



Part V.— SYPHILIS : 
:PTIC and ANTISEITIC TREATMENT OF ITS E.XTERNAL LESIDNS. 

rilAPTER X. 

ncs ASD A«m.«EPTifs .applied t" External SvPHiLrTif Le.-'ion.s .... :;_'l 

1. .\i>€ptic treatrri'-nt of firirnary induration . , . . ''.i\ 

2. Anti.*€ptic rreatment of tin- primary ?_vyjhilitic ulwr '''i\ 

a. Chemical -terilization an'l .-iirfac''.<l rain ape by nie<li<.-at<^l iiioi*t dr'rs^iiif;^ .'J21 

b. Chemical -t^-rilization by strone caustics ....... 'il't 

e. SWfrilization ov the actual cauterv ........ 3'.J*» 



PART I. 



ASEPSIS 



lANE \.mm. i^m^m mm^^w 



CHAPTER I. 



WHAT ARE SEPSIS AND ASKPS/Sf 



i 



It is not intended liere tn cntc-r \nU) un exiiaustive exposition of the 
e*!j«ence of suppuration and the whole complex of conditions known under 
the rmtne of sepsis. It may suffice for the present to give a rough out- 
line of the views thai prevail regardinj^ the causation of the conditious in 
question. 

Albuminoid substance;', such, for iiistnnef, us blood ur blood-scrnni — 
in fact, all the ti&Hues of the dead animal body — will become putrid under 
certain well-known oouditions. TliGse are, Gi-st, maiyfurc ; secondly, a cer- 
tain temperature called wttrmfk, for short ; and, thirdly, the }>resencc uf 
living organisms, or fuugi, named sehizomycetes, better known under the 
name of hadfria and mirroaian. If all these factors are jiresent, the ani- 
mal substance in (ptestion will ferment or jiutrefy. Absence of any one of 
these factors will be sufficient to prevent decomposition. To illustrate this 
proposition, we shall mention eomnion facts. Fresh meat or Hsh, well 
dried, can be ihddinitely ])reserved ; freezing and, to a certain exteul, rojist- 
ing will also prevent its spoiling ; and, lastly, exclusion of micro-organisms 
by air-tight packing or sealing, after boiling, will insure j)reservation for an 
indefinite length of time. 

The active agents of decomposition are the micro-organisms, wliieh will 
develop at once their disintegrating activity as the conditions favorable to 
their development (moisture and a certain temperattire) are present. 

We then either thoroughly dry the substance to he preserved or produce 
and preserve a very low or very higii tem'perature in it. all of which will pre- 
vent the development of fungi. Exclusion of the fungi is herein unneccs- 
eary. The third mode of preservation is that employed in canning meats, 
hoy are first boiled thoroughly, then the vessel wherein this boiling was 
one is hermetically scaled while the substance is «till very hot. Here we 
ave a combiruition of first destroying the vitality of Fueh fungi as are ctui- 
tained in the meal tjcforo boiling, and, secondly., exclusion of access of new 
tnicrrHorjjanisms to the sterilized substance. 



NoTK. — Ttic roo-it effective HU-rilizer is the aptual fniitn-v. It not only (!p?trf»V!« nil tlio nox- 
ious genrm aiDtaineil within tliu tii«i«iii.-s, but ai iht* satiit* lime pruvidefl tlkcse wilh an ufteu drjr 
Mid always hcrrnetio imhA ekgiinut further iufoi^tioii, If tlic cschur and it« vicinity be well ducted 




• • •• ,••• • • •*••••• 

• * 'By b.*1*p|>fcEf 0N» aM) C9MP 



C9MP/nfT. 



CONTENTS. xi 

PAOB 

General part 276 

a. Tedudque of joint exMction 27S 

(a) Septic injection from without 275 

(6) Complete removal of taberouloua tissues 27tf 

(e) Control of htemorrhage 276 

(<f ) Freaerrti&oa of function 276 

b. After-treatment 277 

^wdal {»rt 278 

a. Sumlder-jolnt 278 

b. Elbow 280 

c. Wtist and band . 284 

d. Hip-joint 285 

e. Knee-joint . 287 

/. Ankle and foot 298 



Pakt IV.— G0N0RRH(EA : 

ITS ANTISEPTIC TREATMENT. 

CHAPTER IX. 

Nattbai. Histobt and TsBATiinrr of Gonorbhoa 299 

I. Etiology of gonorriioea. Gonocoocus 299 

U. Treatment of gonorrboea . 801 

1. Acute gonorrboea. Clap 801 

a. Anterior gonorriioeal uretbritis . . 802 

6. Deep-seated gonorrboeal urethritis 804 

2. Chronic gonorrbcea. Gleet 807 

a. Inflammatory stenosis (incipient stricture) and permanent or cicatridal 

stricture of the urethra 807 

(a). Anterior orethra 807 

(ft) Deep urethral strictures . S13 

b. V^etations of the urethra 815 

e. Granular urethritis 815 

d. Chnmic catarrh of the posterior part of the urethra, and chronic ejratitis . 316 



Part V.— SYPHILIS : 
ASEPTIC AND ANTISEPTIC TREATMENT OF ITS EXTERNAL LESIONS. 

CHAPTER X. 

ASKPTICS AND AUTiaEPTICa APPLIED TO EXTERNAL SYPHILITIC LeSIONS .321 

1. Aseptic treatment of primary induration 821 

2. Antiseptic treatment of the primary syphilitic ulcer 324 

a. Chemical sterilization and surface-drainage by medicated moist dressinp^s 324 

b. Chemical sterilization by strong caustics 325 

e. Sterilization by the actual cautery 326 



^ 



ASEPTIC WOUNDS^ASEPTIC TRKATMENT. 7 

of a wound. Hence it is desirable to eni|)loy a liquid tliat. aside from its 
non-irritiint quality, will have the property of iicutntiizibrir or rather 
extinguishing the noxious effects of those pjirtieles of dust tlmt can not 
be washed awMy by the irrir^ation, but remain imbedded in the tissues. 
T'his in rhemiral .<teriUzaiiun. 

Different dicMnfecting; jiuhitious are used for Ihis purjuwe to answer 
various requirements. Their composition and uses will be mentioned here- 
after. 

XOTt— Kiirmiiel, of Hanibiirg, lias shown that a. iliistless operating-room can be liail in a 
well-uppointod liospital, ami \eulier, i>f Kiel, has excellent n'suilfi from ujK'iationn done in sut-h 
a dusileiis room, with well-clcaneod lianiln, appiiralus, au<l Jntilrutm'riO', irithouf thr cmpfiytfuunt 
of ant'urptie fuidt. Even the dre«sinj?s iisod are not imjiroj^naied with any ami*eptic chemical, 
Kut are merely "sterilized" by beinR cxpused lu dry Iteat. No sponges are usst'd, att hhwd 
beitii; removed with a merilizi'd B^tiiitioii of ernitinow s£dt(t>: 1000), wliieh is abeiolutely unirri- 
tating, and ccrtninlj forms the most gentle inauiier uf clenaoiug a wound. 



I 
I 



IL RULUS OF SURGICAIi OLEANLINESS. 

1. Haods. — The hands iind forearms. fspvn'aJhf the Jingcr-nniJs, of tlie 
surgeon and his assistants should be well scrubbed in hot water with soap 
and brnsh for tive niinntcs ; likewise tfre region of the body of the patient 
to be o}>erat«d on after carefully slmviujr off the hair. After this follows an 
immersion of the hands in corrosive sublimate lotion for one minute. 

Note 1. — Kiinimcr» recoinniendation of green »oap (potnfih or soft soflp) ia excellent, on ac- 
cuant of itH great solvent projierties, 

NuTK 2. — Uinps, espt-tially (hose having Blone aettSn^s, pfaould never bo worn In the surgeon 
or his \\\As in an ofHrrutton. Ban|:;le8, and bracelets of female nuraea should not be tolerated. 
Every one's ami* shonbl Ik' bared and s-vnibbed to the eUjows. 

2. The instmnieilts should be subjected to a careful and minute cleans- 
injr witii stnqn and brnsh. especial care bein.ir laki'ii to remove dry particles 
of blood, pus, etc., from the grooves and behind the clasps of the more com- 
posite instruments, which ought to be taken apart each time for cleanging. 
They shonld be immersed for ten minutes in a three-per-cent solution of 
carbolic .icid befitre use. 

Note. — Tiie surgeon should lenm to get alonj; with as few instruments as possible, In 
pcl«>ctidj; in!<tnintents, preference should be given to the most simple. The best instruments are 
those hnvinpc smooth and well-[>ulished surfaees; grooved or roughened handles are liurd to clean 
and unn«ceii»ary. 

3. Wound Irrigation. — Dnrimj ihf opfrnfion the wound slnuild be fre- 
quently irrigated with the proi>er kind of a disinfecting fluid; the hands 
of the surgeon and his assistants should be also washed at not too long 
intervals in a disinfecting fluid (corrosive sublimate, 1 : 1000) ; the instru- 
ments should be kept immersed in a thrci'-jier-cent solution of carbolic 
acid (which is the least injurious to them). 

NoT«. — Whenever any one of thoae enpapetl at an operation touehea a not disinfeeted object 
— bmiide a chair, opens the s^iudow or door, helps the an«'sthetizer during a vonjiting spell of 






RULES OF ASEPTIC AND ANTISEI^IC SURGERY, 



the paticBtf flcrmtcfaes his face, or wipen his noae— t/ m aAio/u/<^y neeeMorjf that his hands be 
arruhbed and dmK/eeMt anar. InstrumeDtj that are ac4-idoiita1ly drfjippc^l should be left un 
touched. Raw awistaata, and ttpedaittt nnraa, male and female, traiiK.^! or untrained, should be 
eanmtlj instrucU.'d beforehand, and eotutanltt/ iralched afterward, regarding this all-inipartaiit 
disdplinc. 

4. Sponges should be beaten free from calcareous particles, then im- 
mersed for fifteen minutes in dilnte muriatic acid to dissolve the remnant 
of lime, washed in cold water, theu thoroughly kneaded by hand with green 
soap in hot water for five minutes, rinsed, and then immersed in a five-per- 
cent solution of carbolic acid, in which thej remain until required for use. 
Sponges used once in an aseptic operation can be used again. Careful wash- 
ing out with green soap and hot water of all the remnants of fibrin and 
blood, then immersion in a five-per-cent solution of carbolic acid, is sufti- 
cient. It i.^ not good to use too man}' sponges at an operation. When sat- 
urated with blood at an operation, they should be washed free from it in 
hot water, then thrown into a basin filled witli caibolic solution, and hence 
handed to the surgeon. Carbolic acid is preferable for preservation of 
sponges until use. because it does not become decomposed and inert, as, for 
instance, corrosive snblimate. 

Jftrrt. — i?e!ectfd Florida sponger are cheap and good. In Xew York a pound can be bought, 
for about tvo dolUn, each sponge cofttli^ on an average two cents. 

5. Materials for Ligatures and Sutures.— Well-prepared cait/uf of differ- 
ent thicknesjies will answer every purpose for ligntui-es antl sutures. The- 
finciit suture work on the intestines can be neatly and reliably done witla 
cat^t No. 0. The most massive pedicle can be safely tied with catgut No. 
4. For ordinary ligatures and sutures. No. 1 will be most convenient, audL 
should constitute the bulk of the snrgeon's supply. 

The simplest way of preparing catgut is Kocher's : Immerse catgut for^ 
twenty-fonr hour^ in goml oil of juniper (ol junijieri baccarum, ffil of' thf^ 
b^rnj, not the oil gained from tlie wood) ; transfer into and preserve ina^ 
absolute alcohol und! use. Alcohol ki'cjis catgut hard uiul firm, yet flexible^ 
Carbolic acid or corrosive sublimate will make it brittle and weak. When^ 
it is desirable to prevent too early absorption, as, for instance, in intestinaV- 
sutures, a hardening process shonld he aildwl to the disinfection. The jirti- 
cle should be washed in alcohol, then placed into a quart of a fivc-jwr-cenl 

solution of carbolic acid containing thirty grains of bichromate of iK)tash^ 

Forty-eight hours' immersion will prodnce catgut that will resist the actior 
of the living tissues for a week nv longer. Large-sized catgut needs a longci 
immersion. Wind up on bobbins. 

Xon 1. — Good catgut can t>e prwuT<.Hj from L. H. KclUir k Co., ft4 Nansatt Street, Xen^ 
York, for n moderate price. Drv preservation makci^ catRDl more suitable for transportation ^ 
Inimene the prepared article for five minutes in ether, lOO; iodoform, 6. Take out and place iar^ 
a Well-corked, wide-moutbed bottle. A film of iodofonn will eover each thread. 

NoTB li. — The author observed outv uumistakahle >rouml mjVction f>i/ improperltf kept eal^it^^ 
Cask. — Jennj Marks, scrrant-girl, aged tweiily, admitted November lo, 1893, to IJount Sini*^ 
Ho«pit«l with habiiuul »ubcora«.-«>id di;stocatioQ of the right tihouldcr-juint. " Sprain *' had bee" 





I 



dia(!;noaticated hy a fihysk-inn, seven weeks previoiiH to her admiiision, who ordered a liaiitient, 
On u<ltui8!<ion, reduction wiis eiisily efToeted by manipiilatioti, but fhe w< ipht of t\m !iinb was suf- 
ficient to reproduce the ili.-«location. A plai»ti'i-of-Pari>i jackol, ineloisiiig the reduced anu, waa 
applied and worn for four weekn witliout any efftx-t. Dee. 11th. — The joint wbj freely openwi 
by an anterior longituithuil inrision, when it hecame evident that the tendeney to di^loeatlon wo,^ 
due to laxity or redundancy of the anterior part of the enp.^itlar ligament. By two senii-clHpli- 
cal incision?, a piece of the eapnul** one inch long and fialf un inch in width wai^ removed. The 
capsular a» well as the museuiiir and the skin woinid were united by three tiers of interrupted 
catgut suture?, a ilmina<2fe-tubc having previously teen e.irricd ju-il wilhin the eapsule. The 
next day mtHkrate fever (K'l Fahr.), )nit great di-jection, headache, ami vi»mi(}ng were ohjserved 
llu' patient coini)l;iining of umch pain in the joint. Dee. LVft. — The iSiermojueter indicated 
103° Fnhr., with u corrcppondiiig increase of the general di.-lnrbaneo. The patient was aniesf- 
tbetizcd, and the wound was exposed. No redness, only stight nedeuia was vi.»Uile. The wouTid 
was reopened. Finn agglutination was present everywhere except iu four places, whore swollen, 
discolored ligatures applied to the circuniflex artery mid »otne smaller ves»ela were seen sur- 
rounded by a halo of yellowish, semi-fluid, hrokfti-d'iwn tissue, evidenlty representing snnill 
absoesses that were forming about the catgut ligatures. They were remured, the wound was 
irrigated with ciirbolic hilivn, and packe<l with gauze. The fever fell oITat ortce, and no further 
complication interrupted the course of healing. The habitual luxation was also cured. 

Silk can be rendered iiiiirritant by boiling it for an botir in a five-per- 
cent solution of carbolic at'id (Czcrny), tlu^n jinvorving in alcobol. 

Sil/i-'ieunn (jut is fxcelletit miiterisil for snhtritiij;. It is luvpattHl bkc 
eilk, and before uso shonld be .-soaked awhile in carbolic lotion to make it 
supple. Its advanta.ffc : it is ea.sy to tbread. 

0. Drainage-tubes and elastic ligatures are cut into ]inipcr lengths— tliat 

is, a little .shorter than the height of the wide-mouthed bottle iu wbicb they 

ifcTP kept- This is filled with a Hve-|)er-cent jsolution of carbolie acid, that 

^should be renewed from time to time. Tlie tubes will uhvay*i occupy an 

upright jK)sition in the bottle, and can Ije taketi out easily. 

NoTK. — Rubber Tubing of black material i* preferable to (he ctiarser and unyielding wblto 
stuff, on accuunt of its softnes.-i and pliability. 

Theoretically speaking, a perffcilif aseptic wtmnd doe^ not require any 
drain:i;.'e. If the .<e«TetionH following an operulion or injury do not contain 
anythitig that is Ciipable of inducing pntritl clumge.% tbey will be absorbed, 
and will not cause any di.sturbance in the wound or the general health. The 
largo blood-elot around a fractured bone i;-; liarmlessly absorbed ; a large 
blood-clot iu nn aseptic operation wound will be also absorbed without local 
or general disturbance, as Mrs. B.'s case (sec page 5) has shown. The 
experienced surgeon who has mastered the tecbnitjue of aseptieism will not 
hesitate to close up witbuut drainage a sraall wound, as, for instance, after 
deligating the subclavian or iliac arteries. But, in operations where large 
surfaces were long exposed, and where the wound is very irregular, the pot<- 
sibility of a however slight and unavoidable contamination should alway.s 
be kept in view, Vents should therefore be provided in the shape of prop- 
erly placed draiuage-tubcs for the easy egrcsi!? of secretion j?,^ possibly contain- 
ing elements of future decomposition. If the healing be prompt, the tubes 
can be withdrawn on t!ie fourth or sixth day. In case of suppuration, 
bland or destructive, they will bo in place, and very opportune. 



i 



1(1 RULES OP ASEPTIC AND ANTISEPTIC SURGERY. 

7. Disinfecting Lotions. — With a few exceptions (very laige wonnds 
rt'fjuirin^ prulongcd irrigation, and in o|)eratiou8 involving the peritonenm), 
two lotions will be found sufficient. For the immersion of the instramoDte, 
a thrrK;-f)er-cent solution of carbolic acid, and for the iirigation and disin- 
frfi;tion of hands and skin, a solution of corrosive sublimate of 1 : 1,000— 
I..VK). 

Smv.. — Tilt! almoKt cxcluflive uku by the author of carbolic acid and oorrosire subUmate 
MM ffrmlcUyn irt intont!onal. It was determined by the fact that these substances are, J&it, 
thortwf^hly reliable and liip;hly effective; secondly, procurable almost eTer3rwhere, in the 
(irjuntry nUmt an well uh in the city ; (hirdli/, bcoaime adherence to certain carefully sdected 
(•iilMtanccM reHultH in a thor<>u;;h knowledge of their proper use under varying conditioos. 

tioih'd waU-r is preferable as a solvent. It alone would be no doubt suf- 
ficirrnt if we were absolutely sure against the introduction of filth into the 
wound. 

NotB. — A remly and handy way of mixing the lotions is the following one : 
OirW/> Arid. — One tabltfspuonful or four teaspoonfuls to a quart bottle of hot water will 
rnaki' a lotion of the Htn-ngth of about three per cent, reckoning 660 grammes to the ordinary 
wUK'-lxittlc 

(,'orrti*ivr Suf/linui/i: — Ke«'i» on hand a few ounces of an alcoholic solution of the salt of 1 : 10 
in a (fluH)<-HU>p|N!r(*d iKittlc (in boxwood case for transportation). One teaspoonful of this added 
U) a (|iinK lK>ttl<! of hot water will make about a 1 : 1,600 solution, which can be weakened by 
dil'ition. TIh* addition of one ti>aHiKM>nful of cooking-salt will pR'vent disintegration of the roer- 
mric preparation. 

lioro-Snlirylir Lo/ioti. — In cases where carbolic or mercurial poisoning 
could 1k! produc(!d by the use of mercuric or carbolic irrigation, Thiersch's 
Molulion is corntnendable as a substitute. It consists of salicylic acid 2, 
\xtrwU; tic'ul {"Z, and hot water 1,000 parts. It is non-poisonous, very bland, 
and th(! peritoneum can l)e watched with it with impunity. External wounds 
of large urn', should be also irrigated with this lotion. A final thorougli 
irrigation with corrosive sublimate should sterilize the wound before clos^ 
ing it. 

KtfTK. — The seli-ction of difleri-nt lotions should be governed by the following experience* s 
(■arlftlie htiotm arr dnuijtrouH to Htna/l children, even in great dilution, and should never be use^ 
on tlietii. Corrosive subliuiiitcf is also poisonous, causing salivntitm, and occasionally fatal diph—- 
theriti<- inflamiiiution of the ileum and the thick gut, if its use is immoderate. Wherever supers 
fu*iul uleet-s or influiiiiiiHtions of the cutis require the antiphlogi.stic action of the very diffusible 
<-artKilic lotion, it should be emijloyed in the strength of two or three per cent. The continued 
use of higher concentrations will corro<le the tissues, and is otherwise dangerous. 

Where a direct u])plicati(in of the loti<m to the wounded or diseased surface is desirable, aa, 
for instance, in all bloody operations, mercuric bichloride deserves the preference over carbolic 
acid. Kven wirak soluticms (as 1 : 6,000) have a drndcd germicidal power, and can be used on 
very extensive wounds for hours without serious danger of intoxication. The final irrigation of 
an oi)eration wound should always be done with a stronger (1 : 1,000) solution. Abscess cavities 
will always require the stronger solutions. 

The greatest advantage of corrosive sublimate over carbolic acid is, however, to be sought in 
its different effect u|Km the fresh blo<Hl-clot and the tissues exposed to its action in a fresh wound. 
It will be seen that irrigating an am])Utation wound, for instance, with carbolic lotion, will each 
time provoke very profuse oozing. Vessels that had stopped bleeding by the formation of a clot 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 11 

within their cat oriSces b^n to bleed anew after carbolic irrigation. This is caused by the 
peculiar macerating cfFcct of carbolic acid upon the fresh blood-clot. Its color turns from dark 
red to a light brick-red, its toughness and cohesion are lost, and the slightest touch of a sponge 
will suffice to detach it from the orifice of cut vessels, thus renewing the hemorrhage. Another 
disagreeable effect of carbolic lotions upon wounds is the profuse discharge of bloody serum 
continuing for one or two days after the operation, rendering one or more changes of dressings 
necessary within a day or two, and thus depriving the wound of needed rest at the most critical 
period of repair. 

Corrosive sublimate does not dissolve clots, hence oozing stops by natural means during its 
lue. It does not irritate the vaso-motor nerves as carbolic acid seems to do, hence the oozing 
subsequent upon an operation done with its aid is very scanty. Drainage is easier, can often be 
altogether spared ; no early change of dressings is required, and cure under one dressing is possi- 
ble, and, in fact, is the rule after its proper use. 

8. Dressings. — We have mentioned that there are two ways of preserving 
the aseptic character of a wound, viz., by exsiccation or by sterilization of 
the secretions. These two methods can also be advantageously combined. 



(1) Types of Dressiiuju. 

a. Simple Exsiccation. — Small, or comparatively small wounds, ad- 
mitting of an exact coaptation of the deeper as well as their superficial 
parts by suture, are exquisitely fit for this method of treatment. Plastic 
operations about the face may serve as a fair type. 

Bismuth and Iodoform. — Certain finely powdered substances, as iodo- 
form or subnitrate of bismuth, have the quality of rapidly inspissating blood 
and serum to a dry crust. Accordingly, after the haemorrhage has been 
controlled and the wound closed by suture, a quantity of the substance 
chosen is dusted over the sutures. No further dressings are applied. The 
escaping bloody serum forms a paste with the powder, which by its steriliz- 
ing property prevents decomposition, while the paste remains moist. Free 
access of air will hasten exsiccation, and the dry, hard crust once formed 
will securely prevent further ingress of dust into the wound. In cases 
where the powder is washed away by profuse oozing, the dusting has to be 
repeated every half-hour after the operation, until the object — the forma- 
tion of a dry crust — is accomplished. 

Note. — Elderly subjects are prone to iodoform poisoning if the agent is too freely use<l. In 
thei>c cases a mixture of equal parts of iodoform and bismuth is safer. 

Small cuts, abrasions, and burns can also be similarly treated, care being 
taken to first render the injuries aseptic by ablution with corrosive subli- 
mate lotion. 

Note. — Acetic Acid. — An excellent way of treating small injuries is to wash them iis soon us 
possible — after staunching the hsemorrhaj^e — witli pure acetic acid ; or, if this can not be pro- 
cured, with ordinary vinegar. The intense smarting is soon controlled by the application of cold 
water. After this the part is dried with a towel. The dry but flexible eschar produced by the 
union of the acid with the exposed tissues gives exceHent protection, mider which tlie wound 
heals without reaction or suppuration. The great ailvantage of this form of treatment will be 
especially appreciated by physicians, as the eschar is insoluble, and the injured or chapped hands 





12 HULKS OF ASEITIC AND ANTISEPTIC SUBGERY. 



trr'atfxl in rliin iiiiiiiiht ran be washed rcpcatMlly witliout campnmiit^ nfmr ornkaa^wtm 
infiTtion lif i^iitnct witli pnH. 

More oxtoris^ivo burns or demulatious are, within reasonable limits, sIm 
juljijjlfd to the cxwiccative treatment. However, to prevent injurr of the 

jrnuHiliiliodK at rlinnf^c of dreflsin^^s, due to llieir matting into the me^hi-? 
of tito puiw, prolffting tlie burned surfuoe bj a layer of robber ti^ae will 
hi- fottnd wry UHeful ami commendable. But the larger the absorbing gur- 
f«ce, the inoro ciintion in luH'fk'd in tiio use of iodoform. 

//. ClIKMIfAL STi:i{IJ.IZATJt>N COM 1(1 NED WITU EXSICCATIOX. PRT 

I^KKHHIKOH. — In cxtonfiive injuries or large operation wonnds the amount 
«if of)/in>,f i« gi'uendiy ho large that dusting alone will not guffice to control 
deronipoMition. Itenide-s tlie jiatieut's jterson, the bedding or splints will be 
unpomf(»rtably MoiK'd ; hence it is nccesfyiry to provide a receptacle for the 
nbMoritlinn (jf the MiTrt'lions, For this ])ur])ose absorbent dressings are uswl 
(hilt bavr Im'it) reiidcrod ut<«'|itic by t^atiinttion with a chemical germicide: 
iodoform, corroMive Miibhinate, or carbolic ucid. A small surplus of the 
chiTiiir'al ukimI will Hullice to |u*cvcnt decomposition of the ub?orl>ed serum 
or blood. No imprrviouH covering (Mackjuto-sb) should be used on the 
oiitHidf of thi! ilm-Mrting. an the free admissicm of dustiest air is desirable. 
It will li(o*tcii thej fXs<iccation of the absorbed secretions, and thus iui^are 
the protective action of the (Iressing.s, even if the chemical employed becoiue 
»-vnpi»ntlc4l or iiu-r!. As I'vaporatioii of the deepest parts of the dres^^ing— 
thoKi' nearcHt the nkiii and farlhesl from the furfuce — is the most dilhcult, 
and JK made ntill nu)re dirtijuilt by their greater saturation with ^rum, a 
few laycrn of iodonjrmi/.ed gauw placed immediately over the line of union 
will Iw of vej'v ui'*'iil rtervjee in h:L><tciiing exsiccation. These are covemi 
with an arnpir mu>H ni drcHsingH impregnated with corrosive sublimate, 
which an' hi-ld down with a roller biinilage. ^m 

'I'luM in ibe nietliod of dressing m()st commonly resorted t^ nowadays, ^| 
and hiu* l>ceo fnimd <be most siniplo and effective by the majority of modern 
vurgeouH. ^J 

c. 8ciikdk'« MoDri'RrATroN of the Dry Dressing, favoring Tinii| 
OiUJANiZATios oi' Tiiii Mojsr BLooD-t'LOT. — There is a considerable num- 
Ixir of caflCH where extensive loss of substance consequent ujx>n an injury 
or an operaticm precludeH approximation of the walls of the wound, and 
reriderH healing by prinuiry adhesion impossible* In these cases u blowl- 
tloJ Torajs itjul mis up the defect soon after the injury or the operation. 
In an jiMCptic wound tluH blood-clot serves a highly useful purjiose in pro- 
t«'(rti(ig the raw Hurface**, prepcrving their vitality, provided that the integ- 
rity of this blood-clot be again protected from exsiccation on one and from 
putrefaction on the other hand. If this condition is fulfilled, granulations 
will gradiutlly consume, jis it were, the bloud-clot ; and, by the time the clot 
«lisappcars, cicatri>;atioii will lie completed. When healing under the moist 
blood-clot is aimed at, the dressings will have to be arranged a« follows: 
Immediately over the wound is laid a suitably trimmed piece of fine rubber 
tissue, previously well soaked in carbolic solution. It should just overlap 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 13 

the edges of the wound. This is covered with a layer of iodoformed gauze, 
and the whole is well enyeloped in an ample covering of dry corrosive sub- 
limate gauze. The outer dressings will absorb and render innocuous the 
surplus of blood and serum ; the film of rubber tissue will preserve the 
underlying clot in a moist condition. 

NoTB. — ^Tissues of low Tascularitj, as bone, fascise, and tendons, will certainly undergo 
superficial or deep-going necrosis if exposed to evaporation, even if asepsis be rigidly preserved. 

Case. — George Braun, German Hospital, aged sixty-six. Rodent ulcer of the nose. FA. 
19, 1886. — ^Extirpation of diseased parts followed at once by partial rhinoplasty. Sutured parts 
dusted with iodoform. Large defect on forehead (the flap including periosteum) inadvertently 
covered with iodoform gauze, without interposition of rubber-tissue protective. When the 
dressings were removed ten days later, no suppuration was found, but the surface of the frontal 
bone was seen to be exposed (no blood-clot), and very dry. After four weeks the first sparse 
granulations were observed sprouting out of the denuded bone, which eventually became cica- 
trized over tn the fall of tlu tame year. Had the protective not been omitted, rapid cicatriza- 
tion would have been secured. 

d. Simple Chemical Sterilization. Moist Dressixgs. — A moder- 
ately moist condition of the outer dressings is very favorable to rapid ab- 
sorption. This fact is parallel with the phenomenon seen if a thoroughly 
dry sponge is thrown on water. It will not absorb rapidly and sink, but, 
on the contrary, will float on the surface for a considerable period of time. 
But moisten this sponge first thoroughly, then squeeze it out completely, 
and then throw it into water, and it will at once become filled and sink. 
Where rapid absorption is desirable, as in the presence of septic or fetid 
discharges, and where clogging of the drainage-holes by inspissated secre- 
tions is to be avoided, dry dressings will be advantageously replaced by a 
moist dressing. By applying a piece of impermeable material to the out- 
side of the well-moistened dressings, evaporation and exsiccation will be 
prevented, and the dressings will remain in a moist condition for an indefi- 
nite period of time. 

Rubber tissue (not rubber sheeting) is an excellent and cheap substitute 
for Lister's "Mackintosh" and his "protective." It can be had in all 
rubber stores. A rather stout quality is the best article, as it is not apt to 
tear, and can be repeatedly used as the outer covering of moist dressings. 
// always forins the outermost layer of what is called throughout this book a 
"moist dressing.^* Oiled silk, well soaked in carbolizcd lotion, is a toler- 
able substitute for rubber tissue. Another substitute is waxed i)aper, or 
" tracing paper.'* A piece of stout, brown paper, such as is used by sliop- 
keepers for packing, well soaked in grease, preferably tallow, will answer 
on a pinch. If none of these articles can bo had, frequent moistenings of 
the dressings will have to be employed in order to prevent eva()oration. 
One or more teaspoonfuls of carbolic or mercurial lotion instilled into the 
dressings every half-hour or so will have the desired effect. This form of 
moist wound-treatment was very extensively employed by the author in his 
seven-years' service at the German Dispensary, and has been found so satis- 
factory both to patients and surgeons that it is still the standard form of 
moist dressing used at that institution. 



OWE LIBRARY, s^^wo^\i mvii^^w 



14 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



(2) Preparation of Dressings. 

a. Gauze. — Gauze, called in the trade cheese-cloth, or tobacco-cloth, 
forms undoubtedly the most convenient material for wound-dressings. It 
is cheap, can be bought everywhere, absorbs well, is soft and pliable, and 
can be easily prepared for use by every practitioner. For hospital pur- 



14 in. 



UPPER AND 
I 
14 In. I LOWER EXTREMITY. 

HIPJOINT. 
TRUNK. 



Tin. I 



r" 



HERNIOTOMY. 



SCROTUM. 



SHOULDER"^ JOINT. 
AXILLA. 
ANKLE i\ JOINT. 




U 111. 



24 in. 



NECK AND ARM. 



2Kin. 



19 in. 



\/ 

V 

AXILLA 



AND BREAST. 



'» ill. 



EXSECTION OF 



SHOULDER JOINT. 

I. 



19 in. 



LOWER EXTREMITIES. 



AMPUTATION 



CF THIGH. 



14 In. 



19 in. 



28 in. 88 In. 

Firt. 1. — rattcms for various dressings, modified fVoni Neuber. 

poses, moss or peat dressings in the shape of cushions or bags are more 
convenient. In the practice of the country physician, however, they are 
out of the question. 



ASEPTIC WOUNDS -ASKPTIC TREATMENT. 



15 



i: 



{a) Corrosivtf Sublimate Gauze, — Tho raw gtiuzu is treated as follows : 
To free it of its oily contents, and thus to make it more absorbent, 
twentv-fiv<? yanl.'? of the fabric are hoili-il for an lionr in a wash-kottlo tilled 
with suffieiont water to cover the nnit*iriul, to wliieh s^hould Ix* added two 
pounds of wasbing-sodtt or a pint of stnuig^ lye. After this the fitiiff is 
waahed out in cold watpr. pa-'^wed throuj^h a clothea-wringer, and immersed 
in a sufficient qnantily of a 1 : IJUIO solution of corrosive sublimate for 
twenty-four hour;*, then |)ar<se<l again through a clothes-wringer, dried, and 
put away in a well-covered gia<*s jar until reijuired for u«€. 

The fabric is go folded by the manufacturer that each fold is just one 

long. It is best to divide tlie twenty-tive yards into segments i)f about 

'^x yards each, which can be again folded by the surgeon into large or small, 

square, oblong, or narrow compresses to suit each individual case. If a 

lung time has elapsed since the preparation, reimpreguation with a 1: 1,000 

solution of corrosive sublimate is advisable before use. 



Note. — In n small jiropiirtinii i.if (.'nst's, «)ntiirt with eoiTcisivp-.snhlimate dressings will uimse 
aa|;r]r-lookiag dermatitis, which at the lSr!»t blui*h renr oMcly resonibles erysipelas. The 
kboenoc of fever and flii.<kne.<)A( the exact liinitalton of the raali by the oxtonl of ths? dressings, 
will soun dii^perac po^j^ible dotibltt. Profuse apjilicalion »f vasiurinc 
or Home other hlarui ujriOiient will roulilv ili^|io»i.' of Ibe irrilatidn. 
The streugth of the inipri'jidtitiori nhould Ih' iIm'ii iiIho reiliiced h\ 
washing the gnuze in wrutcr. If it Hlioiihi be fmirKl thnt mercury is 
Dot bomo ;4l ftll, i: ishuulil be ttnbsiitnted by curbiilie-acid solution ot 
Thiersch's boru-salicylic lotion. 

{b) Infhtformhf'tl frftitzi: — The moist, absorbent 

^ gauze is evenly sprinkled with iodoform powder from 

H a pepj)er-box, or the author's iodoform duster, well 

rubbed iuto Hie meshes by liand. and tlieti piil away 

in a wide-mouthed bottle, 

liolhr batuhttji's are nmdc out of corrosive-sublimate 
jse. 

Fia. a. — TIki uiitlior'a 
Note.— Roller bandnges nuMJe of a starched fabric known as Imlororin dusu-r, with 

i. , ,. „ „ !• ' ,1 r I • 1 ,- screw eap and mnovBhlo 

" cnnoline. or " crown-hninj;, ' are very useful m oorapletiap every bottniit lor re|ilfr»ii*hinir. 

dreading. They nro nioi.sti'ne<l ia water, anil applied over the dry 

roller-bamlai^e. They eioon hccom*' stiff a/arain, ami make a veiy compact and ne«l dressing, 

that will not shift easily. The !»tuiT id the name thut is used extensively foi- filnsler-of-roria 

bandages. 

Id emergencies various substances of absorbent qualities can be utilized 
as dressings ; such are, for instance, cotton, moss, and sawdust, 

b. Absorbent cotton, or <'ommon cotton" batting, well soaked in 
corrosive-sublimate sohition, then wrung out, will make a tolerable dress- 
ing. Its drawbacks arc tliat it packs and gets hard and lumpy, but, prop- 
erly used, it will answer every practical pur[)ose. Care should be taken 
not tfl tear the cotton into irregular masses. xVfter unrolling it, snihibly 
large, s(piare pieces sliouhl be cut olT witb the scissors ; these pieces should 
be folded, then soaked in the lotion, sijucczed out hard, and uufolded again, 





16 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

thus preserving their shape and uniform thickness. Two or more of these 
pieces laid one over another will make a verj passable dressing. 

Case.— Miohae] B., aged sizty-tliree, sustained, corly in the morning of NoTembcr 

13, 1883, a ciompoimd frtu-ture of the left elbow-joint. He was put to bed, and, umler 
the advioe of the fjimily attendsint, iiitpli(\atii>nfl of t'olil wnter were made to the injured 
part. Twelve hoiiM jifler the injury, the autlior found a Y-s*lwi[jed fructure of the lower 
end (t( the htimenis, tlio coriicid shurp poiut of the ujrper fragment protruding thruusli 
B sraall woaiid above the olecranon. The joint wtis filled with a large clot, and some 
ooziTiR from the i)erfonition wns notifetl. The ed^'es af the perforation wound were 
gnii^ly fitting.' aroiind the prolrudiii^f hone, and during the Kuh^L-qiient inuuipulatioos 
irood rwre was taken nut to uIIo-a- tht hune to slip back. Not Imviui; been informed 
of the naturt! of t!iu rnjury, the nutluM' arrived nnprepnred at the patient's bedside. Tlic 
caj^e, however, did not brook delay, hence everything had (o be esteniporired. Scv- 
erid onnnes of a ten-per-cent alcoholic sohitioii of corrosive suhliniat© and a little i»Jo- 
fonn were ordered from the nearest drujcjzist, and at the eanie time several bundles ot 
eotijiiion eotton battiiifj were procured. Soon jdenty of a 1 : l.fiOO corrosive-subliniat* 
solution was ready, in wliirh siinaru piere» of cotton were soaked jh (Jescribed. The 
patient's poverty eompelJed un eetmouiieal management of affairs. An old but deaa 
bed-slicet wan rip[>ed up into roller-buiidaftes, which were likewise impregnated. This 
done, soup and hot water were applied to the el how. arui the akin was shaved clean iJI 
around, but esptcially near the perforation. This was followed by a vlfjorous rnbhinf 
off of the flkin and protnidinp bone with the niereuric lotion, which at the same time 
was eoptously poured over the re^fion of the elbow from u pitcher. After this, reductioD 
of the protnidinij bone and adjustment of the frafTioent.H by eitennion of the arm «r«8 
effecte<l. The sizv of the perforation -hole at once beramo much smaller. In order to 
provide some drainafje, a small fillet of cotton, well ilusted witli iodoform, was inserted 
into the cutaneous part of the outer wound, whieh was also liberally dusted. Orer 
this were filaced four layers of cotton pad*", which were snug-ly handaped to the limb. 
Two lateral splints, made of a pasteboard boi, secured the extended position, in wliiiti 
the arm was suHpcmled front a nnil in the ceiling. The temperature never rose alove 
10(r Fahr. Xor. IfL — The <lre.H>inir.s were removed. The swelling, due to the efTuniyn 
of blood, luid disappeared to a great estent, Oifzing had ceased; no suppuratiuu. 
The fillet of cotton was withdrawn, and the arm was put up in p [daster-nf- Paris spli 
flexed at a rigfit angle. Passive motion was commenced on renioval of the i^plinL, fo 
week« after the injury. Ultimate result was a-scertained in October, 1884: Fleij 
was normal; extension toiikl not be carried beyond 140°. 



IJU. 

I 



c. SAwnrsT, — With a viow to the occasional impossibility of procuring 
any of tire common rlrossin^' matorials in titiies of war or some other jnihlic 
calamity, the author has tested the etlleaey of i^itwilust as a dressing; during 
liis service iit Monnt Siniii Hospital, extending from Aiifxust 1, 1883, till 
FebriiJiry 1, 1884. Clean pine, spruce, or hemlock saivdust vva.s imprci;- 
natcd with a 1 : l,Ot>0 i^olntion of corrosive sublimstte for twenty-fonr hours: 
then it was spread on sheets of muslin to dry, und linnlly was inclosed in 
different-sized hags made of eliee.se-ch>th gauze. To [troveut the shifting ot 
the sawdust, a thin layer of wood-shaviutjs, called by the trade '* e.xcelsior/'^ 
was first inperted into the oj>en bag ; then a proportionate ({uantity of saWSffl^ 
dust was evenly strewed into the meshes of the "excelsior/* and then the 
bog waa closed by stitches made with threads s<»aked in mercuric lotion. 



J 



ASEPTIC W0UND8— ASEPTIC TREATMENT. 



17 



I 



The tliicknest* of the bug's varied, according to their size, fiotir one tt) ^\vo 
inches. After the winind was drained and sewed, some iodofarm gauze 
was plitced next to it ; then came one, two, or more smaller bags, and on 
top a hirge bag, the whole being Knugly fastened with roller bandages. 

Aside from tire truiiliU- of pre]tiiring the Irnga, they were found very con- 
venient in applying and ([iiite ellicient in absorbing blood and serum, and 
preventing decomposition. 

tl. Mo^^s. — The differen t sjK?eie.< of sphagnum, coating the surface of peat- 
bogs and the trunks of dead trees in our northern fore>sts, are excellent 
material for making dressing-bag?. On account of its cheapness, small 
weight, chistieity, and great absorbing power, moss has displaced other 
dressings at almost all of the sur*;ica] clinics of Germiiny. Its preparation 
is very simple. It has to bo gathered with some care — that is, witli no ad- 
mixture of the soil. After being dried, it is impregnated with corrosive 
sublimate, inclosed in gauze bags, and is reatly for use, Moss-bagg are in 
daily use at tSie German Hospital since 1884, and can not be praised enough 
both for their liandiness and etfectiveness. But, like other similar dress- 
ings, they are not adapted to the needs of the general practitioner, and will 
find their principal employment in hospital practice. 



m. PRACTICAL APPLICATION OF RULHS. 



1. In operating. — In order to fjain a eohereiit idea of the practical work- 
ings of the aseptic apparatus, we shall now rehearse all the steps of a well- 
conductod operation. 

Assuming that a cancerous breast is to be removed in the rooms of the 
patient, it is tirst necessary to select a suitable ]ierson to act as nurse. Her 
duty is to administer a laxative the day before tlio o])eratiou, and to care- 
fully scrub with soap and brush the [)atientV breast, corresponding shoulder, 
and axillary space on the day preceding and on the day of the operation. 
A cleiin, well-lighted room is selected, out of which all unncccsisary furniture, 
hangings, etc., should he removed. A bare, well-scrubbed lloor is prefera- 
ble to a carpet One or two narrow kitchen-tables, covered with a quilt 
and provided with a slraw pillow, will make a capital operatiug-tahle, A 
piece of rublior cloth (:ix4 feet) is placed over the (piilt, and a clean sheet 
is laid on top. The nurse provides soap, nail-brush, plenty of hot ami cold 
water, and towels. The operator and his assistants arrive at least a half- 
hour before the appointed time of the operation. Everybody's hands are 
washed in hot water with soap and brush. The necessanes are now un- 
packed and arranged, and the solutions of carbolic acid and corrosive sub- 
limate are mixed, for which purpose six or eight well-cleansed L|nart bottles 
should l>e held in readiness by the nurse. A fountain syringe is filled with 
Bid)lifnate solution, and suitably susiieiided from a nail or chandelier near 
the o|>erating-table. A new pail or bucket is tilled with hot water for rins- 
ing the blood out of tlie sponges ; alongside of it is jihiced a basin filled with 





18 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY, 



a Ihrce-jKjr-eeat solution of carbolic acid for the reception of the cleaned 
snoiip's, from which tlicy oii^Hit to be haiiJcd to the aj^si^^kiiitji by the nurse 
'I'vvo niorc jjijinniicd tin hii.'^ins ure filled with a corrcsive-siihlimate .solution, 
and placed on chairs to the right and loft of the oiH»rating-table for the 
•K'C'sisional rinsing of the handti of the o|M?r!itor and assistants. The in- 
utruttKMits are arranged on an adjacent tahle in a certain order, which, to 
prevent confusion and iO-temiMjr, should be rigidly adhered to during the 
entire operation. 

N<>TK. — Till' rtiithof has fdund tliat it i^ %'orv tNiiivenionl to \w inJepciuk'Ut ni the patiGOi'ii 
ref!Ourct"«, as fnr ua the ne«?»!*ary vessels for Hpongos and in3triiniPii(» are concerned. A nctst. 
of four pood->!ixeil, flat-bnttfimt'd liloek-tin wash-lmsins, sis Ihi MOtip-lmsms (six inches diameU'r), 
anil ftmr tin hakf-panH, will }>crvi> t.-vi-ry pur|>OHf', and the «riiall i>x[>ensc will be abundKnU; 
repuiil Ijy Mie ihiinlinofls utiil senile of comfort that will remilt. This »mtttl inventory will kcqi 
long, ntvtl may ^tTve ap;ain and again at luftny opt^ralions. 

All vessels are wiped clean. The knives, sharp and Wunt retracton^ 
scissors, anatomical, mouse-tooth, tnul dressijig forceps, probes, and grooveAj 
director shoidd be put into one pan witli carbolic lotion ; all the artery for- 
ceps by themselves into another one. Between the two paua is placed §1 
third one. filled with liot water, in which all the instruments not in actual! 
use should be rinsed free from blood before bein^ returned to the carboliO:J 
lotion. This will keejt them and the carbolic lotion clean and bright alf 
the while, and no time will be lost in hunting for them in the bottom of ij 
turbid pool of tioilcd carbolic solution. In a smaller tin basin, ligatures, inj 
another one needles, are arranged, threaded with (Inc (No. 0) and coarderl 
(No. 1 or 2) catgut. A third small basin will hold the dniinuge-tubes and| 
a number of safety-pins. 

The dressings are now attended to. Eight or ten small (6X8 inches), and] 
just as many htrge (10x28 inches), compresses of gauze are cut, care beingi 
taken not to make the dressings t(»o scanty, as an ample (irt^t dressing may 
save the trmibte of many subsefpient dressings. The best rule is to let the 
outermost compresses overlap the wound on all sides hy at lea^^t eight inches 
To this should be added a sufficient number of strips of iodoformed gauze, 
three or four rather wide gan?:e roller-bandages, and the same numlx^r of 
starched or crinoline roller-bandages. All this should be wrap|>ed in a 
clean towel and laid aside in a secure place until needed. 

All this having been attended to, antesthesia may comm<'nce in an adja- 
cent room. The aua'sthetizer should be provided with ether and a rone, a 
tin basin for the reception of ejeeta in case of vomiting, a towel, a hypo- 
dermic syringe, a wide-mouthed bottle with morphine solution for injections 
in ease auit'sthesia be imperfect, a Kimihir bottle with whisky to Iw used iii 
case of heart-failure ; finally, with a di"essing- forceps and gag for withdraw- 
ing the tongue if it should sink back on the ejiiglottis. 

The anaesthetized patient is phiced on the operating-table, and the parts, 
being exposed, are freely soaped and shaved. After this a piece of rubber 
cloth (3 X 4 feet) is so placed over the patient's body jia to leave exposed 
only the field of operation. Now the parts arc well rubbed otf with a towel 




dippf'tl in eorrosive-siililimate solution and freely irrigated, uml a miinlHT 
^of clean towels wrung out of tl»e sjinie solution are suitably spread around 
the field of operation, protectin;,' the operator and asi^if^tanti? against contact 
M'ith the elothing or body of the patient, and providing for a elean iduce 
where instruments or sponges may be laid down for a nu^nlent if necessary. 
The end of a wet towel is tucked under the lireast and armpit of the .side 
to he operated on, and is hung over the edge of tlie table in such a manuer 
as to conduct tlie blood and irrigating Huid into a bucket placed on the floor 
underneath. It serves as a drip-cloth. Every assistant should strictly attend 
t-o tlie duty allotted to him, and not meddle. All unnecessary talk should 
cease, and the work pnjceed in an orderly manner. The first assistant 
should keef) his eyes ojrmi, and know and aid the openitor's intentions. He 
ehonld f>e alert, but not over-zealous. 




Fiij. a. — I'uticnt tuade ri^udy lor uiiijiuUitioii ot nimuuu. 

The aiia^^tlieti/er must fake gtHul cnrc that, in ease of vomiting, no ejecta 
ire thrown on the wound or its vicinity. Towels soiled by vomit should 
[be at once replaced by cleau ones. 

Now the parts are distributed. The trustiest man serves as first assist- 

Laut over against the operator : a younger physician at the left of the operator 

[ij* second assistant, and irrigates or helps as need may require ; another 

physician tjikes charge of the instruments and ligatures, and the nurse 

attends to the s])onges, and kee|>s in readiness *' sublimated " and dry towels 

[and a pitcherful of corrosivc-sufjlimate solution. 

Aprons are donned, evcry!i«»dy's hands are finally scrubbed with soap 
land brush, rinsfd in mercuric solution, and the operation begins. 




I 



20 RULES OV A8EPTIC AND ANTISEPTIC SURGERY. 

Note. — The i'iii|jllt>yritc"nt of rofiious irrigation during opi-nitlons requires measurcti for pro- 
tecting th« person and tlnthlnp of tlsi" suvgeini ii>;a)iist th*" irifliu^iH't' of tlu' rhi-niieals (.-onimoiiljr 
used. An ftni[ik" apron, made of light rubher .sheeting, anil rctiehiii^ froru the chin to the toe*, 
is mo.st convenient, and can 1h' t'lisily cleaned. The surgeon's shoes nniv Iw ])rotected by a pair 
nf light rubbers. However, they arc apt t»» sweat the fett. Tlie author overcame this draw- 
Itaoli by the ui»c, at. the ho;»pltal, of wooikn putlenii (French sabfttx) worn over the shoes. They 
are doniioil and doffed without thi» aid of the hand?*, and koop the fpet warm and dry, and can 
be boujrht lit 75 Ex-scx Street, New York. 

In rrmovinor the brcfi>;t and contents of the axilla, lisemorrhage should 
be carefully attendod to by lijjaturiii^ every bleetlino; ves.^el with catgtit. 
Having removctl the diseased parts, the wound is carefully irrigated, each 
recess being attended to in succession ; drainaiore ant] sutures are applied. 
The projecting end of the druin age-tube cut off " flush '* is transfixed with 
a safety-pin, the wound is once more irrigated through the tube j^o a;* to 
clear it of clots, and the clots and irrigating fluid are removed from the 
wound by gentle pressuro exerted with a sponge or two. lodoformed gauze 
strips are next }>laced along the suture and around the dniiiiage-tube. pass- 
ing under the safety-pin, and a few pads of gauze are held pressed against 
the wound while the patient is slightly raised to cleanse her back and face 
and the table from blodd. The soiled towels are rephuied by dry onejs, and 
the dressing completed !ty applying as many gauze compresses as required. 
These are ftistened rather tightly with giuze bandages, tlie other breast and 
urui-pits being first jiadded with abaorlwiit cottoTi. A large, square piece of 
absorbent cotton, somewhat overlapping the dressings, is next applied, and 
snugly held <lown by crinoline roller-bandages ; the corresponding arm is 
included by the bandage or is placed in a sling j the }«atient is brought to 
bed, and an i»|iiate is administered. 

2. Change of DresBings.— In most cases whore the rules above given 
are conscientiously and intelligently observed, no fever will follow the 
operation. After the eltects of the anrosthesia are over, the patients will 
be found cheerful and contented, feeling no pain or sickness, their only com- 
plaint being the tightness of the bandage, which they will soon learn to 
bear. The tcniperature will range during the lirst three days at about HW' 
Fahr. ; after that it will sink Lo the normal standard. Sometimes, esjK-ciaiW 
if the drainage is not properly placed, and some serum or a blood-clot is 
retained in the wound, the thermometer will indicate from lUO'^ t« 103' 
Fahr, As long, iiowever. as the patient is cheerful, and docs not feel sick 
with headache and general dejection, as there is no sharp, throbbing pain 
about the wound, or some other grave disturbance of the local or general 
comfort, no alarm need be felt. In thes<? cases we have to deal with an ele- 
vation of tem])erature benign in clmnicter, ami identical with the harmless 
fover observed after almost every simple fracture. It is due to the absorption 
of the extra vasated blood or lymph, bland and harmless on account of the 
ab.seuee of putrefactive changes. This is Volkniann's "aseptic fever." 

The tem]terature soon l>ecomes lowered, appetite reappears, and the dress- 
incs need not be disturlicd. 




ASEPl'IC WOUNDS^- ASEPTIC TREATJTENT. 



SI 



Shouhl, Mil thcotlivr liaml. tla^ jtatient complain of ehilliness, lieadaclif, 
sickuceSf t^eneral dejection, and drawing puins iu tlie limbs, or i>ersist4?nt 
und increasing pain about tlu- woimil, the tlicrnioii]ct(.'r iiidicating at the 
same time a high or only a moderate elevation, tlie dres.-fings rihould at once 
be removed, and a search instituted for the cause of the disturbance. 

Previous to this a new dressing should bo prepared similar to Ihe one 
to be removed. This and a tin pun e()ntuiuiii<,' carbolic lotion, with a drens- 
ing-forceps. anattnnical foreeijs, scissors. scal|tel, grooved director, and a 
piece of drainage-tube, together with another vessel liolding a few small 
pads of Cotton wrung out of the same solution, should be placed on a small 
table near the bed. An irrigator filled with warm carbolic or mercuric 
lotion should be suspended from the bedpost or a nail, and a pail for the 



r^ 



^l y * I 



/ 



■1. — 4 llUUv'L 



\ 



-Ul>.'!i ullir al: 



* 



reception of the soile<l <h"es8ings shonld bo at hand. A piece of rubber cloth 
covered with a dravv-sheet and spread under the [ia{;ient\s back will pioteet 
tlie bed. anil a pu:s-basiii or S(puire tin pan Ireld alongBide of the patient's 
thorax will receive the irrigating fluid. 

After this the turns of the roller-bandage are cut through without jar. 
and the outer layers of the dressing are gradually removed. As the deeper 
parts are being raised, irrigation shouI<l commence, in order to moiisten the 
gauze and aid in ild gentle retnoval. Care should be taken not to disturb 
the drainagf'-tidies. Affrr tkf irmovnl nf thf sffiM '^r*'yx('«f/.v, thf /j//y.s'/- 
cian'x handf! Mftnuld bf nitrfnllt/ chansvtl bf/ort' louvhing any part of the 
wound. While the irrigating stream is playing, the vicinity of the wound 
is gently wi|«Ml with a small jmd of moistened cotton, in oi-dcr to remove 
clots of blood or tibrin that can not be dislodged by irrigation. 






RULKS OF ASEPTIC AND ANTISEPTIC SURGERY. 

If Uif eilgcs iind vicinity of the vvhuikI luok normal, tlic skin pale, not 
swollen, and not piiinful to toueli, it slioiild he forthwith redressed. A care- 
ful physiciil examinatiot) of tlu:* intfrnstl orirjtni"! will tlien eertaitily reveal, 
as the niuse of the fever, some internal oomjtliwifiotj, as, for instance, pneu- 
moniju or, lit any rate, some newly developc<l <.»r overlitoked disorder inde- 
pendent of the wound. 

If the aseptic measures employed were insnfficient, the edges of the 
wound win he found swollen, reddened, and jniiufnl ; the wound will have 
lost its iirie[itie character, and is the seat uf a septic process ending in sup- 
puration, Proni]>t action is re<|uired to limit the inevitable destruction of 
tissue, and to cheek the further poisoning of the sysleni. 

From this moment on. ascpficx must give way tu anfi-srplivs; prevention 
having failed, curative measures must step in to eliminate the mischief 
that might have been prevented by the exhibition of more care, attentioD, 
or skill. 

The therapy of soptically infected or suppurating woimda will be treated 
in the following chapter. 

In case that the course of the healing of th'? wound is correct, as indi- 
cated by the absence of local or general disturbance, the first dressing may 
rcnniiu nncfninged for from seven to forty dayi?. Flesh-wounds should be 
dressed on the seventh day, as it is desirable to remove the drainage-tubes 
and sometimes the stitches. The finer catgut sutures will generally ho 
absorbed by this time, and tlieir exposed part can be simply wiped away. 
Where stout retention sutures were employed for the ajiproach of the edges 
of a wide, gaping wound, they will be found cutting throngli the tissues 
by this time, and quite useless. They should be removed, and the stitch- 
holes dusted with iodoform. According to the completeness of the result, 
the dressings will have to be changed every third, fifth, or seventh day. 
their bulk ilccreiisiiig with the diminution of the secretions. Finally, the 
few granulating spots need only a dressing consisting of a patch of some 
unirn'tant jilaster, such jis empl. cernssfe or empl. hydrarg., and an occasional 
touching with nitrate of silver, to aid final cicatrization. \Tliere the ojxTa- 
tion has involved parts of the skeleton, as in amputations of extremities, 
exscctions of joints, necrotomies, etc., the dressings have to be left undis- 
turbed much longer. After exsectiuns of the knee-joint, for instance, where 
bony ankylosis is aimed at, the first dressing is not removed without a clear 
indication before the thirtieth or fortieth day. No patient should be diS" 
charged "cured" before cicatrization is complete, as it has happened that 
such " cui-ed '■ cases, left to their own care, contracted erysipelas the day 
after their discharge, and died of it. 

NoTF.,<-^Atl the manipulatiuns abuut u frL'slily hgjrlutinateii wounil should be very delibtr- 
fttc und f^eiitle. In removing gtkclici8, a forvcpi^ should gently rai^e the thread ; then it should 
be cut as cli>Be to the Btitch-hole na [roapible, und lifihlly withdraflm. Dnunage-tubes are 
(;ra»p<.>d at the ]>roj<^«iirt^ ond, gt^ntly rotnttid to iiikI fro tiU lht.-r are freely morible, tbca irith- 
drawn. iSomctinieii 'li will Ir* Tduiid llml a paiiilei^s fluctuating fiwellinig occupies «<oiiic deofHT 
pan of the wtiimd. In l|ie«c canes i-etciilioii ol wrum is gcnerully e«i««ed by elogging of the 




ASEPTIC WOUNDS— ASEPTIC TREATMENT. 23 

dnunage-tube bj a ciot. On vhbdrawii^ the tube, a quantitT of ckar or turbid Tdknrish «enim 
will escape. In these cascj« it is good to repUcv the cleared ndiing to prerent farther retention, 
and thus to bring about contact of the fieparated walk of the woond, which wiD at once become 
adherent. At the subsequent change of dresaing:?, the tube can be definitirelj remoTed. 

Cask. — Mrs. Clara G., a^red fortj-six. Alrtolar glamdnlar fimeer of an ahrrraHt 
(detached) lobe of the right brea^. Tumor of the size of a $inall fist, situated in the 
axillary space close to the edge of the peotomli^ major muscle. It was connected bj 
a stout pedicle with the adjacent part of the breast-gland proper. Jan. 16. ISSo. — 
Amputation of mamma; total eracnation of axillarr fat and glands. Drainage br 
counter opening made through the latis^imns dorsi muscle. Suture of the entire wound 
except a part of axilla, where the skin had been extensiTelr removed. Course of heal- 
ing fererless. Change of dressings on the tenth day. Primarr union of all the sutured 
parts. Axillary wound granulating. Under the lower flap of the breast-wound a pain- 
less, soft, fluctuating swelling discernible. By gently inserting a probe between the 
corresponding edges of the united wound, entrance into this sac was effected, where- 
upon about two ounces of a yellow, slightly turbid, and very viscid scum escaped. A 
small drainnge-tube was inserted, and the wound was redressed. Jan. -iijth. — Walls 
of the cavity were found firmly adherent. Tube removed. No suppuration. 

The interior of freshly healed wounds of normal appearance should never 
be syringed ; the injection of a strong jet of fluid is unnecessary and often 
injurious, as it tends to separate tender adhesions. 

IV. ASEPTIC MEASURES IN EMEROENCIES. 

Unremitting attention to, and a severe self-discipline in always carrying 
out the measures of strict cleanliness known to be necessary to uniform 
success in the management of wounds will gradually become, however 
irksome in the beginning, a mere matter of accustomed routine. As the 
mind and senses learn to exercise vigilance without special effort, the sur- 
geon's results will become more and more gratifying. His attention, freed 
from the severe strain unavoidable in acquiring command of the detail of 
a difficult business, will concentrate itself n[>on higher objects, and the 
smooth routine resulting from long and severe training will not divert 
attention from the finer detail of his special work. 

It is a great mistake, paid for by the loss of limbs and lives, to believe 
that the mastery of practical cleanliness or asepticism can be acquired with- 
out a clear comprehension of the principle, and without earnest and severe 
training in the handicraft of aftepticimn. Tlie wholesome truth, that failure 
of achieving primary union in fresh wounds is mainly and almost always 
due to one's own lack of knowledfre and skill, and that these attributes can 
be secured only by the exercise of great diligence and many, often unsuc- 
cessful trials, should be constantly present in our mind. Failures are bitter 
lessons, but their honest study will inevitably bring to light the causative 
deficiencies, and will teach us to avoid them. 

The school for learning to employ the principles of asepticism is open 
to every general practitioner in the treatment of the many affections and 
injuries pertaining to minor surgery. Mistakes made in the removal of a 



I 



24 RULES OF ASEPTIC AND ANTISEPTIC SUWiEHY. 

wcTi ur the treatment of an incised wound uf tho luiud arc easily found ont 
and eaaily corrected. They carry mucli atid sunietimeH more instruction 
than a large operation. It i.s wicked U> attempt to learn the first lessons of 
ai^eptie surgery in laparotomy, when, possihly, the surgeon's experience is 
bought witti the life of his trusting patient. The attemjit of removing an 
ovarian tumor, for instance, should be permitted only to tho?e who have 
learned to invariably heal a fresh wound by primary adhesion, as this is the 
Hrft and sole test of the possession of the ability justifying such a grave 
undertakin«!'. 

Emergencies will necessarily involve varying modifications of the means^ 
nevfir a dcviafion fram tlw principle of am-pfii'igtn. 

A ha^ity tracheotomy for the removal of a foreign body, a herniotomy 
to be done in the dead of night amid the squalid surroundings of a tene- 
ment, or the first care of a compound fracture or a gunshot-wound, will 
present {special and varying ditficulties, to be overcome only by good train- 
ing, cirounisi>cction, and vfrsutility. They can be overcome, a.s many 
examples in the exjx^rience of every sMcce?i.sfuI surgeon testify. 

In addition to the caxe of compound fracture of the elbow-joint quoted on 
page 14, another instructive case may be told from the author's experience. 

Cass. — Ik'niiun .Tnlin, liibortT, ajrod si.xtyHtiu'. RigLt, irreducibli', strangulated 
femofiil Lernia. Kuptiirt' of lonjif stuudinp, strnngulat^d sincti the cnoiiiuy of April 1, 
1882. t5jtii|itc>ma of threat acuity necessituttid prompt action. I>r. II. Wottenjrel, tli« 
family attendiinf., nditilnistored the iiniBsthetHi in the middle of tlie aftern«x>a uf the 
ftdluwinf; ilny, while author wsis tnukiiig the necessary prepurutions for the presuma- 
bly iiR'vitiible ojterntion. T!ie pluei' whh a nfirrow, dark, rear rowiu of a rear house uf 
a sqiiuUd U'tifiiieriL, jm<J ii hmip had to ht' pr(Kiire(L Tin; divt'sted piitiontV pubic «nd 
iiiKainnl region wha shiivi-d, wbil** i^tiiP.-itht'j^ia jrro^jressed. A Hat !>akt"-|iaii wns coVfre<l 
with one of the few cknin tuvvidt* to hv had ; on ihb were Pprcrid the instniiiionts, and 
over them was poured a quantity of a five-per-eent carbolic lotion. No sponges were 
on bund, as tiie suiiiiiions had been very hasty, and no time was affordefl for prepara- 
tions. Tiicrelbre, u pari of a ekan bed-slieel w.-im torn into a mimbor of small pads, 
wjjirh wtTo woll soako<i in tlie saiiio hjtiun to stTve jis upoiigcs. .\ romnanl of tbo 
hiliiMi vviis snvi'd iit n jntcht-r for pur|i(Hos of irrigation. Aft*-raii iinsnorL-ssful attempt 
lU reposition, tlie iiiijiiinai region and the HiirK<.'on*s liaridii \vt>re onee more well soap«hl 
and washed off with the carboHf lution. The e[ni:astric artery had to be tied, nnii ex- 
lerniil Iiemiotomy was performed. A small kniirkle of gut slipped back easily iuti> the 
rdiilotriinid cavity, hut evidently did not ropresent idl the contents of the sac. within 
whioh an additional soft body eould lie felt that resisted every (gentle etTort at reposi- 
tion. The sac beiD)? opene*!, a slender portion of omentiuii was found to be mllarent 
to it. This, being (Hs.«t!€ted away, wns rephu'ed into the abdoininal cavity. The outer 
wound was well irrtgnted, imd united by a number of eutjrut nntores. A few stmnda 
of cat put were inserted into the lower angle of the wound for drninape. In the ab- 
»ent*e of other dressings, a ('lean sheet vva» used for the manufacture of u number of 
couipresseH and roller-bandages. These, being well soaked in wirbolic lotion, were 
applied to the wound in the isha[>e of a n|)ica bamhige. Voiniting ceased. Ooziojj 
bcting very scanty, the dressingft soon Ijecnnie dry, and, the piitienl's condition being 
excellent in every respe<'t, they were not disturbed until a fortniuht after the opera- 
tion, when the wound was found hejtleti thrungbont by ttie fir«t irtt«ution. 



i 



I 




ASEPTIC WOUNDS— ASEl^IC TREATMENT. 



S5 



Yet it must be said tliat such conditions render optTatin^ very risky, 
and in every way uncomfortable. If unavoidable, the additional risk must 
l»e phoiddpred by the ]i;itkMit as well as the surgeon. 

Operating Bag and Kit.— 



Tinjely preparation niade in 
the shape i*f jiroeiiriii*;: a well- 
arranged haiid-bug. eontaiti- 
ing the most neees.sary arti- 
cles for operating in an emer- 
gency, will well repay tin- 
i<mall expense and truulile. 

A leather hand-bag, about 
sixteen inches long, will be 
sufficiently large. 

Ilave a suHiciently lun^'. 
rather st-out strap sewed to 
one nde of the interior of the 
bag, so It* to provide loopj* for five or .six bottles, which will be held safely 
in the upright position. The first loop will be occupied by a half-pound 
tin can of ether : the ^ectvnd irf aMoited lo a two-ouuee bottle of corrosive- 
sublimate jiolution (ten |H.'r cent alcoholic*) ; tlie third to a f(Hir-ounce bottle 
of pure carbolic acid ; tlie fourth to a wide-nmnthed bottle containing cat- 
gut and flilk of different sizp> nn spools; the lifth In a widt'-nioutlicd bot- 



VirttiorV iiprtutliitr l>:ii;, witb tin j'uiis ub4 
rulikT cl'itlu* *trtii>i*<l to it. 



1 




Fiu. fi.— Inturidr nl <i|iL'niti!iLj bug. 

lie filled with drainage-tubes of different sizes in carbolic lotion ; the sixth 
a wide-moulheil fruit-jar with tight cjijs containing two or three dozen 
ouges in carbolic lotion. A stout pair of scissors for cutting the dress- 



i 




Fio. 7. — livruMii 'iikHtr«vin,-3it-i>'«u«."h 



Jr'ia. 8.— Interior or Gunmtii uistrumcnt-poucli. 



iu boxwood or tin eases for sufcty. A sido-tiap will hold nail-brush, sufety- 
pins, and one complete dressing rolled up in a clouu tuwel. The body of 
the ha^ is reseiTed for the instruments, whii-h are rolled up m atJothtT ek-un 
towel, and for three or four small tin basins, together with a fotintaiu syringe 
and ether enne. each kept in a separate rubber sjionjire-ba;;. 

To the bottom of the haud-bag is strnppod on the outside a nest of four 
oblon;; tin pans of flttinjf size. 

Such a ba;^ contains all the necessaries for an emergency, and ha» been 
used by the author seven years with much satisfaction. 

NdTK. — St'r;/Je<tl fM>ei:rtrn.irx, ns •reni'i'allv sioliJ liy siiri.'k'.il iiitlcrs, arc mostly JrieompleM 
anil uTii^atisfuetory. Tlii'ir mnin ot>jei'taoti is the Hmiill kizo ami frnilly <if lli(.> hie>(rti[iH-iit3 con- 
Uined in then». Thi' instruiment-pourh (iepictctl in Fip*. 7 an<t 8 ia very complete, and Is wcm 
stra]>pL>d to the waist iimlcrneaih the coat, tt L-'jntaias, bcMidea tlic in:4truTiients hcUl by a cotii- 
j)lt!te pofkct-cttw, n i^lmrp spoon, n kry-hnle saw, a tlat r>blong iV/«/'"rm ilwtlittff-bojr of ban] 
ruW>rr, ami a i^l of divorst? dctiichublL- kiiife-bbdc:', tbat can bo fitti'tl to stnootli hard-rubbor 
handlfs, nil very easy lo clcnn. In an cnifvtHiioy, ilie bip-iioiifh will l>e fonn<J large euoagli for 
the rcceplinii of onu (Xinipk-te dre<«^iug to a tii(Kler;ite-aizcd wound. 



I 




In the prtTtnlitifj chtipttT tlje trciitmt'nt of froshly iiiiidt', Lrkiiii, or tin- 
contaminated wouriJs was di8cut*8fd ; its subject wiis tlic asfpffr form of 
tireatmenl — that is, the nianrier in wiiitli ii firsh iir tlcan wound has to be 
[managed in order to prevent its septic infection. 
The aseptic discipline is a purely preventive one. 

Aniifpptic treafmenf^ on the other hand, refers to .such wounds as have 
?come the seat of infeetinn, causing inJlutnmatioii, snj>])uration, or the 
[higher forms of sepsis — phlegmon and gjingrene. The object of the anti- 
tic treatment is the limiting and elimination uf fatuMiithetl septic pro- 
by drainage and ditiiiifection. It is al.<o preventive, hut iti a narrower 
[teusf^ than tlie aseptic method. Tiiere all mischief is ju'cvented from the 
putset ; here further extension of present mischief is sought to he checked. 
[The aseptic method will generallv preserve all I he parts involved ; the anti- 
:>ptic method can not restore the integrity of jjarts destroyed by ulceration, 
mppuration, or gangrene. 

Jlln»tration (if AnfiAoptlr Meihod. — For the sake of illuritnition, let us 
go back now to our former exiimple of breast-anijintation. 

Some gross fault having been committed, such as, for instance, the use 
of unclean instruments, or a sponge that, having fallen to the floor, waa 
picked up by the nurse and was handed fi>r use in the wound. The mild 
course of the case is compromised, and trouble will follow. 
I In such cases the patient's genend condition ia deeply disturbed, more 
or less high fever is present, with headache, 8icknes.% general dejection, and 
drawing pains in the limba. The tangne is foul, much thirst and loss of 
appetite are complained of. The wound ia painful and throbbing, and the 
patient dreads any movement lest the sore parts be hurt. 

Under these circumstances an immediate examination of the wound is 
imperative, 'J'he preparation mentioned in the preceding chapter being 
made, the wound is exposed. Its edges and the vicinity will be found angry- 
looking, swollen, hot, and tender. 

The stitches should be all removed. The point of tlie grooved director 
should be inserted between tlie edges of the wound, which are gradually 
Bepamted till the indei-tinger can be inainuated. Exerting gentle pressure, 
the wound is thus opened throughout its entire extent. One or more small 
foci containing pus wil! he laid open and discharged. The wound .should 
be carefully irrigated with warm mercuric lotion till the slight hemorrhage 
s, and lightly filled with sublimated gauKC. After this the outer dress- 
with the addition of an externally placed piece of rubber tissue to pre* 





RULES OF ASEPTIC AND ANTISEPTIC SURGERY 



vent ovaparation, should be renewed, iind tlio tinu'ly interference will be 
soon rewarded by n decided improvement in ttie patient's condition. In 
these cases the dressing's mnst f)e changed its often as they become soiled 
throngfh. If the fever should ooniinuf, renewed search must be institnted 
for overlooked points of retention. 

In some cases examination of the wound will reveal only partial or quite 
eireumscribed inflammation. In locating the exact point of retention, the 
sensutions of an intelligent patient will (jreatly aid the snrgeon. If the 
retention be near the edojos of the wound, the grooved director will easily 
separate them and find its way into the focus. A dressing-forceps should 
be tlu'u insinuated along the director, and withdrawn with its branches 
partly opened. Pus escaping, a slender drainage-tube should be in.^erted 
into the track. 

If the iK>int of retention be remote from the edges of the wound, 
and its locality well marked b_v redness and jiain, an incision will be.st 
answer the purjiose. and often may prevent suppuration (if the rest of 
the wound. 

Let ns assume that fnr one resison or another nothing efficient was done 
to relieve the patient on the second or third day after the operation. Finally, 
the increasing seventy of the symptoms v,ill compel some action, and, the 
wound being laid bare, the fnlloiving state will be generally met witli : The 
wound will be more or less gaping, ichor or pus escaping everywhcrf ; the 
skin will a[ipcar flushed, swollen, and painful ; the vdgGS of the wmmd will be 
ujarked by a grayish-yellow, closely adherent coating, that extends through 
its wliole interior. This coating represents molecular, often deep-going 
necrosis of the wound surface. Independent abscesses will often bo found 
established along the connective-tissue planes contiguous with the wound, 
and should be forthwith incised and drained. The wound should be well 
irrigated and loosely flUed with sublimated gauze. Over this should be 
a[ii>lied a mot'jit dressim/ of ample projiortions. covered with an overlapping 
piece of rubber tissue to prevent ova]ioration and inspissation. The secre- 
tions will thus be readily and continuously drained away and disinfected, 
and ihe warm moisture of the dressings will at the same time exert a very 
soothing influence upon the iji flamed parts. Fretinent, at least daily, change 
of di*ossings is proper, accompanied by co[nous irrigation. Detached shreds 
of necrosed tissue slionld be removed witli thumb-forceps and scissors. If 
new abscesses 'form, they must be found and opened promptly. The fever 
will 8oon abate, and the wound will gradually assume a clean granulating 
appearance. As the amount of secretion diminishes, the dressings should 
be changed loss fre(|uently. 

Essentially, the so-called '* idiopa/fiie " phleytmm^ or spontaneous su^ 
punition (abscess) is a form of local septic infection which can be traced! 
back ti) an infectitoj extending from a lesion of the skin or the mucousi 
membranes. 

Even the suppurative or infectious form of usteomyelitis must be classed 
under this heading. 



1 



4 



4 



THE TREATMENT OF ACCIDENTAL WOUNDS. 29 

But, on account of the great practical importance of the subject, requir- 
ing special consideration of several anatomical regions involving important 
modifications of the antiseptic procedure, it is deemed exjiedient to treat 
of this theme in a special chapter. 



CHAPTER IV. 



SPECIAL RULES REGARDING THE TREATMENT OF ACCIDENTAL 

WOUNDS. 

L TEMPORARY MEASURES. 

Taking charge of a fresh case of accidentjil wounding, the surgeon 
should bear in mind that, on the one hand, by the avoidance of 8upi)ura- 
tion, a complete or almost complete restitution of normal conditions can be 
accomplished in a great majority of cases ; on the other hand, suppuration 
will enormously increase the gravity of a given injury. A compound fract- 
ure of the leg, or an incised wound of the wrist, witli opening of joints and 
severing of arteries, veins, and tendons, may serve as examples. 

In approaching a fresh case of bloody injury, we should always consider 
the possibility that the wound may be surgically clean, or may still be asep- 
tic, and that our first ministrations should not carry septic contamination 
into the wound, and thus harm the patient instead of aiding him. As a 
matter of fact, a large proportion of incised and lacerated wounds, of com- 
pound fractures by blunt force or gunshot, are aneptic. They need no dis- 
infection. The surgeon's first object should be in these cases not to spoil 
matters by hasty action and ill-considered zeal. With the comjiaratively 
rare exception of injuries to large vessels accompanied by dangerous haem- 
orrhage, where immediate action is imperative, conditions should be created 
by the surgeon, under which safe — that is, aseptic — approach to the wound 
is made possible. Temporary protection of the wound in the sliape of a 
simple dressing is meant thereby. lodoform-powder dusted profusely over 
the wound and its vicinity, a compress made of a clean towel dipped in hot 
water or carbolic lotion, also well dusted with iodoform and tied on to the 
wound, will be sufficient. The addition of a temporary splint in cases of 
compound or gunshot fracture will make transportation to the i)aticnt's 
home or to a hospital possible, and will thus afford time for the absolutely 
necessary preparations. Extensive or even sn])erticial examination of uii 
accidental wound by probing or digital exploration in the street, on a train, 
or in a railroad-station or drug-shop, is stronj^ly to be condemned, as it 
almost necessarily exposes tiie wound to unavoidable infection. Meddle- 
some and untimely surgery of this kind smacks of ostentation, is unneces- 
sary, and in many cases positively more dangerous than the injury itself. 
H 



au 



HI LES OF ASEPIIC AND AMTISKPTIC SURUERY. 



Bergmaiin'ri experience during llic Russo-Turkiali war lius shown that moet 
ginisliot wounds aiT useptic, and Uuit, with tiie exception of those cased 
where .shredii of soiled clothitig or gun-wada wore carried aloug by the pro- 
jectile into the h'vttoni of tlie wnund, heuHng without suppurntian can lie 
innfidentlv oxpeeled if tlie wound id nut infected by meddlesome and uii- 
eleimlv t-urgery. Tlie.se experiences refer principally to gunshot fracture* 
'►f the knee-joinL 

As a m;i Iter of fact, it may he safely aj^sunn^d (hat an examination by 
}>robing or digital exploration, performed on the lilthy floor of u public 
place or on the street pavement, even by the most experienced surgeon, can 
not be, and is not cleanly or aseptic. It is extremely dangerous, unneeejstiary. 
lienee culpable. Even in most cages of profusio arterial hiemorrhage, mesiid 
constriction with an extemporized tourniijuet, a£, for instance, the ** Span- 
itih windhwir," or digitid compression of tlie alferent urterial trunk, can l>e 

successfully einpluy(.d, while the patient 
is transferred into a suitable locality, 
where permanent relief c;in be safely af- 
f(»rded by dcHgation. 

The Collected and bnsineisslike manner 
of the surgeon will at once allay confu- 
sion, prevent hasty and injurious inlcrfer- 
ence, will infuse the jialient and thoee 
|iresent with hope and eonlidence, and 
will fiieilitate well- 
considered and ra- 
tional actiou. 

As a rule, the 
fate of ti fresh 
wound is deter- 
mined by the views 
and training of the 
jdiysician who first 
attends to it. If 
the patient be so 

fortunate a?f In fall in with a man fully imbued with the spirir, and familiar 
witli the jiraetiee of aseptic surfjery, he is truly to be congratulated, because 
his chances of avoiding suppuration are excellent. If his lirst attendant he 
one of the still numerous band, to whom wound infection by dust or lilth 
adherent to hands or a probe he a niytli, woe unto him ! Witlmut previous 
cleansing, immediate prohiug of the gunshot wound of a vert4.'bra, for 
instance, accompanied by digital exploration, will be performed on the 
patient extended on a mattress laid on t!]e dirty floor of a railroacl station. 

Of course, the bullet will not be found, mid nothing beyond the infec- 
tion of the wound will be accomplished- A dressing will be applied any* 
way, and the patieni will be taken home, Snjipuration, that olherwiso 
might have U-en avoiiled, will surely Het in, and the patient is doomed. No 




Fn.. it — K.\U-m|>urizcd Uiuniiquet — " Spsuii'*!! miidluss." 




THE TREATMENT OF ACXTDENTAL WOUM)a 31 

amount of consnlting can deviae a way, for no surgical .skill can establish 
efficient drainage of the inaccessible parts of the wound. The chances for 
recovery were thrown away here from the outeet. 

On taking charge of a fresh wound , the fearful and often irremediable 
consequences of a first &lse step should be always present to the mind of 
the surgeon, and his attention should be directed chiefly to the aroidance of 
septic infection. A temporary aseptic dressing baring been applied, the 
general condition and comfort of the patient should be looked to by the 
administration of stimulants or sedatives. After transfer home or to a 
hospital, the necessary measures for permanent relief should be carried ont 
as soon as the patient's general condition will permit. 

IL IXEFIlflTIVE RBUBF. 

Preparations, comprehensive and thorough, as required for an aseptic 
operation, should now be made in the manner described in Chapter IL 

The patient is well stimulated if necessary, is anaesthetized if the case 
require it, and, his clothing being removed by cutting or in ^me other 
proper manner, he is placed on the operating table. 

After this should come a caref ol cleansing and sterilization of the sur- 
geon's and his assistant's hands by scrubbing with soap and brush and 
immersion in a germicide lotion, followed by a likewise thorough elean«fing 
of the integument in the vicinity of the wound. Plenty of ifoap-lather, 
with the use of a razor, scrubbing with soap and brush, rubbing and wish- 
ing off with a solution of corrosive sublimate, will soon accomplish this. 

1. Contaminated Wonnds. — The character of further procedures will have 
to be decided by the answer to the question : /» ihe wound clean or in it con- 
iamitutted? Gross evidence of contamination, such as, for instance, street- 
dirt imbedded in the wound or the clots, or the knowledge that the wound- 
ing was done with a filthy instrument, as, for instance, a foul and fetid 
butcher's cleaver, will answer the question in the affirmative. In these 
cases the leading object should be thorough cleansing and disinfection 
of the wound, followed by very comprehensive measures at drainage. If 
the external wound be small, it has to be well enlarged, .^kj as to afford a 
good insight. Every nook and recess of the wound should be svHtematically 
gone through, cleansed of clots and rlirt, thoroughly irrigated, and well 
drained. Great care must be taken not to overlook rt'CCMes, as one particle 
of filth left behind unawares, may cause very grave trouble. 

Drainage of the more remote recesses should be made as direct as ixj-ssi- 
ble ; that is, a rubber tube carried to the .-urface from a distant corner of 
the wound through a properly placed counter-incision, will f>e more direct, 
therefore better, than a long tube bent or twisted and brou;;ht out through 
a distant opening. 

Haemorrhage must also be. of course, well stanched by ligature or 
otherwise. 

Divided tendons, nerves, muscles, or fraeture<i bones are next united by 





RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Buture, and, if the t'dgcs of the wound be viable, tliey are also approximated 
by sutures. Where extcnj?ive lu,^ of sabstance precludes uniting of (lie 
ed^es, or where uncontriiflable oozing prevails, the wound should be pjickcd. 
This is best done by tirst lining the entire wound with one layer uf iodo- 
form ized gauze, within which is packed a .suitable number of loose balls of 
sublimated gauze. After alinal irrigation and clearing of the draiuage- 
tube.-?, the wound and its vicinity are envclo[)ed in a moist dressing that 
should be protected from evaporation by a large piece of rubber tissue or 
Mackintosh. In case of fracture, the limb is supported by a splint. 

On account of their frequency, and their gravity in case of suppuration, 
Bcalp-wounds and tlu'ir treatment may receive six-cial mention. 

iSmfp-wotiUflff have Ix^en held undeservedly in bad repute on account of 
their alleged tendency to suppurate. They heal as kindly as, and in fact, 
oil aeeimnt of their great vascular supply, heal better than, many other 
Houuils, pruvided that they be lir«t carefully cleansed, well drained In-fore 
suturing, and sufficiently protected by a suitable dressing from subsequent 
contamination. 

Jn ease of a greater denudation of the cnmium, the loose scalp should' 
be rinsed (after shaving and thorough cleansing of the skin), blood-elota 
should be turned out, and the wound well irrigated and rubbed out with 
corrosive-sublimate lotion. A bistoury is inserted into the deepest part of 
the recess formed by the dap. and thrust out through it. Into this oiK-'ning 
a short piece of slender tubing is placed, after which the edges of the 
wound arc brought together by an exact line of sutures. A dry dressing will 
Ix* pro]»er in these cases. 

If the ste[m described above are adequately taken, as a rule no septic 
fever and no destructive suppuration will follow an accidenttil injury ; 
though aseptic fever, due to absoqition of non-deeomjiosod secretious, may 
often enough be observed. 

Tissues or bone whose vitality was compromised by the crushing force 
causing the injury will be gradually detached. This will be accompanied 
by a rather scanty secretion of thinnish sero-pus, and very little fever, if 
any. 

Case. — P. S., a^'cl thirty-sis, wnn, .January 26, ISRfi, rnn over hj a heavily Laden 
truck, ftinl wii.n at onre bnmgtit to the German I]oB|)itii], wlHTe lu* wag Hna'sthetized 
at>o(it two tioiirH after tlie accident. Under strict iiRTUHtinns tJa- wound was examine*!. 
A laet?rntion of the iiiti'munent in front of and correspondinp to the iniddJe (»f thu left 
lep, four iocLos long, was found. Compouud cominiimte<J Irftolure of the titda jind tibiila. 
The tibia wa-s brvken into four, the tll>idii iuto at lea.st three fnignientH. Severe 
btetnorrhnge from the torn tibiallH antica artery had caused mi enurnious infiltration of 
tlic le|;, wltieb bad uttained double the size of its fellow, and wus quite cold. 
Esmarcb's bandage wtis iij)t>lled, the external wound wiisenbu-ged to uboiil eipht inehes, 
the massive dots, some enntaining particles of street dirt, were turned out of the 
luiisculfir iiiter.>*tice». and fr«>rn between the friiffments one yterfertly detiehed piece o( 
tite tibia wti*i extracted. Fmrri t|je middle of the main cavity into wbirh the tr»g-J 
inenta [imtrndedt a einiuter-inoision was rniide backward through the culf of the left 
inti> which a lnrge-»ized drainage-tube was jdaiied. Three more fonnler-iacisionH, cor* 



i 




THE TREATHENT OF ACCII«yTAL WOUXDjS- 33 



responding to as manj PBecaM* . vcre imaiit. TW V«a jrurr <««U »«c b«- focBiL A 
large moist drewing vas appficd. ami the fimb £xed b<CT«ea tvo v«fl-p«lded bt<rii 
board splintis held togcdicr hj a {wre nat baa^i^. ModtnC: ooosg toQtd tht 
dressings somewhat doling tlie foBowimig night. Tk(*«<o*«- the ^*f9ie iMadare vne 
reinoTed in the mondng. and the «ikd (nru 'jt the cadaijing dreaH«g were veO 
dasted with iodoform. Aaothcr cnrelope o€ gasae wn» bid oa to^ of dw old dreoBngs 
and the quints were replaced and £fe<«e*cd with mmdm hiadlagea. Jmm. SUi, — The 
patient^s t^np^vture had not riaea ahore 1*'«>' Fafar_ he eooiplaaed of xtrj fittie pain, 
no bKm<HThage had followed, the circnlatioe of the Bnih waa good, heaee dke dnMiB|.i 
were not distnrbed nntfl thia date. The woand wnc fovad to be in good conation : 
some blood-clots were stiD adherent to the drainage>CBhca. Wonnd wa» re^ drM a td and 
limb pat ap in a solid piastcr-of-Far» splint. In the beginning :he dresings were 
changed aboat weekly : from Febraaij IScb. ererr fortnigbt. Mmrrh Si. — After the 
exuberant grannlations sorroanding it had been sc r ap ed aw^. Ae entire beflr of the 
tibialis anticiis nnisde was fonnd to be of a grajisb-Tcllow color and neo xM ed. It wa» 
not patrid, althoo^ a good deal of secretioa wa» preKnt. The woond wa» enlarged 
and the necrosed moscle was remorcd. Thereafter the atcrt tion diminisfaed materiaDj. 
althoo^ five sequestra were eoBseccirelj remored. Conaoiidation wa» rather slow, 
bat finallj complete, so that the patient was able to walk withoot suppo r t in Octo- 
ber of the same jear. Shortening about one inch. If left to tbemaelTes, deep-seated 
md extenaire contaminated woonda, pnatsting a anaO external orificcu are, for obri- 
ons reasoofl, most dangeroos^ Free ezpooore. tborrjogh-going deansng and disinf ectioa. 
together with good drainage, are then impcrktire. 

2. Awptie Wouds. — ^Tbe nature of many wounds and their caitaation 
are such as to preclnde the probobilitr of contamination. Mo«t gnnshot 
wonnds and many compound fnctnres belong to tbi^ claae. In these caees 
interference should be Terr discreet. It shonld consist of thoroagh cleansing 
of the int^nment, ordinarily an a^ptic dry dre«*ing. or, in ca^ of doabt, 
of superficial drainage and a moist dressing, t<^ther with reduction and 
support and retention by splint where a fracture requires it. 

Cass. — John D., aged thirtr-two. December 4. 1885. sostaioed a compound eom- 
minoted fractore of the apper half of the tilna bj a horse-kick. Dr. W. T. Kodlich, of 
Hoboken, saw him immediatdj after the aoeidect. cat off the clothing, disinfected the 
ricinitj of the small wound, and dreiSHed it amfJj with iodoform gaoze. A temporary 
splint was also applied, and prtibing or examination yeat tkomghtfuUy refrained from. 
The patient was broagfat to his home, where, the next daj. he was anaesthetized. The 
temporarr splint and dressings were removed, the vicinitr of the wound wa^ carefaUy 
cleansed and disinfected, and. with the observance of all oeceasary eauUUe. a thoroagh 
examination of the injary wai» institate<L .\ r'om{>oand comminuted fracture wa^ easily 
made out, and three loose fragment?^ of bone were removed. The laceration of the 
soft parts and ecchymosis were found verv moderate, and confined to the tissues an- 
terior to the tibia. \ couple of short drainage-tubes were inserted into two recesses, 
and, the wonnd being well irrigated, was enveloped in a moist dressing. The limb 
was put up in a solid plaster-of-Pari^ splint, with the knee bent at an obtuse angle, 
and was suspended from a frame. 

The temperature remained normal or almost normal throughout. 

Def. 18th. — .\ppearance of wound normal. Moderate secretion due to limited 
necrosis of a loose fragment of bone. Dee. 28th. — Second change of drer^sinir*. Ex- 
oberant granulations have filled up the defect. Jan. 18th. — .\ fenestrated silicate-of- 




RULKS OF .VSKFTIC AND ANTISEPTIC SURGERY. 

wkIu splint was Hp[iUtHJ. Tlie secretion oontiniiMl to be stMinty, lo May coasolidation 
was perfect, liut a. small sinus* remained UBtil OctobtT, when, after the extraction of 
sev^rtil small spioula of Lone, definitire bealinf; of th» wound tinnued. No appreciable 
shortening res nl ted. 

Note. — In the mure extensive injurifs of the cstrvmiliea caust-d by crushing force, the 
gmvity of the cusc hin;;es more ii[M>n tho t-xtent of the injury to the soft pans than to the bone's. 
A conijK>un(l fraclnre by direct fonx'^for instance, tlif Muw of a hammer upon the tibia, whcr« 
the crushing anil laceration of the soft i)artH are comparatively liniiteil — is liy far not as dan^eroiu 
a.*, for injftanee, the stripping off of the entire latcjjument of the lower extremity, or the cru.«h- 
iufj and pulpification of the large mui^clcs, vessel!", and nerves* .situated nn the anterior and 
inti-rnal nspect of the thigh, tlioui^h these latter injuri'-s be uneoiuplieated with fracture. The 
ahi>ek and the presence of cittenalvc thrombo$(i.-<, in addition to the fact that, with the large quan- 
tity nf mortihed tissuefl, preservation of the ai^eptlc state is extremely uncertain and difheult, 
cloKS iheSf injuries araong the niont grave and dangerous. 

3. Gunshot Wounds, — The f:ict thsit most fresh gunshot wcmnds are a>x'i>- 
tic has been pointed out by Esmarch, and is now well eatabli.^'hed. Reyher 
wild Bcrgmann'a experiences in the llusso-Tiirkish war put the fact beyoud 
C(>nLr<;versj. 

Wise precaution against infecting a fresh gunshot wound will be riclily 
rewarded by excellent results. In most ea>*es cleansing- atid disinfectioti of 
the skin in the vicinity of the jtoints of entnmce and exit, together with a 
dry drettnuK/^ will be s^ufficient. If the case is complicated by fracture, a 
suitiible splint, preferably ]>la:?ter of Paris (Bcrgmann), should be added. 

If the ct>ur.se i.s free from -septic fever and :<nppnration, this will be mani- 
fest within the Hrst three or fonr dayn ; in that case, the first tlres.siug ami 
the splint can be left undisturbed for the length of time recpiired for the 
accomplishment of bony union. 

Flcijli-wounds will be healed within a fortnight or three weeks. Gun- 
shot fractures will reijuirc a longer time for healing and consolidation, but 
are in no way different from ordinary compound fracture?. 

The projectile will cause very little or no irritation in aseptic — that is, 
non-auppurating — gunshot wounds. Generally it will become encysteil. 
Search for the projeetilo in the bottom of the wound i« rarely indicated. 
It can occur, however, that pressure of a projectile or itjs fragment, or a 
sliarp spiculumof bone on n nerve-trunk, may necessitate search and extnio- 
tiou. This must be done under careful asepsis. 

It is even not necessary to remove a projectile lodged under the ski 
It will do no harm if left there until the channel which it cut by its passu 
through the tissues is obliterated, when its removal by incision can not lead 
lo an infection of the bullet-track. 

In cases of injury to large vessels or the intestines, immediate interfer- 
ence can not be delayed, but should be carried out under most rigid aiiti- 
septic precautions. 

NoTK. — Roeent suocefwci* (W. T. Bull) achieved by immctliatc laparotomy and suture of the 
wounded intestines jitHtify the procedure. 

Where the nature of the charge or the short distance from which the 
shot was delivered makes the entrance of a gun-wad probable, or when? the 



Zm 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 35 

examination of the snperjaceut clothing shows a large defect, rendering the 
probability great that shreds of soiled cloth have been carried to the bottom 
of the wound, dilatation, search, and extraction maj be indicated. But it 
is better to wait in cases of doabt, as even these foreign substances may 
become encysted and harmless. 

Should suppuration follow, the patient will not be worse off than if a 
fruitless search had been made at the outset, and the use of the suppurating 
track as a guide will materially facilitate the finding of the irritating body. 

Note. — Reyber's obaerrations (Volkmann's ^ Sammlimg," Noa. 142, 143, 1878) may serre u 
a fur sample of the radical change that has taken place in the resolta of the treatment of gun- 
shot f ractarefl. 

Gunshot fracture of the knee-joint was formerlr coiuidered an indication for immediate 
amputation. Reyhcr treated eighteen fre^h cases asepticallr — that is, bj nmply cleansing and 
disinfecting the skin about the wound, and occluding the same br an antiseptic dressing. Where 
the wound was gaping, or where there was ground to suspect the entrance of (firt or shreds of 
clothing into the bullet-trad^ dilatation, irrigation, and extraction of the foreign body, with sub- 
sequent drainage, was practiced before the wound was sealed up. Of these eighteen cases, fif- 
teen recovered, with movable knee-joints — 83*3 per cent of reooTeries. One patient died of 
fatty embolism in twenty-four hours after the injury ; another of haemorrhage from the divided 
popliteal artery and vein on the fifth day ; and the third one of pyaemia. 

Of nineteen that came under his care several days after the reception of the injury, with 
well-established suppuration, eighteen died, and one recovered with a stiff joint. In spite of an 
energetic antiseptic treatment by incisions, drainage, and irrigation, a mortality of 85 per cent 
«as noted. 

Of twenty-three that were not subjected to any form of anti^ptic treatment, twenty-two 
die<l, one survived, a mortality of 95*6 per cent— clearly justifyin<: the practice of the older sur- 
geons, who at once performed amputation in cases of gunshot fracture of the knee- joint. 

Infected accidental wounds or gunshot injuries that become the seat of 
suppuration can be classed under the heading of phlegmonous processes, and 
their treatment will be dealt with in a subsequent chapter. 



CHAPTER V. 

SPECIAL APPLICATION OF THE ASEPTIC METHOD. 

A. General Principles. 

L TECHNIQUi: OF SURGICAL DISSECTION. 

Modern surgery demands that the invasion of the uninflamed tissues 
of the human body by the surgeon's knife should be surrounded by all the 
safeguards that are known to be effective in preventing suppuration. Tlie 
mortality following oj)erations sanctioned by pre-antiseptic surgery lias been 
remarkably depressed by a conscientious and intelligent adherence to the 
principles of surgical cleanliness. A large number of recently devised use- 
ful oj)erations have become legitimate under the assumption that suppura- 





RULES OF ASEPTIC AND ANTLSEPTIC SURGERY. 



tion can be excluded. The large joints, the tendinous elieatlis. and the 
|)entoDeal caritT are nov eafelv acoeasible for cnratiTe or even diagnogtic 
purposes. 

The etat«meni that a real obeerranee of aaepticiam offers a sure guarun- 
tee again.'tt guppnration. be the performanfc of a bloodv o[)i'ratiau however 
clnni:»y, rough, and uogkillful. is true, but can not be pleaded as an excuse 
for the ab^nce of that equipment of pathological and anatomical knowledge 
and technical skill which go toward forming a good surgeon. Although 
the general standanl of safety and sncce?* in surgery has heen considerably 
raised, excellence vrill be attained by tho% only who unite the qualities of 
a good diagnnstician, pathologist, and anatomist with the tact, energy, aod 
technical i»kill of the accomplished surgeon. 

The technicjue of surgical dissection is based upon principles:, the oh- 
Berviince of which enables us to safely explore and manipulate any accessible 
part of the human body. 

Aaide from tlie ever-pre'?ent desideratura of preventing infectiou, thtj 
avoidance of accidental injury of important organs and the control of haem- 
orrhage first deserve attention. 

7'fn' prirn'ipU' of dointj rt^rry xtep of an nperafion undfr the guidancp of 
the rifv, is the t/ivsi important discipline of dissection to be acqtiirfd. It 
shcmid never be sacrificed without the most stringent necessity. Its non- 
ohsiTvaiiee 18 tltt* ssource of niojit tliat is embsirnissing, appalling, and dia- 
fistroUH ill iijwrativt' work. 

Upon thin princi/dfi is based the rule to alwaytt moke an ample and ade- 
quate infisfdu, whieli should he grarltijilly dcejK'npd layer by layer, until 
the part fioiiglii afUT is freely expo:jt'(l. 




Fio. 10.— a, Bellied Acalpel for cutaneoiu indMion. fi, )>Untf-iV)ml(sd Aotilpul for d<<cpcr <liaBeolv>rS' 



For the cutaneous incision a bellied scalpel, held like a tiddle-lx>w, i^ 
tlio most uaofnl. A careful and clean iiK-isinu will insure ;i liiioiil cicatrix* 
A.-* stjon Its the skin is divided, the snbciiliiiiL'uus vessels will beeouie visil)lc- 
If ilicy tire crossing the lint' of iocisimi, they should bo grasiied betweei» 

hvtt artery forceps, divideiJ 
bclwecu, and safely tied 
off with catgut. In cut- 
ting f]iron<rh the fascia, tlu? 
grooved director used to play 
an important part in for- 
mer times. Its use hus l»een 




Flu. 11. Muiiiii'r 111 lioldiii^ Ml 
iueiniijii. 



kdif'i'- litf the I'utuiUMiiw 



supj flail ted by a safer modt' 




SPECIAL APPLJCATIOX OF THE ASEPHC METHOD. 



37 



of preparation, known as cutting between ttco tkumthforcep*. The aathor 
once observed that, in thmsting a grooved director andemeath the fascial 
coverings of a hernia, the hernial sac was opened, and the adherent got 
nearly torn through. As it was, only its seroos covering was lacerated. In 
another instance, pnnctnre of the deep jngnlar vein by the point of the 
grooved director happened, and led to very annoying haemorrhage from the 
deepest parts of the wonnd, which made exposure and ligatnre of the injured 
vein very diflScnlt. It may be said that, anless very thin layers are taken 
up by the grooved director, the sargeon never can tell beforehand what he 
is going to cut throngh while nsing it Veins especially are easily injured, 
as, being pnt on the stretch, they become empty. Stretched, they lose 
their identity to the eye, and look exactly like ordinary connective tissue. 





Fio, 12. 



FiQ. 13. 



Securing and tTing ve8.->eU traversing the line of incL-'ion. 

Cutting between two forceps has the peculiarity that, a thin layer of 
tissue being raised before each cutting, air enters into and rareGes its meshes, 
rendering clearly visible the vessels, which can be easily isolated and secured 
before they are cut. From this result two very great advantages : First, 
the patient does not lose one drop of blood from a vessel secured previous 
to its division ; and last, but not least, the wound remains dry and clean. 
No time is lost in hunting for a retracted vessel in a jkjoI of blood, there 
is no occasion for hasty and rough sponging, and everybody preserves an 
easy tenor of mind very essential to success. 

The advice, so often met with in text-books, that the knife should be 
laid aside where the tissues are loose, and that tearing or scraping with for- 





RULES OF ASEPTIC AND ANTISEFPIC SURGERY 



ceps or tho finger-nail is safer, Ja, to mj the least, very questionable. Tliis 
advice if? born of tho fear of unexpeetGcl liaBmorrbnrre, which, however, can 
bo alwap avoided by cutting between two forceps. The beginner, especially, 
is prone to carry tliit* mode of blant preparation to great lengths, and lacer- 
ation of large veins, the jjeritoneum, or oysts ib the result. 




U. — iJulting bctweoti two thtamb-forcfps 



A consideration of no Bmall importance is the fact that a clean-cut wonnd 
will sometimes hoal in spite of some local reaction and fever. This meaaH, 
that the blood- and lymph-vesHols of the parts concerned being not ranch 
bruised, sufficient nutriment is carried to the walls of the wound t*> over- 
come a moderate degree of mierococcal infection. Where the nutrition of 
the parts is s^riouHly interfered with by tearing and bruising pertinent to 
blunt dissection, a much higher degree of asepticism is required to secure 
absence of suppuration. 

Note. — The old siirpcal tenet, that torn and bniised operative wounds are not prone to b«d 
kindU', is ba8«l upon ihv fnct that lic-vitaliiiod tii«8tios rorii) an i-stii'inaUy favorable pabulum to 
niicrobial devulopint^iu. The observation that very well nouriiihiil tiritiiic!*, an, Tor ittstancc, ihtat 
of the tticv, will ht-al readily under almo!<t all eireum^tanoes, and without tht* obscrrancv of anti- 
septic precautionB, i» explained by the fact that thev are very well vascularized, and a rich supply 
of oxygenated blood i» one of the strongesit ^erniicide:i. \Vc often aaw the part* become rod, 
swollen, and painful, ami were expecting s<n[jpuration, but in vain, as all the local symptoms and 
the fever receded, and good nnion followed. 

As the wound is gradually deepened, sharp or blunt retractors should 
be employed to well expose to view its bottom, in which is centered the sur- 
geon's interest. The skin, muscles, fascite, tendons, or the periosteutn can 
be held hack by sharp retractors ; vessels and nerves, the peritoneum, ami 
friable glands or cysts should never be hooked up by them, blunt retractors 
deBcrving the preference. 

Most of the retractors commonly sold by the instrument-dealers are 



i_ 



I 




Fi0. 15.— SinaU 
blunt retractors. 



Fio. 10.— Medium-.Hkzi<d blunt 
retractor, a, Actuui size. 



C,Trt:MAM»t.*co, 





Fiu. 19.— Large I'oiir-prongtd sbtirp retrucUir (Volkiiiuun). 






Fio. "JO. — MfUincr ol holding the knitl' for deep disoection. 



RULES OF ASEPnC AND ANTISKITIC SURGERY 



The shapes and sizes moat u«eful for wenenil surgical work are depicted 
by Figs. IS, Ifj, 17, 18, and 19. 

The deeiier the knife penetrates, the nefirer it approaches important 

orrrans, the shallower \U 
strokeis should become. 
A somewhut jtoiuted 
scalfK?! should ho uwd, 
and Its strokes, esi>ecial- 
]y where they ecver dense 
tissues, sliould be made 
with the very iH>int of the 
ju^trumeut, which should 
be held like a ^len, bat 
rather steeply. 
Use of the grooved director^ or the scissors, or the .nckle-fthaped bixfourg 
In the bottom of a deep wound is always unsafe, as it may lead to nnex- 
pected hffimorrhage or something worse. Especially dangerous is the last- 
named instrument, as its very nature renders impossible the observance of 
the principle of no/ eutlintj whal we do not am. It cuts froai within out- 
ward, takes up unseeu tissues, and may become the cause of unnecessary 
troiihle and embarrassment. 

Should it become evident, as the wound deepens, timt the tirst incision 
is inadequate, and that, in order to aiford access, its edges must be subjected 
to severe tension, and that work is thereby cramped, an extension of the 
first incision is in order. This should be done methodically from without 
inward iiutii the wound is siilliciently enlarged. 

NoTR. — The author u^nce »aw an ovariotomi^t make abdotiiinal section with exag^niicd 
tniiiutcm'Sr*, Irjct by layer, uiiltl the belly was o[)ened, tying cadi small vessel as it was cspoded. 
When a digital tfxjiloratiDn hud inndc evident the ini4iiJli(.'ic-ney of the incision, he enlarged it hj 
culiintf l/iro'if/h f/u: etifire thickness o/tlic nbdominai tcatt wi/A a tfotii /ftir ofxcusorsat one afrcJb. 
Of course the inciaitin was uneven, Bome layers being further cut than others, biemorrbage w»» 
conaiderabte, and finding and securiag of the retracted vessels not ea^y. 

The shape of every operation wound should be such, if |)08sible, m to 
afford tlie best conditions of accej's, 



\ 



and, later on, fur natural drainage. 
77tt' funnvl }<Jtapc (Fig. 21, a) is 
meant b}' this — that is, that the first 
incision should be the longest, the 
next one a little shorter, the last one 
the shortest. Even if no drainage- 
tube is inserted in such a wound, i»s 
long as the closing stitches are not 
too tight and too many, the interstices of the suture will afford ample 
draimige. 

liotile-shaped icovnih (Fig. 21, b) are disadvantageous in Gvery way. 
They result froui a too small cutaneous incision, are uneouifortable and 



Fig. 21. — A, Funnel-ahaped wound. 
Bliuped wound. 



BoOl^H 



SPECIAL APPLICATIOX OF THE ASEPHC METHOD. 



41 



insafe during the operation, and after ckk^nxe offer poor conditions for 
lataral drainage. They always require a drainage-tnbe. and. even with a 
/nbe, if not absolately aseptic, become a rery hof-bed of snppnraiion. as the 
iischarges of infected recesses may not find ready egre^ss. 

Where the incision mnst be carried through comdfnf^ or imJUtm*^ ti^ 
<ue.1t, preparation betireen two forceps will be generally impossible. All 
.he more stress should be laid upon the amplitude of the first cut. and mpom 
'he adequate dUataiioH of the wammd bjf ttrrie eable and 4tolid retractor*. Xi 
:he wound deepens, the hooks should be alternately released and in^rted 
leepcr, so as to follow up closely the work of the knife. 

On account of their hypenemic state and density, haemorrhage will be 
found a great deal more profuse in inflamed than in normal tissues. The 
presence of vessels will become manifest only by the haemorrhage caused in 
3utting them. The smaller vfceries can be easily controlled by increasing 
the tension exerted by the retractors on the edges of the wound. Larger 
ressels must be tied off. But the density and often the brirtleness of the 
tissues prevent grasping of 
the bleeding points with 
artery-forceps, hence an- 
other expedient must be 
used. 

An ordinary curved, or, 
better, a perfectly round 
haemostatic needle, armed 
with catgut, is carried with 
i needle-holder through the 
tissues adjacent to the bleed- 
ing point in two or three 
stitches, so as to surround it like a purse-string, 
bleeding ori6ce. 




Fio. 8S. 

H»nioe<tatic 

ne*dle. 




Fi«. -a. 



-MantxT^'f af>p1rinf; bjemosUtic 
needle (£.->iiiarch^. 



Being tied, it closes the 




Fio. 24.— Dieffenl.adr.H net-il. -Ii'-Lkr. 



When a plexus of con.siderable ves.sels, especially veiii.s, i.s cucountered 
in the bottom of a wound, or where, for some reasons, it is desirable to 
hasten oj)erative work, the emplovment of mas.-* ligatures will be found an 
expedient and safe way to rapid progress. 

Thiersch's spindle and forceps is an invaluable apparatus for a])plying 
mass ligatures to dense tissues in difficult and deep situations. A blunt, 
probe-pointed, curved needle and a straight ivory spindle, armed with stout 
silk or catgut, and an appropriate forceps, make up the apparatus. The 



42 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



probe-poiuted needle is |^-asj>ed by tlie beak of tbe forceps, and is cau- 
tiously insimuited under the plexiii.'!; or maiis to bo tied off. Veins and 
arteries arc not apt to be injured by the blunt point, an they are inclined 
to slide off from it.- As soon a» the ligature thread ia drawn through under 
the mass, a knot is made, iti.d. the j^pindles servin«j as solid handles, it can 
be tightened with a irreat dent of lirmnesa and security. The mass can be 
fely divided between two of these ligatures. 

Tbe treatment of veins in operative wounds 
is similar to that applied to tu-teriet:. There are 
some points, however, that constitute an impor- 
tant difference, and deserve special attention. The 
tension exercised by retractors i.s very a}»t to ob- 
literate the normal characteristics of veins. The 
dark blood they contain is driven ont of them, 
and they can not be distingui^^hed from ordinary 
connective tissue. Especially in blunt prepani- 
titjn, hiceratione of veins are apt to occur and 
cause i^urious difficulty. To find a bleeding vein 
is not as esisy as to locate an injured artery, readil? 
marked by its jet of blood. And, even if the 
bleeding point is recognized, it is not always easy 
to stop a torn vein, as the laceration may be, and 
in fact freriuently is, an irregular and exten.sive 
slit. On the other hand, venous ha?morrliage can 
often be effectively checked by simple pressure or 
plugging. If the tijiding of a torn and i-etracted 
veiu should be ditticult and involve too much 
time, it will be found a good expedient to plug 
up the {>Iace froFu which the bivmorrhage issues 
with a strip of iodoformcd gauze, held in place 
by light finger-itrcssure until coagulation occurs. 
Formerly the author used a bit of sponge for tliia 
purpose, but the following experience has shown that ]$ix>nge is not a safe 
material : 

Cask. — Theresa Kopa, housewife, aged forty-eight. Fehruary 10^ 1883. — Arapu- 
tatinn of left l»retist, with eviicuutiurj of tlie coatLTits of the iixilla for (ifirrhtis of tlii« 
matniiiftry plutitl. Wound sutiirod thruugliout; tlraiiiaj?e by counter-incision through 
lati^srmiiH dorHi. Aseptic dreusintr. After feverlesH conrse, tirst change of dressings 
on Febrnary 21s^ wlifii tliL' wound wm fmnal nnited. Drninape-tnbe was withdrawn. 
Frh. 22il. — Severe chill, idik'truuifmiif* iiililtration of axillary repion. Ffb. 3:3d. — Incis- 
ion tliruu|i;h cicatrix, and cvaoiuition of a liir^« quantity of pus, followed by u snjall 
fragment of N[JOUge ; drainage-. I'ninterrupttHl benling of the axillary abi^oeaa bj 
(granulation. 

In removing the axillary glands a small vein was put on the stretch, 
and, being ruptured, retracted so far that it could not be f<Hind. A good- 
sized sponge was stuffed temporarily into the recess from which the hjpmor- 




Fi<i 



2f<.— ThipixJi'ft Bpindlu 
uiipaihtac. 



4 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



43 



I 



rhage issued, and the ttperation was finislvuil. Wlu-u tin- s]><)nge waa ex- 
tracted, it ciinie away, as usual, witli some resistance, due to the matting 
of the blood -clot into its meshes. The s]>on^e was a very s^oft and brittle 
one. and its own coiie^iion was jipjMirently less than ttie cohesion of its 
surface to the tissues matted to it. A small portion of the sponge tore off 
and was left behind in the wound. It causeil no trouble for eleven days, 
and only after the disturbance of its relatinns by the removal of the drain- 
age-tul)e did its decomjiositlon set in. Since that time a strip of ittdoformed 
gauze was used for the mentioned purpose by the author, wliieli wouhl not 
tear, and could uot be overlooked, as its end is curried out of the wound 
for a mark. 

Close attention to the details enumerated above will .secure a dry and 
easily accessible wound. No sudden and uncontrollable hw^morrhage will 
occur to create flurry or alarm ; no embarrassment will cause undue haste 
or an ill-considered move ; the patient will fare well, m^ even with the seem- 
ing deliberation, the operation will be speedily accomplished, and, what is 
the main thing, no unnecessary loss of blood will be sustained. 

n, SUTUUES. 

Primary union with a linear cicatrix is the ideal of the healing of an 
ptio wound. As it de|>ends to a great measure upon an exact coaptation 
iU edges in such a manner, that circulation of the integument should not 
be interfered, with, and as exact coaptation under varying circumstancei* 
requires a variation of the procedure, a discussion of the important differ- 
ences in the technique of suturing may receive some consideration. 

E.xact coaptation of the corresponding points of the edges of the wound 
by finger-pressure or otherwise, be/ore and while pansittrf the nHtch, is the 
first condition of a true suture. Where tliere is no considerable loss of 
integument, and where the edges of the wound are eijually thick and have 
sufficient body, this can be done easily by compressing the edges between 
the index and (huinb until they touch on the sume level. A good-sized 
curved needle is then passed through lx>th edges of the wound, which 
will be retained in their correct relation by simply tying the catgut 
thread. 

Where one of the edges is thick and the other rather thin, coaptation 
is more difficult, as the thinner edge is apt to slip back, leaving a portion 
of raw surface exposed. Or where both edges of the wonnd are thin, jis, 
for instance, on the neck, the scrotum, and the dorsum of the hand or 
foot, tlicy have the tendency to curl UTider, raw being in contact with epi- 
dennidal .surface. Both of these relations will produce an uneven line of 
foture, and will frustrate exact primary union. Partial healing by granula- 
tiOD is then unavoidable. 

Under these circumstances the best result will he achieved by the fol- 
lowing phm : The edges of the wound are hr(tught together and pinched 
up by index and thumb in such a way as to form a continuous ridge, on 





44 



RULE8 OF ASEPTIC AND ANTISEPTIC SURCJERY. 








Kio. 2«. 



tbe top of which ahouJd appear tlie line of incision. A sfraiyht needle is 
thrust transversely through the base of thia ridge, and tin' suture is tied 
while the tiugcrs still retain their position. Tlie itppeanince of the cora« 
plott'd suture is rather grotesque ; but, 
wlien the stitches arc absorbed or re- 
moved, the peculiar-looking ridge will 
Jhitten out spontaiieoualy, and the re- 
sult will be a beautiful fine cicatrix. 
See Figs. 'Z\i and 27. 

In tying a surgical knot, a certain 
little knaek will be found extremely 
useful, espeeiidly where good assist- 
ance can not be had. It consists in 
jamming down the first or double cast 
into the angle of the sutui-fi nearest to 
the operator by a aligiit jerk, made upon the distal i*m\ of the thrcud, whil 
the mesial one is held steadily on the stretch. This jamming of the catgut' 
will be just suRicient to hold the edges of the wouml together, until with 

the second cast tbe knot is 
tied. It will even hold to- 
gether edges apj>ri»ximated 
with some degree of force. 

Where there is much loss 
of integument, aiS in many 
eases of breast amputation, 
or where the suture-s may 
liave to stand a good deal of 
strain, as, for instance, the 
abdominal stitches after ova- 
riotomy, aside from the su- 
tures uf coaptation above 
njcntioned, >iitpporlinif or rr- 
ffiffivf aufurcs are neecsstjiry. 
They have to embrace a 
good deal more integument 
than tbe Hner stitches, and 
sbo' !d be inserted from one 
half to two inches away from 
the edge.-* of the wound. Lat- 
eral concentric pressure by the hands, of an jissistant will very much faeili- 
tiite the pro]ier placing of these sutures. 

They can be made in several ways. Tbe simplest one is to pass three 
or four or more interruj)ted catgut sutures of wider scojie, and then to tic 
them while the edges of the wound are firmly gu[>ported by an assistant 
(Kig. 28). The required number of liner stitches is passed afterward. An- 
other good way is the application of a mattress suture, illustrated in Fig, 





SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



45 



29, combined with a continuous coaptation suture, all done with one piece 
of catgut. 

Where silver wire or silkworm-gut arc available, the quill suture or 
Lister's button suture will give much satisfaction. Both of these forms of 



Fig. 28. — a. Interrupted retentive suture. 




Fio. 29. — Combined mattrcKS suture and Glovor'B 
Ktitch. 



retentive suture will be very proper after abdominal operations. For the 
quilled suture, small cylindrical pieces of well-disinfected wood will answer. 
Buttons for Lister's retentive suture (Fig. 30) are cut out of stout sheet 
lead with a pair of scissors. It is sold by dental- supply traders under the 
name of " suction lead." The wire or gut is armed with a perforated shot. 



"0 vl 0° 



J^ 



°0 tX^ 0° 

Fig. 30. — a, Plate and shot suture. 
b. Interrupted suture. 




Fio. 31. — a. Catgut suture from RuppuraUng stitch- 
iiole. 6. Catgut from sweet stitch-hole, nearly 
abt<orbed. 



which is clamped to its end ; over this is slipped a button. The suture is 
passed, and the needle is unthreaded. Over the second end a button and 
shot are slipped, the stitch is tightened, and the shot is clamped. 

In uniting more extensive wounds, it is better to commence at the mid- 
dle and not at the angle, as the latter way may result in uneven distribu- 
tion and puckering. 

After abundant trial and comparison, the conclusion was arrived at by 
the author that, as a rule, the interrupted suture is in every way preferable 
to the continuous one. The exceptions are mentioned at the proper place. 

Tlie chief advantage claimed for the continuous suture — namely, the 
saving of time — is illusory. As regards safety in holding and exactitude 
of adaptation, the interrupted suture has no peer. 

UL DRAINAOB. 

Small aseptic wounds of a favorable, that is funnel shape, do not re- 
quire drainage by rubber tubing. As few stitches should be taken, how- 
ever, as po.ssible, to permit the escape of tlie oozing between them. Small 



EANE LIBRARY. SUWO^^i wm^W 






RULES OF AHEPTIC AND ANTISEPTIC SURGERY. 

wounds of bottle shaix^ will do very well witli u few tlireads of catgut placed 
in one angle for capillary draiii»«j:o. Litrjut'r wounds, esj^ecially tbose with 
a sinuous cavity, rcfjuiro drainacjo by rubber tubing. 

Before using tlic tube, a number of oval holes should bo cHjiped out of 
its side. 

** Throutjh drainaye,'' with a view to Bub!^e4^cnt irrigation, is beat 
effected by placing the mesial end of the tube just withiu the cavity to 

be drained. Drawing 
a long piece of tubing 
transversely through the 
cavity dues not afford 
Fio. 81i.-Perforuttd rahU^x lll•a■u.a^rl-lubs. ^''^ "^^'St conditions for 

thorough irrigation, as 
tile bulk of the irrigating f^treani will pass directly through the tube with- 
out entering the cavity at all. Where two or more siiort pieces of tubing 
are placed just within the cavity, the entire mass of the iirigatiug stream 
is thrown into the cavity, to ej*cape through the opposite opening only after 
having washed the entire extent of its interior. 

Aseptic rubbfr tuljcs never cause "irritation." Increased discharge or 
irritation of any kind is dne tu infection introduced into the wound by 
means of the tube at change of dreswings. If the withdrawn tube is 
touched by unclean hand.'^ and is then reintr«>dnced, it itj apt to cause Irrita- 
tion. But it is not the tube but tlie dirt adhering to it that is the cause of 
the trouble. 

The persistence of sinuses after certain operations, notably exsection:?, 
was also attributed to the U(<e of drainage-tubes. This mistake is now ex- 
plained by the knowledge, that the sinuses in question do not heal ou 
account of reinfection by tubercle bacilli, extending along the tubes with the 
discharges from an incuntpletely evacuated tubei*cular focus. 

In aseptic wounds, the ottiee of the drainage-tube is performed by about 
the end of twenty-four hours after the opcnition. But other considerations, 
notably the unwiHingiiess of disturbing the rest of the wound and of the 
patient, make it ijiexiK-dieut to reopen the dressings eo soon for the purpose 
of withdrawing the tube. It is generally left in ftitn until the first cbau; 
of dressings. If there is no purulent discharge visible in the dre-ssiu, 
removed on the sixth or tenth day, the tubes can be safely withdrawn. If 
tlio hcaliug was not entirely faultless, as seen from the presence of more or 
less pus in the dressings, it will be safer to reintroduce a short piece of 
tidjing for the ])urpose of keeping [Kitent the external end of the tube-track 
until the discharges shall have become scanty and serous. 

When a wound is in good condition and no pyogenic or tubercular 
infection be present, the surgeon will find it a very ditlicnlt matter to keep 
a tube in phice for a long time, should he desire to dn so. The cicatrization 
of the deeper parts of the drainage-hole will irresistibly expel the tube, or 
granulations will invade the lumen of the tul>o through its lateral fenestra, 
and will simply fill it up completely. 






SPECIAL .VPPUCATION OF THE ASEPTIC METHOD. 



47 



The tulje should be always extracted for inspection at the first chftiige 
[of dressings. If it is found to Ik? lilled m* ftith ft more or loss solid clot of 
reel blood or tibrin. the interior of the wound eiin be a.ssumcd to be in 
condition. Should the clots be foul und .<enii-lluid, the Lube muat be 
shortened mvd replaced after thorough tdea!]sin^^ 

The decalcified bone drainap;e-tubes. devised by Neuber, have l>een 
abandoned by the author on account of their many inconveniences not over- 
balanced by the advantage of their absorbability. 

Xeuljcr's " caiializdHon,'^ that is, tnrning in of a part of the edge of the 
roand, and fastening it to a deep-lying part of the tissues by suture, atill 
found a limited a|>plicati<m in t!ie author's practice, aa will be seen in the 
chajiters referring to it. 

I It may be said, on the whole, that rubber tubing has so far not been 
supplanted by anything better for purposes of wound drainage. 



B. Application of Aseptic Method to Diverse Ohoans and 

Regions. 

L LIGATXJRES OF ARTERIES IN THEIR CONTINUITY. 

With due ob:?ervancc of the rules of surgical dissection and of the land- 
marks pointed ont by anatomy, the exposure and deligation of the larger 
arteries will present no serious ditHeulty. 

Tile treatment of the vascular sheath deserves some special remark. 

Free incision of the sheath will bo found to facilitate very much the 
isolation of the vessel. No fear need be entertained of causing thereby 
necrosis or suppuration in an aseptic wound. 




I 



Fto. 3S.— InciiiiDi^ the vascular aheiith (Esmarab). 

The sheath should be grasped and raised with a pair of mouse-tooth 
forceps, and the cone thus formed .should \jc incised with the knife held 
horizontally. The incision can be extended to half an inch in length. See 
Fig. 33. 

Isohition of the vessel is best accomplished by gently insinuating into 
the slit tlte point of a bent silver probe, while the edge of the cut is held up 




n 






Fill, 'JO. — Miiniier of boldiri^ tliu ktiil'c Tor duep dlsaectioii. 



RULKS OF ASEPTIC AND ANTISEPTIC SURGERY 



The sliapea and sizes most u«efnl for general surgical work are depicted 
by Figs. 15, Hi, 17, 18, and 19. 

The duoper the knife peuetratej?, tlie nefiriT it iipproactiosii imporUnt 

(ir'Tiin.'^, the shul lower its 
strnkc's should become. 
A somewhat )K)iiited 
scalpel should be used, 
and its strokes, cspeeisU- 
1}' where they sever dense 
tissues, should be made 
with the very point of the 
instrument, which should 
be held like a pen, but 
rather steeply. 
Use of the grooved director, or tlie scissors, or the fiicAie-shaped bistoury 
in the bottom of a deep wound is always unsafe,, as it may lead to unex- 
pected hsemorrhao-e or something worse. Especially dangerous is the last- 
named instrument, as its very nature renders impossible the observance of 
the principle of fiof cutting whttt we do not see. It cuts from within out- 
Wiird. takes up unseen tis.sucs, and may become the cause of unnecessary 
trouble and enibarrassraent. 

Shtinid it beeome evident, as the wonnd deepens, that the first incision 
is inudeijurtte, and that, in order to afford access, its edges must be subjected 
to severe tension, and that work is thereby cramped, an extension of the 
first incision ia in order. This should be done methodically from without 
inward until the wound is sutlicieutly euhirgcd. 

NuTE. — ^Tlie aiuhor nnci' saw nii ovariolomist raakc abdominal section with exaggerated 
niiiiiiteiK'hH, tnytT by layer, until the belly waa opened, tying each sinall vessel as it was cxpoaed. 
Wlieti a (ii^iul ex|il»ration bad aiadc evident the iuijii(Iideiicy of the indsion, he enlarged it 6y 
cuHiitff throuijh tfu entire ihiekneM of the abdominaf teail tcifh a sfont /xiir o/»cUsors <it ont lintkt. 
Of course the inci^^ion waj*. nni'vcn, aonie layers bciii'r further cut than others, h^morrliage wa* 
coii.'^ider&blu, ftud finding and securing of thv relvneieil ve.Hftels not easy. 

The sha]ie of every operation wound should be such, if possible, as to 
atford the best conditions of access, 



_j:? 



"^ 



aud, later on, for natural d ruin age. 
The funnel fihape (Fig. 21, a) is 
meant by this — that is, that the first 
incision should be the longest, the 
next one a little shorter, tlie hist one 
the shortest. Even if no drainage- 
tube Is inserted in such a woimd, as 
long as the closing stitches are not 
too tight and too many, the interstices of the suture will atTord ample 
drainage. 

liotth'-shappd wouTids (Fig. 31, B) are disadvantaEreous in every way. 
They result from a too small cutaneous iueision, arc uncomfortable aud 



t'l. 



-A, Fniinel-ahoped wound, 
shupud wound. 



Bocik^H 




SFIX'IAL APPUCATION OF THE A>SEPTIC METHOD 



41 



unsafe dttring the opemtion, and after closiiro nffor poor comlitioiu* for 
natural drain. i^zc". Thev nlwuvs rcoiiirc a draiim£rf'-tnlx% and, even with a 



tube, if not ubsolutcli 



bec< 



lot-ljed of 



I 



y aseptic, necome 
discharges of infccteii recesses may not Hnd ready egress. 

Whore tlie incision mnsl be carried throiipjh rnudi'n.'itif/ or iajJittitfti /jV 
itut'H, prepiiration betwoen two forceps will be ^jeuerally impoiisible. All 
the more 8tret« should be kid npon the amplitiule of the first cut, and upon 
the adequate diiaf*tfinn of ihc tmmiui hy sfriu'trabli' and soJit/ rrfrar/urs. As 
the wound deepens, the hooks slionld t)C ulU-rnately released and inr*erted 
dee|>er, 90 a» to follow up closely the work of the knife. 

On account of their hyiienemic state and density, hsemorrhage will be 
found a great deal more profuse in inflamed than in normal tiasues. The 
presence of vessek will become manifest only by the hiemorrliage caused in 
cutting them. The i^malier arteries can be easily controlled by increasing 
the tension exerted by th*' retractors on tiie edges of the wound, fjarger 
Tessels mu«t be tied off. But the density and often the brittleness of the 
tissues prevent grasping of 



^ the bleeding points with 
artery- forceps, hence an- 

■ other expedient mnst he 
u^ed. 

An ordinary enrved, or, 

better, a perfectly round 

H hseniostatie needle, armed 

with catgut, i.s carried with 

a needle-holder through the 

H tissues adjacent to the bleed- 





1 



Kio. 28. 

Ilu'rrKwtulic 



Fin 



23.— Manini 'I ; i 



i.«ll:tiifltat)0 



I 



ing j>oint in two or tliroe 

stitches, so as to surround it like a purse-string. 

bleeding orifice. 



Being tied, it closes the 




Fia. 24.— Di.ffent.aL-h'.-* lu-eai. -Ii>.iair. 



I When a plexus of cout^iderable vessels, especially veins, is encountered 
in the bottom of a wound, or where, for some reasons, it is desirable to 
hasten o|>ertttive work, the employment of mass ligatures will be found an 
expedient and safe way to rupid progress. 

T/tirrsrirs spindlr and forepps is an invaluable apparatus frtr applying 

B msKs ligatures to dense tissues in ditHeult and deep situations. A blunt, 

probe-j>ointed. curved needle and a straight ivory .^pindlc, armed with j'tout 

ailk or catgut, ajid an apjiropriate forceps, make up the apparatus. The 






RULES OF ASEPTIC AND ANTISEPTIC SURGERY 

what there was of it soeincil To hti transniittfil, Uniit wns not uoticeaMe. A 
well-iioreeptible futhiesa aiui resi»*taii('f cotild still be niade out in tlio right supra- 
olavioular fossa. Occjisionaliy short aritl mild attacks ot slinotiag pjiins were felt 
in the arm anil uape of the neck. A claw-like deformity ot the nail^ of tlic right liaiitl 
reinaiHed imalrore«l. In Aii|tiist, puisjjtion and other signs of relapso were noted, 
with iiiorousin<» (laiii, radiatTnjj; toward the occiput. Ronowcd injectioDt* of ergot were 
Avithout avail. In Ortubor, during the author's absence from town, Dr. Adler incii*e<l 
an ah^tiess pointing in tlie supraelavit'ular spdci", and a few days later performed tra- 
cheotomy for threatening asphyxia. A sharp pneumonia followed, from which tl»e 
patient reeovered only to sticcmnh in November to sudden i^uffocHtion. No autops^y 
was permittetL 

Cahk VII. — John II. Nittinger, grocer, agod forty-five. No syphdis; had had 
articnhir rheiimati;*m seven years before. Pulaating sweHlng of left popliteal space of 
the size of n man's tist. Leg had been <\it!emfttoiis for three months; marked emacia- 
tion. Jan. SO, ISSfi. — Ligature of loft femoral artery in Scarpa's triangle. Priniary 
union ttf wound. Recovery retarded by eiretiniseribed necrosis of integument over 
tuberosity of calcaiietnn (due to prcsj^ure?). Discharged cured, March 30, l^o. 

Oabb VIII. — Emnmnnel Lnecke {see history on page 172). 

Oask IX. — Robert Khiile, school-boy, aged fourteen. Congonltid arterio-phlebec- 
tastaof anterior part of left foot; pulsating, du-^^ky swelling, of doughy feel, of dorsum 
and phtnta pedi.H. Along the course of saphenous nerve were seen a series of flat, hunl, 
dark-blue, rough nodes, soiiio of them as large as a .silver tpmrtiT, their size tapering 
off toward ankle. Two of them were uh'crated and covered by a dry scab. Left foot 
on the whole larger than its mate. Pulsation of femoral arterie;* abooriually strong. 
Ik'nrt hypertrophiad. Ablation of diseased parts waa declined. Juhf 7, 1885, — Liga- 
ture of siiperficiul femorul artery, Short stoppage, and return of puliation. Imnie- 
dialo ligature of external iliae of same si<le. Wounds sutured ; no drainage. Primary 
union. Necrosis of terminal phalanges of fir^^t and second toes, of the integument of the 
external aide of leg, and of peroneua longus muscle. Scanty iiseptic suj)puration, and 
very slow detach raent under antiseptic dressing. Tardy cure. The cicatrices on the 
toes became ulcerated in the winter, and thu pulsation of the tumor, which hud not 
diminished iu eize, had returncJ. Jan. B9, 1886, — PirogofiTs amputation. Unu.snal 
nnndver of ligatures required on account of many ahiiorraaUy lurge arteries. Cap of 
culcaneum was lixed t<i tibia by steel nail driven through from below. Catgut satnre. 
Drainage through counter-incision alongside of tendo Achillis. No fever. First 
change of dressings February Iftth. Primary union throughout, except where a narrow 
strip of tlio integument bad necrosed along anterior part of incision, r>rj dressing- 
Fvb. SJ^th, — All firmly healed. Patient walks well withont support. 

Note. — In eiposing the cstema! iliac artery, the i^mall group of lymphatic glandM found 
underneath the transversalis faBcia, just above Poupart's ligament, may serve as an unfailing 
guide. Ah »ooa m these glatids cornc to vievr, the peritancum can he stripped up without diffi- 
culty. In incising a deeply Bituatcd perityphlitic ab.sces!<, the huiuij glands serve *» a good land- 
mark to preveiit the operator from cutting into the fascia of ihc ihopsoas miude, which woold 
dii'ert hina undtr the vessels, 

.^ . n. EXTIRPATION OF TUMORS. 

In retnaTlfi^arJiinBiCti's- three requirements have tobecommouly held in view: 

First, the avrridani^e; oi sofitic jnfection from without or from withiti. 
Srcondljf, the complete i-cmoVal-'trf ttie newplaam. 
Thirdly, its safe removal. 




SPECIAL APPUCATION OF THE ASEPTIC METHOD. 



51 



(■ 



\ 



How to avuiil itifectinn from without was seen in previous chapters of 
this book. Hy infection from within, two kinda of infection are meant. 

One is the eontuinination by septic contents of tlie tnmor that may cscupc 
into thu wound througli un accidental cut or n hiceration of the tumor, 
Ciiuscd by rough handling or 
the careless use of sliarp re- 
tractors, as, for instance, in ex- 
tirpating sujijmrating glands. 

Cksx. — Sarah Barn, servant, 

ageil Bixteen ; i>I<l IVtt's iliAoast* 

of the cervicul vmtebno; liirp' 

glandular swelling of right sub 

maxillary rejnon, with several ei- 

miseii leadiag <' own toward the 

spine. It was jtretty certuiii thut 

no ,«eriou!» deirree of the affection 

of tlie vertehras poald be present, 

as the function of the cervind 

bpioe WHS nearly normal. Xocfui- 

her 4i 1886. — Flap incision and 

essection «f the hirfre tnasa of 

tul)ereular gliinds at Miaiat Sinai 

Hospital. Tbfui^'h the utmost earo Fio. 34.— GluUul luuiwr litioie cxtlrpfttioii. 

was exercised in nut jrrnspiDg the 

g!ands with ^hjirp-ptMiitetl iiistniiuent-H, uuo of tlic-m broke down, and poured out 

ita contents into tlie lurfje wound. As milisequcDt cventj^ demonstrated, 8eeniin(?ly 

lliorongh irrittiition with a stronj^ soluttmi of corrosive subliinato did not disinfect all 

tlie ymrts of the wound. Tlie dissection mainly extended into the tntormuM-ular spare 

— nttinely, flu* i'lit hefwci-n The si-aleiii tun] \\n.- posterior border of the tiTcnio-m.istoid. 

After the removal of the iiiass, the 
flnjrer was easily inserted into a 
tr.'ick leading toward! the second 
vertebra, the anterior surface of 
vvliich was found rou^^h and hare 
of perjosteutn. It was* thoroughly 
^^craped and irrigated (the instrii- 
iiielit eiiuld be felt IH gitn from the 
oral cavity); the outer wound was 
drained, suture*!, and dressed. Not. 
5th. — High fever, with much de- 
jeetion. Skin below eur red, [»aiD- 
fnl. and swollen. The flap wa« re- 
o]R'iK'd, an<l a Hfuall ahsoetH* was 
detected just under the base of the 

flap, where probably irrigation had beeti in.suttieient. Upen ireatfuent. Temperature 

fell ofT U) normal at onre. The patient was discbarge<l cured December Ittt. 

The other kind of infection is the disi-serninatitm through the lymphatics 
of cancerous or sairconintous cell-elements into the body can.sed by pressure 
due to rough tnuniimlution of the tumor. 





Fm. ii5. — tihitoul ■Irii'wii;!'. 



J 



t 



NoTK. — It ia a irell-koo«n fact that, ia suae eum of oal^Miit tumor of jslow growth, aftfr 
opeTBtion, a large nomber of $ecot»larT nodes will «:prin«; np and develop wiUi <rrcat rapiditT Is 
the neighborhood of the ckmliix. Two eaiuea, atber »ngh or eombined, may be at the bottom 
of tbu phenom en on. 

Either the oper^on wmi iaeoBplctc — that i^^, the aun^coo^s £»ection hugged the tumor 
too cioselv. learing behind a aomber of ooi^unding mkroacopical fov-i,— or the forcible mauipii- 
lations of the tuotor dining the operatioa have di»9«i!niDat«d along the Ijinplmtics and vvim 
embryonal celi-elements of malignant character into the vioinitv of the wuiiod or througbnut llw 
body, Thi? is commonly called *'diai^ of the efaaiacter of a mali^ant neoplasm, due to 
mechanical irritation.'' 

Undoubtedly there are many ea^es where an incomplete operation leads to wide dis«cmtiui- 
tian of the eleiuent« of the neoplasm. In the^e ca^e§ relapse in the unhealed wound or in ibe 
fresh cicatrix isi obserred, together with the simoltaneoua appearance of regional and more 'li«- 
tant nodes of new formation. 

Thus an incomplete or tough operation may, by generalixatiao of the disease, hasten instead 
of relardiag the patient's ileath. 

liesisoriable hope of the complete removal of a malignant new-growth ia 
the main justification for o]>erative interference. There h, to be sure, a 
consideniblc class of caaed where complete removal ia from the outset injt 
of the question. Great discomfort from putrescence of a sloughing tumor 
or frequent hjemorrhasfcs do sometimes indicate partial removaL lint, 
wherever possible, complete removal is to be aimed at by ail permissible 
means, as the non-return of the disease depends solely upon the fullillmcnt 
of this condition. 

Our thirtl object must be to remove the tumor with the least possible 
amount of imraediate danger to the patient's life. Careful and deliberate 
dissection, giiidwl by anatomical knowledge, limiting of the hferaorrhage 
to n minimum, and uvoidanci' of accidental injury to Important organs, is 
meant iieroby. 

The most important condition to be fullSllt'd in eschewing these dangera 
18 an (idcqnate inrisinn. 

A too large incision never can do any harm, its worst con8cr]uence being 
the necessity for a few more suture-points. An insufficient incision, on the 
other liand, may be the source of great danger to the patient, and of much 
embarrassment to the surgeon. 

When the incision is ample, the new-growth and its connections can be 
readily exposed without the use of much traction from sharp or blunt hooks, 
and forcible grasping and dragging to and fro of the tumor itself will be 
unnecessary. Most of the vessels that are to be divided will be noticed, atjd 
can be cut between two artery forceps without loss of blood. Accidentally 
injured vessels can be easily secured and tied off. 

The wretched exjiedient of digging a malignant tumor ont of its capsule, 
and leaving behind the latter, should never be resorted to, aa a 8pee<ly 
relapse is certain to fcdlow. 

l)is!*e('ti(Hi should be done altogether with the knife, and exclusively 
in healthy tissut's. Blunt metliods of preparation are not to be used at 
all, since they are unnecessary, and involve a certain amount of rough 
force. 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



53 



III removing iutiltmting or illy deliued malignant isew-growths, the sur- 
geon's knife should give the tumor a wide Ijerth, and all cosmetic or func- 
tioiial con.'iderntious not iuvolving presojit djuigcr should be disregarded, 
tlie lirst object being the com[ilete enulication of the disease. 



H In tin ample wound the lu 



I 



Flu. ;!iL — .\.\illury tumor l.-elnrc extirpatimi. 



mor can be luuidk'd with the ne- 
cej^siiry gentlerress, and the main 
attAC'k can be directed upon its 
adhesions to the surrounding tis- 
■ues. 

With rare exceptions, sharp re- 
tractors an? never to be plunged 
into the tumor, The_v should be 
I used i>n the edge::! of the wound 
for dilatation, the tumor itself 
being held by hand through- 
out. 

The softer the muss of the tu- 
mor, the more care must be oxer- 
ci.-ied not to injure it, Cvsts es|ieeiaUy require very tender treatment. 
Lipomata and iibromata wdl stand a good deal of roiigli handling with- 
out harm. 

NoTK. — In rorrner days lipomatn Hf»e<l to have a Iwd rpiimtntion. It wiw naid ihut thctr 
extirpation »'os ciften folli>weii by frvsijirlan and jiltlepntin). i tin- of tht? liicl ojK'rations wer 
I wituesiieil by tUu audiur was doae upon a lu-althy ycmuR man In 1H68 in Prof. I>.V tiinie, at 
Vienna, for a lipnina (if the shntildoi-. It rau:*t'd rlu- patirntV <U'ath 
fiom .-loptictvmiti. Thio peculiarity, noled by surpron;* in ttincs ^one 

hy, wii!* iindoiiltti'illy dui- to 
the ri'ailiiiess with which a 
plilp^ijcHiuua pracess will 
sprt'iid ill lonco niid ill-nmir- 
ishi-d adipose tissue. Of 
t'imitfc, the infi'Ctiou always 
Willie from the liundu mid 
nppaninijt of tlic smgeoua 
thciuselvos. 

Wher*' fihnulti dls- 
xcviion first be t/iffft- 
ed io, is a ijuestiou 
that puxzle.s every be- 
ginner, and it isnotin- 
dilTerent from wbit-h 
side we ajiproitcli a 

[tumor. Surgery owes to Laiigenbeek a clear exposition of the principle 

[which should guide us in thi.-? matter. 

In rzt'isivi] tumors holdiiuj rJosc rrht/imts fo hrrf/f v^.ty/'h, as, for insJtance, 

those in the neck, axilla, and in Scarpa's triangle, the tjreateHt safety Ih's in 




AxiUiiry winnul, ttiiited, iillur exiii-jjiui'tn rjl' tumor. 




% 





RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



first expomntj these vesmls ahovf and below thf /umtn\ .<<(> ff.s fo have full ron- 
troi of them during tlie s^ubssequcnt steps of the oiwruticni- This precautiou 
offers great security against iujurv fif those vessels, and at tlie same time 

red uccs t o a nn n i ui u m 
the othenv'istt formida- 
Itle dangers of such ao- 
ridental injury, should 
it oeeiir. If it become 
i'vident that tlie tu- 
mor has involved the 
walls of the adjacent 
hirge ve!5.<els, a ligature 
above, another below 
the growth, will ptr- 
niit uf a safe and '-oni- 
])lete exseetiou in one 
ma!?.s of the tumor and 
the diseased parts of 
the vessel. 




>b, — Fkijj ilJtisioji litr tt-iaiiviil nC riiiinjf ul. neck. 
dmiiK'il nud sutured. 



Wouiui 



Note. — It in the foiniiion tt'iidcnt'v of yonng .""iirgeons* to carry too far the di!'.<<H'-t5oTj of 
a Te«M.'l adhoriu":; to u tiiiiuir. Tlii> is uctnutt'd bv tht- dcsrn; of pre--<»'TTiiip tin- intfi^ity of tli<' 

vossH ill quesfHHi, aud ity tlit- natural {tisiiiclinntioii 
tif L-.oinplieatinK the opeialiuii by dtiublc URature, 
which ugaiii involves extra diA^cction. The rou- 
aequeiicc of thfs 
tendency may he 
twofold : either 
(ii>rii«a<i of the 
luraur adhering 
ii> the vessel wall 
ure left behiiKl to 
vtv\^- ijpeeily rc- 
iajiw, or ihi.' vein 
i* eut or turn. 





DrfK>iii^r h>r ijcek wouudw. 



FiM, 40,— Dri'istiinff of ni'ck wound ei)iii|i|ctMl 
by Futilier-lUFiiue bib and arm-nliug. 



SPECIAL APPLICATION OF THE ASEPTFi' METHOD. 



I 



Whrnev*!r themtrgeon hiut Hucceeded in fur in in*/ n pedicle to a tumor situ- 
ated in the vicinity of large vessels, ndtintj of such a pedicle ivithtmi Jirsi 
tying it off in a i^crtf risky step. Tnictiou u]ion the tumor wnll oljllti-rafo 
any vessels incUnlod in tlie i)ediele, and, wlieii <'iit, tltc innuccut-ltiokin^ 
mass, closely resembling orditmry connective tissue, may open up into unex- 
pected ftud overwhelming springs of welling blood. The stump will at once 
retract, and finding and ijcciirhig the retracted vessel in un inexhuustiblo 
pool of blood is a terribly ditliciilt, .sometimes impossible, thing. Should it 
be an artery, tlie tips of two or three Mngers must be thrust, at once into the 
place from which the iiiemorrlmge is issuing. The blood must be mopped 
up by nipid sjionging, t<t eiudde the surgeon to find the ves^sel, iu order to 
secure it with an artery forcejjis, or to sni-round it by a suture passed through 
the adjacent tissues. His mettle will l>e put to the severest test, and it 
will be a lucky day if his piitient do tmt sucenndi on the table. 

In trying to secure the stump of a large veiti aeeideiitally cut across, the 
wide exteut of its circumference will offer much difficulty, as iin ordinary 
artery forceps is too small to take iu the entire lumen of the vessel. One 
or more great leaks will remain, even if the vessel be fortunately grasped by 
one forceps. Two, three, or more additional iustrumenta have to be brought 
into recjuisitioji till tlie end is acconi|)lisbe(L The luiste, natural and 
almost unavoidable on such occasions, will easily lead to further tearing of 
the soft walls of the vessel, and, finally, salvation will have to be sought in 
plugging with iodoform gaujje. 

Here, like in other things, prevention is much easier than cure. 

Lateral fporitiff ar sJiilin<j of a hin/e vein is another accident to which 
may lead disregard of Langenbcck's rule. There arc two ways out of this 
contingency. One is to expose and deligate the vein 
above and below tfie laceration, while the Hngcrs of an 
assistAnt compress the injured part of the vessel. The 
other one is the application of a lateral ligature or a con- 
tinuous suture of tine catgut ofcluding the rent. 

Both of these hitter metliods, however, are difficult 
and not very reliable, though they have succeeded in the 
hands of several surgeons, including the author'^.* 

They were bred of the fear of tying huge veins*, for- 
merly so prevalent on account of the dangers of phlebitis 
and, in the extremities, of gangrene. In cases where a 
large portion of the vein wall is lost by sloughing or cut- 
ting, and the resulting aperture is very large, lateral liga- 
ture and suture are impossible. Whenever feasible, a 
double ligature sliould he applied, whether it concerns the deep jugular or 
axillary and femoral veins. Ijangenbeck's advice to tie the accompanying 
large artery has been much impugned lately, as it was found that gangrene 

* In » t-*Jif*e of oxseetion i>f lyriiphomttta of tlie neck, ricme La 1880 in the German Hospital, 
where t)ie deep juj^lar was injured. The patient recovered. 




Fio. 41,— Lflti-ml lig- 
ature and continu- 
ous 8Uture of in- 
jured vt'in. 




n 




BULBS OF ASEPTIC AND ANTLSEPTIC StTRGERY. 



of the extrt'iuitv followed its adoption. On the other hand, a growing nnm- 
btT of ca^es are on reconl, where deligutiou of the femoral or axillary vein 
led only to temporary dii;turbauce of no great import. 

Case. — Henry Kickriegel, carpenter, aged twenty-three, admitted to Gemian Ho*^ 
pital, March 2. 1887. Two (lays later the boose-eurgeon extirpated a mass of (inp 
puratiog glands from Scarpa*<» triangle of the right side. Tht- 
Hopbenons vein, "which passed into the tumor from below, 
was tied and cut across. Likewise were treated a nitmWr 
>>l larger vfine entering the tumor from above. The fciiKiral 
vessels were not exposed, bat thf 
pu]^:tti(>n of the artery could be 
(listJnrtly felt, and it was care- 
Finally, tlie 




'I'i. — Periosttjil uiyxiirairi'imi I'l lUij^hj Wlore reiimvjil. 

maaa wnt* freed all arountl, utitil a i^tuut pediitle was funned, which was ^een enterii 
tlie oviil foriiraen of the faHcui latji, Tliis lu'dicle was tied with fatf^'t an<l wai» c»ik 
through. In tlie iiieuD time the [mttont hud be- 
('ouie wuii-fonj^ciousi uud befjun to strufri-'lo, where- 
upon, KuddoiiJy, an enormous Jet ofveuoun blood 
was seen to well up from the bottom of the wound. 
The ii|ii'riilor )ibm(;ed hl.i fist into the pool of 
lilood, and thus fiiieree<k'*l hi tduM'kirijr the hjeinoi" 
rhn^e imtd [)r, 
HuchniMini, tlie 
I'liief of the Iiotise- 
HtulT, appeared, 
who luckily siu?- 
reiiileil, with the 
aid of Tlnersfh's 
*fpi (idles in t>;iss- 
mg two lifiutiires, 
one below, the 
other above the 
bleediuKiHtiiit, ef- 
foet«udl> Htoj»|iinif 
the (onniiluble 
lotw of lihiod. Im- 
mediately, ileep 

eyutiosis and uxleuia of the lower extremity developed, and the author, who saw the 
patient direetly after the operation, ordered elevation of the limb, which 
aliout by its vertii-al auspeiwiou in a wire cradle. March 5th. — Cyonotii? 




Fi« 43. — I'nited wound lUU-r niimval 



wan bronfHii^^J 
d isjippearedL^^I 

J 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



57 



I 



cedemti much diiniuished. TerajnTMture, ll>r5°. Circitbitiini of liriili ^uod. The 
*ouii<l (till wt'll, but. Mured IBtli, teifiiH-rnture rost- tn lOS Falir., and sitni'^ i>l" i»hleliiti3 
of thf femoral vdn in the iiiUldk of the tliigh iippL-arcMl in thf sbttpe nf u ('vHiulrica], 
paiDful. .'ind Lard mfiltratii'Ti. This and a niitnhvr uf sitniliir iittufks were snibdued by 
the application of an ice-bag. The persisK'nt tpdtnna was combated by ehuitic: com- 
jiression with Martin's bandage, suppleiiiL'iitt'd later on by massage. Mai^ 15th. — The 
patient was disolmrgwl cured, very little of the ceduina being still notb-euble. 

hi ihis ca.*e, Jip|nireiitly, a portion of tlio trunk of the femoral vein was 
drawn into the cona of tJK' pedicle containing' tlie mat of the .-aplienoua 
vein, and wa.8 excised ntoiitv with the tumor. 

The ligature slipped off, and a wide ^^aji was opened in the side of the 
femoral vein corresponding to the place of entrance of the snphena. The 
peculiarity of the wallt? of large veins to yield to lateral traction is well 
known to surgeons, and is a just gource of an.xietj, as the extended vein 
becoming empty can not be recognized. 

Double ligature of the vein will be insufficient to check the haemorrhage 
when a large branch inosculates between the two ligatures. Such branch 
ranst be separately exposed and tied. 

Case.— Mareb 27, 1880. the surgeon in charge of the ward for syphilis and skin 
disensea at the German Hospital excised a large glaJidular tumor frum Scarpa's tri- 
angle on John Te Gemyit, aged twenty-fi>«r. The 
operatiini iva» fi nibbed without ai'cidvnt, and, ai;- 
cordiiij.' to tlie then [H'evailing custom, the wound 
was ninjiped with an eigbl-per-i-ent solution of chlo- 
April 11th. — A birge slough of the 
vein wall wa** detached, and fear- 
ful hannorrbage cusued, which 
[)r. Lnewenthal, the Iiouse-sur- 
geon, fould not check «ontplete- 
ly by local pressure. When the 
Hulhor wiw the [»iitk'nt, lie was 
nearly exsanguinated, though 
coDseiouH. No pulee could be 
felt. Without anjesthesia the 
femoral vein was exposed below 
the opening in its wall, while pressure by three finger-lips completely euntrolleil 
the bsemorrba^re. 

N'OTK. — ^Tliru!»ling of the fist or of a sponge into the wownd will not check hemorrhage 
effectually in th»'Be cashes. The tips of the fingers pn-fised exrictly upon the bleeding orifice, and 
without innch fon'O, will always succowJ in euntroliing the vessel. 

As the vein Ided from above, too, Ponpart's ligament was eut across, and the external 
iliac vein was tied. MUir this the loss of blood berame very much dintinisbed, but a 
considerable vein inosculating jast opposite the defect in the wall of the femoral vessel 
required separate exposure and deligatioTi, wberenpon the JiEomorrbage ceased eom- 
pletely. Cnfijrtunately, the total loss of Idood hud been so considerable that the patient 
sarrived the operation only a short time, and died io collapse from acute anteniia. 

Ihliiiution and partifil e.cst'c{i(m of the axillari) vein for ingrowing cancer 
of the axillary glands has been oft4?n performed by variou.s surgeons with 




Dres^iiiir ulU-r rt'iiiuval n\' myxcHurciiiiiiu ol' ihijjL, 




i 





RULES OF ASEPriO AND ANTISEPTIC SURGERY 



entire success, iiud van bf under taken without h'sitatinn whenever un 
avoidable. 

In (Idigating the deep jufjular vrin^ avniilanceof the pneitmoijaMric nervfi 
will rrqttire close attenfion. Wlien tliere is enough spjice to expose and 
libenite the vein frcoly, this will not he fmmd very dilticuit. Low down at 
the root of the neck however, tlic decision of the fjuestion whether the 
liijiiture encompasses the nerve or not imiy occasionally be impossible. 

Case. — Mrs. Catharine Plunkett, aged sixty-four, Extirpatron of recarrent lynii>Lo- 
sanomft of neck, neccnilier 22, 18SI5, at ML Siiuii Hospitjil. A tumor «jf the sizi- of 
a lii'iiV egtC WHS tocuteil hiw down hi thv HUfKra-cIiivteitlar fossa. Thunfrli it wh-"* tn-^U 
miivtible, ita close relation to tlie largo cervicnl vessels was iintiripatwL A Hap inci^^- 
ion and careful dissection laid bare the jugular vein above nnd below tlje lunior, when 
it became evident, that it wmdd be im|i08sible to remove it without excising a eorresj>oud- 
iri}? portion of the vein. The lower li^^ature luul to be applied somewhat l>ehind the 
Mterno-clavicular riru. and on acmmnt of the buk of space tlii-* was very diJtietdt. Isinla- 
tion of the vein iiiul to he done witb ttie greatest caution to avnid its injury. Finallj 
a silver probe wormed its way nroiind the vein, and the ijuestiou aros*, Was or was 
not tbe pnenmogastric nerve incdiided in tbe ligature? To test this the thread wa» 
finnly tied in u sinfjle knot. No etiange whatever of the respiration or pulse beins 
rioted, it wasi aswiittied tliat the nerve was not enu^ht, wfierevipoii a doidde H;:ature was 
passed thronjrh by inean.s of tlie first tiiread, and, bein^r lied, the vein was cut aero^. 
Hot on inHpection of the mass it became clear that tbe nerve was included in the \\p\- 
titre an*! bad la-en cut throti-rh. The tnmor was easily dis-^iected u[» after this until a 
pedicle was formed cuutaiiiiug the Jngular vein from above. Tliis beinj; lie<l, the 
tumor was removed. Drainrtj.;e, suture, and dressinfrs were afjplied in the iisaal 
uianDer, Tiie patient recovered without one untoward sym]itiim. Dec. 31tt. — Tli« 

first dressing was removed, toiieiher 

with tlie druinajre-tubes. Jan. S, 

1S87. — She WHS diseliarged cured. 

lluving thus gone throuf^h 
the entire subject, we may sum 
up in the following points : 

To aceomplisli a tlioroup:!! and 

at the same time safe removal (»f 

a tumor located in tlie vicijiity 

of large vessels, an adequate, that is, very ample, in- 

ci.sion is absolutely necessary. 

Note. — (in the trunk and (be exlrendties, atrai;;lil incision?, with 
the udditjiin of n tmnavei'se exteaskni, wiH be found iiuwl contriiicnl. 
Where 11 imiisvcrt<e cut is iitopporttnie, iMinsidcrable gain in !>pace can 
be etFecteil l>y mffulafiuff the line of Incision. 




Fio. 45.— Ontlines of flaji- 
inciHluuB. 



Fio. 4*'. — «T. T-4Iu(mm9' 
tncision. h. Codu-^ 
luting ineiMon. 



In Searpa'-s trian^Je, tint especially about the neck, flap iiicisinnd are tbe most convenient. 

\[etliodical dissection, guartled by as many preliminary double ligatun^* 
tis necessary, will insure a steady and unititernipted progrcsg of the o|>era— 
tion. Loss of blood will Ije minimal, and the flurry and haste incumbents 
upon profuse accidental litenifirrliafre will uot lend, as it always does, to the 
disregard of the rules of asepticism. 



i 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



Aseptic canonR arc easily forgotten dnring frantic efforts to check dan- 
gerous ha'niorrluicre, althou<jh it is conceded that aToidance of suppuration 
is all the more important bueauiie of the injury to large vej?Mels. 

Aflcr thorough irrigation and cleansing, the drainmfc of the cavity is 
to be attended to. li .<<hoiiIfl bv direct — that is*, should reach the i^urface 
on the shortest possible route, if neeeri,sary through a couriter-incisiou — and 
cure niujit bo taken ()f not letting the Sfpiare inner end of the tube impinge 
ujKin a large art<'ry. Es«jK'eially must this point l>e heeded where the tube 
consists of hard niaterial, as iwrf oration of the vessel by friction against the 
hard edge of Iho tul>e is possible. 

NoTK. — There are rases on rcoonl where ihc itiuominate was ulcvraU-d through by frk'tion 
prciisurv of the margin of a iracUcotomy caaauliu 

The inner end of the tnbe should be jihiced so as not to tnuch the vessels. 
the general direction of the mesial end of the tul>e Wing parallel with them. 
To seen TO this position the inner end of the tube should be fastczu'd to a 
suitjdilo ]>ai't of muscle or fascia by a catgut stitch. 

Change uf dressings will Iks re«|uired, according to the size of the tumor, 
on from thr tixth to the tetitli d;iy, vv'hi.'U the tubes can bo witbdrawii. 

m. AMPnTATION OF I4IMBS. 

In jHTforniing a major amputation, the nrcKlurn surgeon has to .solve 
three problems : 

Till' fir f<t is to avoid septic infection of the amputation wmiud, or, if 
sepsis of the limb be present, to eliminate' it. 

The .scniiifl one is to limit luvmorrhage to an unavoidaide minimum. 

The third problem is to secure a good stump. 

1. Aseptics and Antiseptics of Amputation. — To i he ado|>tiou of aseptic 
and antiseptic measures must be ascribed the reiuarkuble roduetion of the 
rate of mortality after major amputations, now prevalent wherever such 
measures are practiced. Fttrmerly one third of all cases were directly lost 
mainly through primary septiciemia, or ]iyajmia, or iudircctly by secondary 
hapwiorrhage due to ulcerative destruction. At present^ deaths from acute and 
chronic blood-jjoisoniug or secondary ha:'niorrha;,'e are very rare, and lindted 
to cases that v<mw uiuler the surge()n\s knife in a neglected or septic state. 

The total mortality, as computed from nearly 1,(J(UI uuselected hospital 
au^K of various surgeons, treateil on the new plan, is about Itfteen per cent. 

The author's persou:d ex|H'rienc:e embraces forty-three cases of major 
amputation, mostly (loiir in )ios]iil:il |>ra<'(ic('. These were: 



AinpiKaiiuiia of lite tliish . . 

" •• l.'i: 

" '• " foot 

** " " ghouliioi 

" " " nrtn . . . . 

•* " '• futvanu . 

Totul 



22 
7 

7 
1 



48 



60 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The ainputatioiis were performed : 

For ^iupponuing compound fnctare in. 2 cmaes 

" phlegmon in 6 *' 

" acute and ciironic osteomTelltis in. 6 " 

" spontaneouiT gangrent' in 6 " 

" incurable ulcers in 5 '• 

" articular tuWerculosid in, 12 " 

" pble^^on from uratic arthritic iu 1 ame 

" malignant new.growih3 in 6 cases 

Total 43 " 

Of this number were cured : 

By primarr union 16 eased 

" partial adhesion 14 " 

With suppuration ... 8 " 

Cured 38 " 

Died 5 *♦ 

Total 43 " 

The five fatal cases were as follows : 

0a8e I. — Max Loffmann. Amputation of thigh at MooDt Sinai Hoqiital for 
secondary hasinorrhage due to phlegmon of popliteal space after ezseotion of knee. 
Patient came on table collapsed, and died immediately after ablation (see page MS). 

Care II. — Gustav Leuber, aged forty-nine. March jSf, 188S. — Byrne's aniimtatioa 
of foot, at the German Hospital, for tuberculosis of tarsus. Died Haj 6, 188S, of goh 
eral marasmus, due to pulmonary tuberculosis. Wound nearly healed. 

Case III. — Carl Frank, aged sixty. Senile gangrene of foot and leg; •mpntafted at 
the Gonnan Hospital. On account of the collapsed and septic condition of Uie pctieoti 
twenty ounces of a six-pro-mille saline solution were transfused before commoicing the 
amputation. The pulse rallied, and transcondylic amputation was done, bat pttieot 
died immediately after the bone was sawed off. 

Case IV. — Louis Bnurbonus, carpenter, aged twenty-nine. Acnte pro g re a nye 
gangrenous ]>hlegmon of hand and forearm. Septiosmia with petechial emption. 
February S4, lf<80. — Amputation of arm -at the German Hospital. Patient died two 
hours after ablation. 

Came V. — ('utharino Argast, aged fifty-four. Senile gangrene of fore part of foot 
Nfpteviher 18, 1882. — Synie's amputation at the German Hospital. ICarastic thrombo- 
sis of the femoral vein. Died, October 23d. of inarasnius. 

The author's total rate of mortality would be 11 'GS per cent. 

Exchuliujj: the hopeless and moribund cases Nos. 1, 3, and 4, the death- 
rate will l)e reduced to 4"G5 per cent. 

Not one of the patients died of acute septicaemia or pysBmia clearly 
chiirsreable to the operation. Case No. 2 died of tubercnlosis ; case No. 6 
(senile pan<;rene). of thrombosis due to general, marasm. 

Consideriiifj the large ]>roportion of amputations of the thigh (twenty- 
two), and the fact that ablation was done twenty times for acnte septic pro- 
cesses under a vital indication, during a more or less prononnced state of 
gi'neral sei>sis. the final results may be favorably compared with those 
achieved witiiout anti.septics. 



SPECIAL ^VPPUCATION OF THE ASEPTIC METHOD. 



61 



To further a better undei^tanding of the methods employed for the 
maintenance of the a^ptic condition during aropntation, it vill be nece^- 
to clasg all c&sea re<^uiring ablation in three groups. 
a. Clean- Cases. — Thf firat group conas^ on the one hand, of cases 
where ampntatiun i^ indicated for varioaa reMona, each as deformities, 
tumors, etc., in which the skin of the member \i unbroken, and no enb- 
cutaneous, acute, or chronic supparation \a {ire^nt ; on the other hand^ of 
injaries requiring amputation, that come under treatment immediately 
after the accident. 

These are called cUnn cojues. They require the ordinary aseptic precau- 
tions, such as shavin;:, thorough scrubbing, and disinfection of the field of 
ojieration, and a careful protection of the hands and instruments of the sur- 
geons from contact with non-disinfected parts of the patient's body. This 
is best accomi>lishcd by wrapping the whole limb, excepting the field of 
ojieration, into a swathing of disiinfected towels, which should be fixed in 
position by safety-pins or a few turns of a roller-bandage. The patient's 

feet and hands, disinfec- 
tion of which is difficult 
at best, should never re- 
main unnecessarily ex- 
[M>si>d in amputations of 
the up|)er or lower ex- 
tremity. If the opera- 
tion is to be done near, 
or on the hand or foot. 




1 



these must Ijc, if time ix'rniit, 
mbjpctfd to a carefnl prt'lini- 
inary process of cleansing. It 
isisti? of a prolonged bath 
of wunn 8oap-watLT. und sub- 
sequent packing in eoaijjre^seji nmistciicd with a two-per-cent carbolic solu- 
tion, and an external WTajjping of rubber lissne to prevent cvaimration. 
Large nias.ses of eindermis will bo soaked off in this manner, and can be 
removed by gentle friction with u bnir-h or llanncl rag in soap-wattT. This 
process must be re^ieated until the akin is perfectly clean, and does not shed 
epidermii*. The part to Iw oj)erated on is kept wrapped in a carboliaed 
towel until anaistht'sia is well under wav, and the operation is about to begin. 

10 





RULES OF ASEPTIC AND ANTISEFIIC SUBGERY 



Esmarch's constrictur being applied, and tho patient** body protected 
by rubber sheets, these and the parts of the limb nob needing special dis- 
infection are covered with disinfected moitst towels. The parts of the assist- 
ants are distributed, and every one takes bis place. Now the surgeon 
unwraps the tie Id of op- 
eration, itiid, having once 
more rubbed it off with 
corrotiive-sublimate lotion, 
begins to operate. 

Frequent irrigation of 
the wound and e.^pecially 
rinsing of the handi? of 
operator and assistants 




Fio. 48. — Section of leiinir. Irrigator iikiy'mif 
from the Ivft. 



should not be neglected until the dress- 
ings are finished and the patient is ready for bed. The other precautionary 
detail mentioned in a previmis eha[)ter should also be carefully adhered to. 
With the exee]nion of the finiv, most instruments required for amputa- 
tion are easy to cloati. Thu saw is a fri'qnent mcdinm of prjofjenic in- 
fect ion. 



Oabe. — An) oil] Hitter, met-hanic, Hged thirty -four, was amputatcHi at the knee- 
joint eigbteen yearsi ago for acnmpound fracture of the lejf. On account of inBufiicieut 
cnverliig:, Jk large ailliorent (Mcatrix o* riipied the umler antJ posterior »idaof tlie conilylt-Si 
which were constantly ulcerated. Ru-ainpiitation of the thij^h nbove the condyli's, 
January 8, 1887, at tlie Geriimn Uospital. Drainage and suture. Fever developed 
on the second day, rising to 103° Fahr. on the third, wherefore tlie honae-sargeon 
moved the drciisingii, bul found nothing to explain tlio pain and fever. On the fifth 
duy tiie atithor inspected the stiniip, and fiiund firm union of tiio flaps between each 
other and to tiie sawn surface of the bone, the drainaj?e-tiibes still filled with fi 
sweet clots, but the extremity of the stnrnp decidedly club-phiiped and tBdematoas, thtf 
u'deina beiug of the deep-going, firm variety, characteristic of acute osteomyelitis. 
Thestutup w'VL'^ nowhere painful on press-uro, except at a point corresponding to the 
upper niarcin of the »awn surface of the bone. In a few days pus began to einde 
from the drainage-tube placed at the time of the operation through a counter-inoisioB 
into the quadricipital burM, und the [lutii'nt's levi-r subsided, Feh. inh, — The nppef 
margin of the sawn surface wa* exposed and a narrow, sharp edge of necrosed bono 
was detected. This was chiseled away until healthy hone presented ; tintula scrape*!, 
wonnd sutiirei]. Primary union ; patient cured, March 5th. 



4 

fth^^ 




I 



SPECIAL APPUCATION OF THE ASEFTIC XETHOD. 



Apparently some filth luid been detaclMd froa the teeth of the aw vhea 
it was drawn across the baoethe fixst fev tuBeB,«ad faeeaBels^ed near the 
nj^per margin of the bmie aedami, rwiif^ there a cire MMcri bed acute 

oeteomyeliti^, endiD<r in necroos. 

XoTK. — The proper war to deaaie a asv-blaie m tm Mf«b il ikovnghi; for imr mmbc* in 
bnt wntcr with soap and a ttif ktwA, bcU •oow Ike Wade. 4wb «• isMene H ■ caitafie 
lotion nntii lued. It i* bef>t to 4» IUb m the !■« Ai*f beiHe Ibr optratMB. V^piiy ■*& « 
Jtould h< aeoided, a? a nizinker of ■!■•■ fibers arr deCacked ihtuhf cad (caMB aAcRBl 
the i^eth of the saw. 



» 



b. Mildly Septic Cases. — ^The leeoad s>^o^ eaotraw case* dtarmeUr- 
ized by chronic tuppmration^ doe to tabercolaeb of joints or booei^ or to 
ulcerative proccssee of Tarioiu kidds reqnirii^ aa&patatkm. Infection of 
the amputation wound throogh contact with hands or iqipantos that hare 
touched the qIccts or fistnlae. or through eaatpmg ncretioni^ ocean rerj 
easily in thei<c case^:, and i<pecial precaatioas hate to beemplojed toa?oid it. 

A careful examination of the affected parte riMold be nude sereral days 
or a week before the time appointed for the amputation. Ahtcetma tkould 
be incised and drained^ retentions remored by coanter>incisioD, and the 
amount of eecretion reduced by all known meaosy as, for Instance, frequent 
irrigation and change of dre«-ings. 

The field of oj)eration should be prepared as indicated for the first 
group. Immodiutely preceding the operation the suppurating focus or 
nicer should be irrigated and dreised in bed, and OTer the usual dressing a 
piece of rubber tissue should be tightly bandaged so as to overlap it on all 
sides, the margin of the gutta-percha adhering to the <(kra. 

The patient being anesthetized, Esroarch's constrictor is applied, and the 
rubbers are arranged in the proper manner to shield the patient's body from 
drenching with the irrigating fluid. After this the whole sorface of the 
limb, with the exception of the field of operation, is wrapped in clean 
toweltj, the carbolized towel coTering the site of tlie operation is removed, 
thiB and all hand:- are linally disinfected, the irrigator is started, and the 
amputation ehould commence. 

It is not ver>' difficult in these case^i to exclude suppuration and to secure 
primary union by the exercise of a moderate amount of care and by intelli- 
gent attention to important details. 

Should infection occur on account of faulty management or the in- 
herent difficulty of the case, the inevitable suppuration will be mostly of a 
benign character, and well-nourished and well-coapted portions of the wound 
may even heal by primary union. 

Where amputntion hax to be dotif through ukeratiitff or auppuratinf/ 
jHirts of a limb, the surgeon has a still more difficult problem to solve. But 
even in some of these cases primary union can be achieved. Before com- 
mencing the operation, Ihc skin surrounding the ulcer or sinus most be 
thoroughly scrubbed with brush, soap, and water, then the ulcer or sinus is 
repeatedly washed or injected with an eight-per-cent sohition of cliloride 
of zinc, and the granulations are thoroughly scraped off with the *harp 





RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Bpoon. Indurated or illy nourished tissues are removedj imil all debrU u 
washed jiway witli tho irrigutin*; streitm of nicreurial lotion. Afti-r this the 
ariiputaLicHj is done as ususiU j,'ood care heing taken to jjruvide for ample 
drain iip:c. 

c. Septic Cases of Greater Ixtkssity. — To the third group belong 
all cases in which an acute pnnjirilienf sfpiic process of spontaneous or 
traumaiic origin necessitates ablation of tiie affected limb under a vital 




indication. Profusely su 
purntiiTg cotoponnd fmc 
HITS, ra|i!dly progressive 
jtlilegmons of the hand 
iind arm, cases of embolic 
or other forms of sponta* 
neons guDgreiie, compose this Dlas.«:, in which the sur^'eem has to cont*'n<l 
not only with the local trouble, but abo frequently with a dci-p and dan- 
gerous general intoxication of tlie system, due to the masi^ive absorption 
of ptomaines and bjtcteria. 

In many of these eases the processes determining phlegmonous destrnc- 
tion have progressed beyond the highest limit of amputation, and securing 
of an aseptic state of the wound is impossible. No amount of irrigation 
will here do any good, and the surgeon, having removed most of wliat is a 




I 




source of further infection, hue to trnst to good lock and the pover of 
Btcsietance of his fiatient, aided by ample stimnlatioa and other rwtoratiTe 
Hlticasure8. In the!>e cases the open after-treatment is in order. 
H But, even iu those instances where ampatation can ret be done in 
Bbealthy tissues, preservation of an aseptic state is an extremely difficult 
"matter on account of several reasons. Fir^i of all, we haveprofoiK secretion 

of pu8 or ichor, containing an extremely virulent culture of micro-organisma, 

ta few individuals of which arc sufficient to ^tart up another phlegmon. 
Nobody who has not tried it can conceive the difficulty of keeping free 
from contamination iu sucii eases. Another difficulty lies in the limits to 
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ our choice of the 
^^^^^^^^^^^S^^^^^^^^^^^^^^Wfl phice 

tion. When we 

J^^^M^% .^mf ^^^^^E ^ ^^^1^^ far of the 

reach of the infec- 
tion, we should al- 
ways do it witiiout 
regard to so-called 
conservative con- 
-iderationjj. What 
it! firxt in btt con- 
srrvrd here itt fhr 
lifr of the jmlinif, 
and before this 
view all objections 
ought to vanish. 

But, when the 
proce.<s has extend- 
ed up beyond the 
knee or the eHinw, 
how keep free from 
con tami nation then? True, the section 
may go through heulthy tij-suei? ; but, 
oven with the greatest cure, t-outuct-in- 
fection is almost unavoidublc. 

The measure? to be emiiloyed in these 
oaAee< arc similar to those detailed for the 
second group, only with this difference : 
that attention to every step of the prepii- 
ration should be more rifjid ; that, if \ros- 
f^ihje, the lilthy part of the preparation 

I should be done by a separate person or 

persona; and, finally, that the judicious nae of our strongest antiseptics for 
irrigutiori (l : 50Q to 1 : 1000 of corroj^ivo i^ubliniate) is jusititied. The lotion 




ttici, 5Ci,—Com[>Kt»m>n of cm N«HtM-«f hv 
sponjres p1iu.v(i over the I'ulded flups. 
Kciuoval of constricting biuid. 



I Heed for rittsiinj^ the hands must be repeatedly changed, and everytliiiig that 





RULES OF ASEPTIC AND ANTISEPTIC SURGERY 



has come in mediate or immediate contact witli the fociiB of infection must 
be rigidly rejected. 

Amputation wtnnuls belonging to this group sluHild not be sutured, but 
require loose iincking and moist dressings (open treatnient). 

Our Hrst and set*ond gronps coincide with ** primary" and ** srcondary" 
the third with '* iniermetiiate" ninpuiatitmn of the old nomenclature. 

2, Hfflmorrhage,— Esniarch*s ajipuratus and the animal ligature have uu- 
doubtedly had a great share in bettering the statistics of major amputation. 

«. Artificial Ak.'EMIA. — The most imjiortant and really bloml-saving 
part of Esuiarch's apparatus is performed by the constricting band. use<l 
instead of a tourniquet. The theoretjcal advantages of the use of the elastic 
roller-bandage, employed for evacuatiTig the vessels of the limb, are offset by 
some serious drawbacks. It is an undeniable fact that the aerostatic p 
ure will elTectnally prevent the escape 4>f considerable quantities of blood 
from a limb, the circulaticm of which has been sujipressed by central con- 
striction. Therefore, the expulsion of all the blood contained in a limb is 
not an absolute reijuirement of blood-gaviug in non-mutilating oj>erations, 
as, for instance, joint exsectious. 

In amputations the blood contained in the removed limb is an abi^olute 
loss, but its quantity can be effectually limited to a very small amount 







Fni», ol, .-i-j. — Ksiii:iri'li'^^ rirlory fnrcepB. 





Ft«. M. — Itnlin's sirtorv (brccps. 



Fro. 54.— Shoirin^ 

ll)f diffvn-noc b<- 
tweon '/, a e<*A, 
anil /', a wortt^ 

CI"!**. On 
prexflion. ^Kiiiiti. 
of It renimn ia 
coiituct : diOM! of 
* pup. 




by previous vertiL':d eloviition uf H>o limi). And this losa is abundantly 
rejjaid by the au'reealjle assuranci', that no septic material nr infectious cell- 
elements, di'taehetl from a malignant new-grusvth, are thrown into the gen- 
eral circulation with tlie blood and lymph which is expelled from the di.«- 
eused limb by the elastic roller-bandage. 

The retention of a certain quantity of blood in the vessels of tb© stump 
affords additional advantages of no mean value. By pressure upon tl»o 
stump, the smaller and smallest arteries and veins each will pf>ur out a 
minut* quantity of blood, which will greatly aid the surgeon in finding and 






Flo. 55. — Manner of t^ini; 
wiii.t. \£niia(vii.> 



J them before the removal of the constrictor. Thos all coomderable 
ostia can be occluded, 80 that, on detaching the robber band, no sporting 
vessek Tsill he observed, and the capillary oozing will easilj be controlled by 
corapre^jsion of the wound, aided by digital pressure 
exerted upon tbe main artery of tbe limb. Com- 
pression sliould not be done by packing the wound 
full of sponges, and folding the skin-flaps over these. 
True that their elastic pre^^sure will check hsemor- 
rhage. But, on the other *^ide, most of the small 
thrombi occluding the vessels, that are continuotti- 
witli the clot occupying the outer meshcB of the 
sponge, are torn away when the latter is removed, 
and renewed oozing results. The same objection 
must be raised against vigoroUii sponging of the 
wound-surface. Even after oozing has stopped 
completely, fretiuent sponging is apt to renew it, and thus to prolong the 
time required for stanching the hsemorrhage, 

A better way of employing compression is to fold the flaps over the wound, 
and then to arrange the sponges outside of them. This will insure tbe good 
efect of compression without the disadvantage mentioned above (Fig. 50). 

As soon as all visible vessels have been secured, the wound is compressed, 
ai»d the constrictor is removed while the limb is held verticjdly. The assist- 
ant who removed the constricting band applies digital compre^ion to the 
main artery. Immediately after removing the rubber band, the skin of 
the parts that had been subjected to artificial anaemia is seen to flash up, 
and to remain vividly red for from live to ten minutes. This is the })eriod 
of excessive hyperasraia, due to paresis of the vasomotor nerves. lIyfH?ra'mia 
is all the more hustint; and intense, tbe longer and the tighter was the con- 
striction. Attention shuuld be devoted by the surgeon to learn the exact 
amount of tension of the rubber required to just stop arterial circulation. 

Tbe band eliould never be applied before the patient is relaxed, and it 
should not remain on longer than absolutely necessary. 

Note. — Tho rubber confitrictor exerto mn enormous amount of conMaat auil iindiniini.shing 
prassurv. hi'tiw it niuwt lie usstd wilh diwrt'tion. Applying it to tin- tbigli belli in 6cxion may 
lead til rupture of all fli-iLunt if the Uinb is r^tntighteDed out afterward. 

For a number of years, the author has discardefl all specially made 
bands and apparatus recommended by authors and sold by dealers for the 
prodnction of artificial ana*miu. 

A piece of pnr*' jfum-flaittic tubing, of the thickn^ns of a man'fi index- 
finger or ihumb, and of the h'mjth of one and a quarter yard, is all that in 
necessari/. Its application is illustmted in Fig. 5G. The limb being held 
Tertieulty for a few minutes, the elastic tube is jmt ou the stretch, and thus 
coilcil about the limb once or twice, its tension and the number of turns 
being deterniint'd by the relative thickness of the limb, tbe muscularity, 
and amount of adipose tissue underlying tl»e skin. To estimate the tension 





t 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

required, the feel of the radial and dorsalis j>edis arteries may serve respect- 
ively. As soon as their pulsation di&ipiiears, the constriction is sufficieut. 

When the requirtxi 

] ^ "^' ^^^B^^^^^B amount of constriction 

is secured, tlie ends ol 
the tube are crossed, 
a short piece of cord 
or muslin bandage is 
passed under the cross- 
ing, and is tirmly tied 
in a sJip-knot. The 
ends of the tulx» being 
released, the rubber 
crowds up against the 
ourd. iirid can not slip. 
(Fig. 5;.) 

Thi^ nuxle of con- 
striction is very ener- 
getic, and deserves the 
preforeuce for very 
large and muscular ex- 
tremities. 

Another praitiMl 
itiifi more f/entle tcay 
of applyiiifj f'lash'f roHf/rfc/ioH i.<< bif invuns of an ordifttrri/ /utrr ifniit rollrr 
or ^fariin'H elits/ir htindftffc. It is etipceially suited fur eoiaciaiod limbs and 
foi" operations on wo- 
nu'u itf di'lieate frume, 
and children. 

The manner of ajv 
plyiiig ilartiu's band- 
age is well illustrated 
in the aceuuipanying 
cut;*. As maTiy turns 
of the bandage arc 
su])erirn]ioscd tightly 
around the limb jls 
necessary. The last 
tuni is grasjied in 
the left hand, and is 
pulled away forcibly 
from the limb, form- 
ing a bight, into which 
is thrust the remain- 
der of tho roUpr. As soon tis the left hand releases the loop, it tighteu^ 
about the roller, and holds it in place lirmly and securely. (Fig, 58.) 




< 



n 



. — MjiiiiiiT uC npfilyin;^ elaBtic eorjstriot'ir (nil. 
lor the produotiou of artifioial anifmiu. 




SPECIAL APPUCATIOS OF THE ASEPTIC MKTHOD. 



b. LiOATUBES AXD FiVAL U .£Ji06TASij^ — The visibfe luBiiHi of all cut 
h — veins and arteries — are tied with eat^u which is in CTerr waj pref- 
erable to silk, llie iihjections raided agaiast the ntw la te ria l have been 
entirely disproved bv experience. The aotbor never savoae caae of «ee- 
ondarv hiemorrha^ from a res^l tied with catgat ; and knows oi two cases 
only, quoted on pages 5 and 56 leqwctivelT, where ca^ut l^satone elipped 
or gave way. In >x)tl). very brittle cat^t wa« naed, and the knot was not 
sufficiently tightened on aecoaot of the fear of break^ie. Therefore it may 

»bo said that improper 
material was improperly 
apj>lied in both of tbeise 
instances. VfF^A. ^^^^ ^ 



■ In tying larger veii- 
sels it \% very neces.*ary 
to grasp and withdraw 
them from their sheaths 



Kfor inspection. 

V Art fries will some- 
times be laterally nicked 
jnst a little above the 
transverse section, and 

B the ligature must be ap- 
plied above the lateral 
o|»ening. 

LoTfj^ veinj< mn«t be 

I also well inspected, as 
it may happen that the 
lumen of a ha>rily tieti vein may be only partially occluded by the ligature. 
An ordinary artery forceps can not grasp at once the entire circumference 
«f a principal vein, and the author has repeatedly seen only one half of the 
vein deligated in the shape of a dog*8 ear, the remainder of the vein con- 




Fio. &*■.- 



Applyinff of Mutio^K hmniaiitt m » constriotor. 
A. Martin' » bnida«^ «'« nii. 







flu. 59.— Tho wrong w«y of detttobiDgtbe skin-flap. Tlie knife should beheld vertically. (Eamnroh.) 

timting to bleed in spite of the ligature. The best way to isecnre tlie entire 
lumen of a large vein is to grasp and withdraw it with one or two fuireiw 
n 



70 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



until its whole circumference is clearly visible, and then to twist it around 
its own axis, when it wilt be seen to form a neck which can be easily tied. 

AtJieromatosis of arteries is no valid objection to the ui)|ilication of the 
catj^ut ligature. 
The f^mspiiifj of 
vessels affected 
by it is ditlieult 
on aecfinnt of 
their liubihty to 
Blip before, and i-jo. 6,)._Li.,u*n'» b...H. lorct-i'". 

break after, be- 
ing caught by the forcepB, The ligature niust not be tightened Uw mneh 
on an atheromatous vessel, or it may cut through it. 

Vessek imheilded in sclerosed tissues must be secured by a eireular stiteli. 
After the removal of the elastic constrictor, local compre.s."5ion of tin* 
wound is kept up until the marked byperaemia of the limb begins to wane- 
Then, an assistant compressing the main artery, the wound is exposed. The 

glazing of elutted blond i? re- 
moved by iiTigation and gentle 
friction with the tipi^ of the 
lingers, and the assistant is di- 
n-eti'd to release the com}ire.<-o(l 
main artery. Then any addition- 
al vessels seen spurting should 
he secured. The hypenemia "f 
the limb will have coiK«ed by 
this time, and with it the 002- 
ing. 

Note, — Should a larpor nutrient ir"^ 
ttTV be divided at tho time of tbe lec^ 
tioD of the bone, its bleeding can br 
rL'jidily .sto[iped tiy ilie insertion of • 
f*liiiit jiieic of moxxl catgut into the 
*<|njitinp orifiee, where it c*n ho loft \)^ 
hind witlnmt ativ harm. Tlio cuipl"»- 
niL-al of wui for the 8*iuo purpose i# 
iiiiKafo, unless tht* material ia first tter- 
ilizi'd Ijy bfjilitjg. 




FiQ, ('1.— Ampiittttioti wound of Hii^h, 
drained. 



■UtUITil iilid 



The st^itement that Es- 
marcb's apparatus is not blood- 
saving, hut, on the contrary, 
causes undue haemorrhage, is misleading. It may be positively said that 
ekillful management of the application of Esmarch's constrictor will enabk 
the surgeon ttt jjorform major operatitjns with an a^^tonishingly small amonnt 
of Inemorrhage, and that los.<of much blood after the removal of the rubber 
band is due to faulty manipulation. 





out niucli extonuil 
proKsurc.'. 

In perforniingeir- 
culariimputaHon, the 
}U"5jii-Uint lioldiuf^ the 
mesial part of the 
limb can greatl}- in- 
tluence the shape of 
the stump. As it it* 
desirable to produce 
a wound of the t^litifie 
of n liollow cune, 
multiple circular sec- 
tions of ni>t too great 
«lepth are commend- 
able, wliile the assist- 
ant 8ucces»tvely re- 
tracts each la3"er divided by the amputating knife until the periosteum ia 
cut through and pu.'^lu'd well back. The soft j>arts are incIoKsed in a two- 
or three-tailed compress of t*nblimated gtiuxo, and the bone or bones ai'e 
sawed off, care being taken on the Jep and forearm to complete the sec- 
tion of bntli bones .vimul- 
taneoui^l}. After this the 
sharj) edges of the bono 
are clipped off with bone- 
cntting forcejjPt and the 
vesflels are attended to. 

Mu8oulo-cutaneous flaps 
inake a very <;<Hid cnvti'ing 



Ku». til!. — Aiii|nttiit'uin wtiuml of lej;, i*utiirc'd uiiil <lniirn.'il. 
tivt* button aiilures. 



h'eti-n- 



Fto. 63. 
Dreawiu; <■(' amputmion 




to inofJt stumps, and can he very cattily ailapted. As soon n.< the ha'mor- 
rhage Is |>erfectly under control, suture of the wound can be commenci*d. 







II »<>imti 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY 



The author is using exclneively the interrupted puture, for rotisons elsewhere 
meutioued. 

If the case was iinimpeucbably aseptic, and no suppuration is exjx^cted. 
one mediuni-^iiKed drainage-tube will sufKce to carry away the first secre- 
tions. Otherwise abundant ways of egres.* mu^t 
be [irovided in the shape of several ])roperly div 
tributcd tubes. The profrudin<; end of each tuU^ 
is tniiisfixcd with a siifoty-])in, and I'ut off on a 
level with tlie skin. An ample dry dressing, con- 
sisting; of a few layers of iodofnrmed and a gen- 
erous mtiss of sublimated gauze i' 
snugly bandaged t«» the stunjp, so a^ 
lo reach at least twelve inches above 
Hie line of section. 

If proper eare was devoted to the 
stanching nf the Inemorrliage, no great 
pressure will he required to check the 
oozing, which is, anyway, moderali* 
after the use of corrosive sublimate 
for irrigation. 

Tlie idea of bringing alK>ut close 
apposition of the wound-surfaces bjr| 
energetic j)iTSSure is not to be ciilti- 
vat<.>d, as it will lead to frequent marginal necrosis of the flajts, frustrating 
complete primary union. Surface !ip[><»sition should r.ilher be accomjilishc 
by a proper fashioning of the wound and tlaps, 
and the sutures should exert no tniction what- 
ever, but should merely secure contact of the 
cutaneous edges. 

For .securing contact of the deeper portions of 
an amjmtfttion wound, Lister's lead-plate, or hut- 
ton, sutures are very advantageous. (Fig. V>2.) 

Note. — In former times, when car- 
lm!ic lotions w<to cm[i1oyt'(l far irrifju- 
liun, oozing iisi-J to U"? quite free, and 
nfi'L's.Hitali'd ihi- u.-^e of a porxl deal of 
prwuiin?, wliicli wa."* Htoiofwlml tempcrrcl 
by till' iuterjinsrtion of tIJck laytTS of 
Ji«i'iH«l cotton bt'tweun ilii> dP0i<!9iii£; 
(irofior aiij the outffr l>aii(lrt;ii-. Flnjv 
Tiwrar»ffi wtTP iht'ii iiiucli iiion- coni- 
Tnon tiiaa nonnday^. 

The sole olfico of the dress- 
ings is to lightly support the 
wound, and to absorb and ren- 
der innocuous the secretions. .luys* unvr thi' ..[trutior.. Cum. .,( Mr*. \v»uhw. 



Fii). 64. — Drt'Btsmff of atnpiiluti 




SPECIAL APPLICATION OF THE A8EPTIC METHOD. 



r3 



IV. OPERATIONS ABOUT NON-STJPFURATINO JOINTS. 



custom is to make rlii' first change of dressings about u 
fortnight sifter the operation, when the drainawe-tubes can be withdrawn. 
Another lighter aseptic dressing is then applied, and remains undisturbed 
for a week. JJy the end of Ibis time the dr;iinuge-t racks will have either 
healed eompletelv. or {heir phtce will be marked by a small i>atch of graini- 
lations. requiring merely a borated-jialve or simple adhesive-plaster covering. 
Tliis refers to correct cases only, JSIitmId septic fever develo]> or mar- 
ginal gsmgrene be noted, fretpieut moist dressings are in c>rder. mid the rule< 
Pjpropriate' for the trealmcnl of suppurating W(»uuds obtain preeedeTiee. 
Case: Ifluttrntin/f n Correct Course of Ilfulintj. — Mrs. Pauline Wahher, seam- 
stress, Hfied fifty-one. Far-gorte tiiborciiluiH (k-stractiun nfkiief-joiiit, willt tistiiln, tla» 
latter the result of a previous exp!urai<jr^ int-islou. Feh. JJftfi. — Aiij|jiUutiuu uf tlugli 
in middle third. Asoptic fever, witli rise of teraperature tu 103° Fiihr,, on the two<hiy» 
fidlowing tlie operation. Ffh. IStft. — Ten)i>eriitiirf, 9ft'' Fahr. March Ut. — First 
<Lrti);ie of dressing-^; ilmidajfL-tiilx-s reaiowd ; wound rt'dri'ssetl. Mitrch 7th. — Woiuitl 
completely heidei), i'Xcti[it wltery mic minute* i*pot ol irrannhitious umrkn tin.- turiiiLT !<ite 
of ft tube. Slitrrh ISth, — All tirnily cicatrized; the sturnp can bo lightly pminded 
without paiD. March i7'/«. — Palicnt discharged curctl. See Figs. 01 and fi5. 

\ 

m 1. Puncture and Irrig^atiou.— ('hranic hydrops, or, us V'ldkmann calls 
it, caljirrluil synovitis of ibe kuee-joiut, is often benefited or even cured 
by puncture and subsefjiient irrigation, 

Schede's rule of using corrosive sublimate (1 :L>i<^Ht) 
whenever the synovial fluid is turbid, and carbolic 
loticui (three jier cent) when it is cleur, can he com- 
mended as rational. In tbe former case pyogenic 
tdements ciinse the production of a certain amount of 
lyiMH'ythes. und hence the use of a strong germicide 
like corrosive sublimate is appropriate. 
Sinijjie hydrops, where there is im ad- 
mixture of pus-cells, is comparuble to 
bursal hydrops or hydrocele, and is 
bene li led by the ai> 
[| plication of an irri- 
tiint substiince like 
carbolic acid. 

The manner of 
propcdnre employed 
by the author is as 
follows : 

T%vo largo- cali- 
bered (■rocarsare ren- 
dered aseptic either 
Sy boiling the tubes Un- an honr in a five-per-cent solution of carbolic acid, 
or by heatiujj tliem iu a large alcohol flame to incandescence, after which 




I klll'!--.)Mij|l . 





74 



RULES OF ASEFIIC AND ANTISEPTIC SURCiERY. 



they are dropped into carbolic lotion. Too nitu-li taiv ottu never be exer- 
cised in attending to the proper disinfection of the trocur-tubes, att their 
hollow shape renders their eleansin? a difficult matttr at best. 

Case. — Thoruas Cftaey, lioKtler, jiged twenty-three. Ilydnrtpa of right knee-j</ml 
of SBveral years' stamiinp. .Ifurch I4, J.'?.f7,— Puncture and irrigation with Thiers<ir» 
sohition an<l c.arbt>li*> l<itiaii. Dorsal splint. The irwars hud rcoeived a rather !iHi>er- 
fi<'i!il atli'iitioii by boiling of tun sbiirt dunntion. The following' thty liifrh fever nppearwJ 
witli great distoutiot! of the juitit. Mtrrc/i I5th.— A y-piration vieWtHl pii.-. ^f(trrh I6lh. 
— Miilti|>Ie ineiBitm anil draiiin^'e. The fever not abating, allhoiigti Boort-lion wa» very 
Boanty, the linih \va-< Knspendisl in a wire cradiiv ond wei^Hit extension was applied. <w 
a* to enable the b<iuse-surgcon to frtMjncntly irrigate the joint without distarbing the 
patient's r<*st. lu spite of the nmst attentive troatnieut, new abscesses developed, and 
the patient's evident failinir finuHy comiwlled ampntation (>f Ihc thigl), which was done. 
May 3()tli, by Dr. F. Lan^e. The patient recovered. Extensive tuberculosis of the head 
and shaft of the tibia was ascertained liy examining the specimen. 

After the nsuiii preparation of the |Kilient'i! liml;. the trocars are thrnst 
into tlie knee-joint from oj)j)o.-iite witles, uiul the >iynovial fluid is let out. 

To remove MocchIeb of coagnhited tibrin, Thiei-scb's solution ia first used 
for washing out tlie joint cavity. The reason for this ia the fact that car- 
bolic acid hardens the fibrinous clots and makes them tough and unfit to 
pass the cannula. Corrotiive sublimate, on the other hand, is {>oiaouou^, 
and dangeroua quantities of it niMv be absorbed if irrigation be carried on 
auflBciently long to free the joint ol all deposits of fibrin. 

Ca8F.. — John Scbiir/, nuisim, a^ed thirty, chronic hydrops of knee-joint. April i, 
lf(S6. — At tlie (uM-iodti UnsjiituI, doultle punrtiire and rather prnlonf:tHl irripation with 
eitrrosive-mibhinatc lotion (1 : I. "<•'>) on account itf tiio jtresence vt' hirtre ']uantitie« of 
fibrinoii*^ deposit. April lofh. Merftirpilhrn ; sali votiun and sharp eolie, la-Htinfr for five 
day«, with some fever, endio)? iii recovery on ap[»ropriate treatment. Hydrops cured. 

As soon as Thiersch's fluid is seen to escai"* clear from 
the efferent cannula, corrosive sublimate or carbolic lotion 
is suhsti tilted therefor, and the joint is tborougidy flushed 
with it. Tu jirevcnt the retention of a daiigornU!! amount 
of eitlier of these solutions, the joint is flexed and emptied 




Fui. •'■r — V'nlkiiiftn'a T-splint, 

by external pres-^ui-e. The tubes are withdrawn, a amall patch of iodoform 
gni\7.v is atlijclied with a strip of adliesive plaster over each punctiu'e-hole, 
and the lindj i.s placed on a durdal aplint. (Fig. 67.) 



SPECIAL APPLICATHJN OF THE ASEPTIC METHOD. 



75 



2, Arthrotomy for Chrouic Fibrinous Hydrops, for Vegetaiians, Tumors, 
and Floating Bodies of the Knee-joint ". Hyukcips (Jeni-. — In casos 
wht-re a thick coutioor of tibrimnis tlepusit is lining the entiru cavity of the 
knee-joiut. siniple |uiucture and irrifration will be found imprufticablc on 
accouut of the euiitiououf^ olog;;iii<T of tlie uffereut caiinulit. To eomplett'ly 
free tlie joint of tliese masses, immediate incision must be done. Tlie in- 
ternal asj3C>ct of the knee presents the most convenient place ff»r this [>ro> 
cedure. The skin and fascia are sueeossivi'l y incised, and all bk-edin^j vessels 
are carefully tied. On being expojiod, tlie bluish cajrsule la out into, jiiid 
the incision is extended to about an inch in length. After (bis, irrigation 
by Thiersch's solution i> ])racticed, arid the joint is repeatedly flexed and 
extended to aid detachment and expulsion of tlie niemliruiie, wbjeli can l>e 
hastened by sweeping the inde.\-(lnger through all the reces.'^e^i of the joint 
The sliglit ha?morrhage following thi^^ nianipuhition will eeax' spoiitanc- 
oasly, anti the clot* are wa>]ii'd out by a strong jet of irrin:aling Huid. 




Fio. OH.— ArTuugeiiictit <»t rubln'r wliei'W for i>pi'ratioDH aKnit the l'»wt<r extremity. 

After the insertion of a short piece of mediuin-Bized drainage-tube, which 
should reach just within the cavity of Hie joint, the capsuhir incision is 
closed by a few interrupted catgut sutures. 

The fascia and .skin are likewise united, the protruding end of the tube 
ie tranKtixed with a safety-jiin and tritumi'il olT short, and the joint receives a 
final flu.-jhing with eiirtMHic or nu^reurial hptj<»n according to the indicutiiUis 
mentioned in the preceding pamgraph. 

After this the wound is dressed and the limb is fixed upcni u dorsal splint. 

If the a.«eptic measures were snfticient, no reaction whatc-ver will follow 
the operation. In cases where the hydropic flnid wa^^ limpid, no secretion 
of any account will be observed, and the tubes can be withdrawn at the first 
change of drcsjsings, whicli is usually done on the fifth day after tlie opera- 
tion. As soon as the wound is in progress of cicatrization, active movements 
and cautious use of the limb should commence, the joint being }>rotectud 
by a small aseptic dressing, held in place by Martin's elastic bandage. 

Cask of John Sctiarz, pnpe 74. who whs dirtcbarged cured June 2i». 1886, with 
p&rtiallv restored and constantly iiii|irovinp rnolHJity. 

Passive inovemfnlx are nn necessary and rertf painful. Restoration of 
the mobility should be hastened by cold or warm douching and subsequent 





76 RULES OF ASEITIC AND ANTLSEPTIC SURGERY. 

massage, uod it8 t)Ti!il establis*htijeiit left to {he aotive efforts nf the pariont 
himself. 

VascB ill which large ijuantities of firmly adherent meinbrarje wi-n' 
removed and some ha^nioirltage followed, esiieeially if the hydropic tluui 
vfiis very tiirliid, will develop a nunlerate seeretioii uf serous bhind pn?;, ihat 
may eundnue for some time. Some fever will also occnr. to subside Jis soon 
iis the dressinjr.s are changed and t!ie joint is washed out again. 

It will commend itself to apply in these cuses a fenestrated pla«ter-of- 
Paris sidint, and to repeat irrigation once or twice cbiity i" the beginning, 
diminishing the nnmbcr of washings pari pmsu with the disappean^nce uf 
the sfcretinn. As soon na the di^-charge shall have fwcunie serous and 
&ojinty. the tiilw can Ije witlidrawu and the caae treated sus above explained. 

Case. — Fred. Scliockfr, liihorer, ttged twenty-six, hml Uwn suflfering for mveral 
yeftrs fn.im ii painltss, rmissiive, hydr<.»f>ic difitcntion of the right knee-jr»iiit, thrtt cmild 
not be tnvcod to a traumatism. Considerable Intend mobility was tiio inuin caux'of hit 
seeking relief at Monnt Siniu Hospital. Dtr. 7, 1885. — Double pimcturei and irriga- 
tion were done, but bad to lie abandoned on account of large masses of der.se fibrin. 
Immeifiiite iociAioQ and ek-aring of the joint were jiracticed. Fever rtnd some seiTetiou 
heing note*!, tbe dressings were eliunged fJeeciiitier loth, atid, tlie limb Iteing |»ut u|' in 
n feaeytrated [>la.Hter splint, irrigation witli corrosive subbnmte wa.s employed iwiee— 
later on, once — daily, Dec.'^uth. — Normal temperature wuh noted. Feb. Ut. — Irriga- 
tion discontinued and BpHnt removed. Feh. 20th. — Patient discharged cnre«l, with 
inerea»ing tlexion (twenty degrees). 

h. Vegetations. — The favorite seat of vegetations in the knee-joint is 
that lax part of the capsule sitiuited below the inferior nnirgin of tlie patella, 
which is overlaid by a thick cushion of loose fat imd (he ligamentum 
patellse propriiim. They are rarely pedunculated, their common apiJear- 
aiice being that of a yellowish or purple coxcomb, and their direction tnins- 
verse. The functional disturbance produced by them is somctinK's very 
slight, but occasionally extremely severe, especially when it hapiKnis tbut 
their nuirgin is caught and jammed in between the articular surface*. 
Ba-morrhage with acute synovitis and an effusion may follow this accident. 

The diagnosis of vegetations, sufficiently masfiive to cause functional 
trouble, is not ditiicult to the careful exauiiuer. Frequently tlie patienta 
themselves will point out the kernel-like slipjjing bodies of soft consistency. 
They are easily distinguished from fire lloating bodies by the fact that on 
maniintlation they never disappear enlirely from their seat of predilection, 
to reappear in a distant part of the joint. 

Topical treatnvent is generally jtowerless against this complaint, 
although the constant use of a Martin's bandage may mitigate the trouble 
by confining somewhat the motion of the Joint, and thereby diminishing the 
chances of contusion of the growths by jamming. 

In aggravated ftnius, arthmtoiuy and excision of the vegetations is 
proper With strict attention to the cautela' before mentioned, the joint in 
incised, and, the patella being tilted upward by a sharp retractor, the masss 
is gra8|>ed with a pairof mouse-tooth forceps, and is bodily excised. Should 




'ECL\L APPLICATION OF THE ASEPTIC METHOD. 77 

it extcud across tJie entire width c>f the piitclla. another lateral iiicijiion will 
have to be made on the opposite aspect of the knee, to enable the surgeon 
to complete the excision. 

If nineh hvpem^mia of tho {j^iowth l>e jtresent, as showu by its puiiilish 
color, iijpmurrhage may be rather free. In such a contingency the raw sur- 

re should be scared with the thcrmo-cautery. 
Toilet of the joint cavity i^ followed by suture, and a small drainage- 
tnbo is inserted to i^erve as a safety-vulve. 'I'he jiiib-sequeut treatment coin- 
cides with that gjveu for t*imple hydrops after puncture and irrigation. 



P 



Oa«b 1. — MJAs Lena V.^ tiged fourteen, veuotiitinns occujtying llio mternul inffrior 
nmrgiu of the pattlla, Jhe putivnt had Ireipient attAcks of sudden, vcrj *ihar|' 1'"'^* 
in the knee, followed by etfiision. Varions jilans of local treatmont had beeu t-m- 
ploywl UHsufceasfnlly for about a y«nr. Ike. '>, W."?/.— Willi tli« aBsistanci* of Dr. U. 
tHrbarlau, the fuinily ntti>ndmit, imisioti «f knre-joiut uri its inner siMpod \va^ dono. 
A series of yellow, sjiioittli bodiys prt'sviitiriff, tfiey svert?' excised with fiireeps and 
corved sK-issors. Druinatfe. sntare, and jdasttT- of- Paris splint. vSorae fever, due to 
c'oustipatioa, but no inflamtnation followed. fJec. Uth. — A laxutire Ibeiuf^ adniiniiiterod. 
a copiotis stool wa* had, wheretipun the temperature at once fell to, and reniaiued al 
the normal standard. J)te. IJtfi. — The tube was removed. About New Year's tlie 
patient conujienced to walk abont, and sbitrtlj after wan dischHrfred eured. In the 
spring of 18?^fi circinuseribed sweUiug of tJie synovia! mfuibraiie in ihe vit-inity nf t!ie 
cicatrix was noted. It subsided npnn the iiBe of an ela«lie baiuhtij;e, which was idti- 
raately abandoned. Tn .Junnary of 18S7 the patient was still perfectly welL 

Case 2. — Frank Mann, clerk, aged twenty-five, well-defined painful vegetations 
to bo felt near the lower margin of the knee-pan, on both sideti. Duration of trouble, 
six months. Functional distnrbnnee very marked. Aprils, ISl.Sfl. — Double imision 
of knee-joint nt (he Oernian lliis[)ital. Extfision of a deep- rod, transverisely nituated, 
coxciuub-like groxvth (roui the lower I'im of the patella. A jruod deal <>f ouziny neces- 
sitated searinfj of the denuded surface of the rup»ule with the thermo-caalery. Draiu- 
plaster-of-Pttris splint. Eventless course of healing. Tfie tube was removed on 
be tentli day. Patient discharged cured, with good motion. May '20, 188H. 

c. Flo ATI xo Boi>ies op the Kxee-Joixt : 

Cask.— E. Behrmann, painter, aged thirty-eight, fjirge Hostinp body of the knee- 
^t, with chronic hydnijis. 3foi/ 15, 1886. — .\rtlirot^)my at the German Hospital. 
revion* to the incision the fl<iatiui^ body was fixed by finfrer- pressure near ibe line of 
section, but disappeared in tlie joint cavity wLen the hint stroke of the knife o|>eiied 
the capsule. The anthor ssweitt tlirouph the jnint witli a well-rinsed finger, and fiMmd 
the IxkIv in the bur^a of the «iiijalrice[w uiiiscle. By mean:* of bimanual inflnipulation, 
the bo<]y was brought di>wn to the aperture, lUid was rexdily extracted. Irriy;atiou 
with oorrosivc-Huldimate lotion, drainitge. suture, and fixation upon a dtirsal spliut lul- 
lowed the extraction. Normal course of healing. June IB, I88t). — The patient was 
jharged cured with good function of the kuee. 



^1 



d. SiTrRixfi OF THE FRAtTiREn Patella. — AUbouirh not perfect, 
yet the functional results achieved by the ordinary forms of treattneiit em- 
ployed in caseti of transverse fracture of the patella are ^enen^lly fo good, 
tlmt arthrotomy. for the sake of wiring nr otherwi!?o suturing the patellary 

fragment;?, it^ nirely if ever justified at a time immediately following the 
12 





78 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

injury. Hamilton has shown that even a considerable degree of diastasis 
of the fragments is not incompatible witli a very fair functional abilify of 
the limb, provided that the intervening liganientourt band be «:tr«>ng, the 
action of the «|nadrieep8 vigorous, and the lateral extensions i>f the quadri- 
ceps tendon uninjured. 

It seems, then, rational, in cases of patellary fractures, first to employ 
the usual methods of treatment by rest and apjiropriato bandaging, and thus 
to await the result. It never can be predicted with accuracy, and may turn 
out to be very fiatisfactijry after all. 

Should the result be unsatisfactory, either through failure of anion or 
gubaetjuenfc rupture of the uew-formed ligament, arthrotomy and secondary 
euture may properly be taken into consideratiou. 

On account of the presence of large quantities of blood and gernm, found 
shortly after the accident effused into the joint and its vicinity, priiuar}* 
arthrot<)niy for i»atellary fnicture is a more risky undertaking than the sec- 
ondary o|H?ratioTi. The slightest error in the use of the rt.scptic a]>]>aratus 
may cause irrejtarable duniage, and may coet the patieufs limb or life. 
Kspeeially,daiigerous are those cases in which open ulcers or abnisions, or 
other secreting wound-surfaces due to the primary injury, arc located near 
tfie field of operation, be they however small or superficial. Pyogenic iu- 
fection and suppuration of the knee-joint are here nigh to inevitable. 
Anchylosis is the most favorable issue that can be expected in case of suft- 
puration ; very often, however, the limb will have to be sacrificed. 

The conditions for the successful performance of the secondary opera- 
tion are, as far as the chance of avoiding suppuration is concerned, infinitolj 
better. The effusions due to recent ti-aumatism are mostly absorbed, the 
parts have recovered their jihysiologieal equilibrium, and faults of aseptic 
technique are easier to avoid and not as Imrd to remedy as in recent coses. 

The circumstance can not be urged a.>^ a serious dniwback, that a few 
weeks after the accident, the fracture-planes are found covered with new- 
formed connective tissue or a cicatrix, and that this must be first removed 
before suture can be applied. 

More difficulty may be encountered in overcoming the retraction of the 
quadriceps. But even such high degrees of retraction as are occasionally 
observed in complete failure of union, or met with in old secondary rupture, 
representing a diiistasis of several inches, can be managed so as to permit 
euture and buny union of the fragments. 

The mode of procedure is well illustrated by the following history : 

Cask. — Mrs. Lizzie P., housewife, aged twenty-eight, au extremely obeee woman, 

contracted in 1884 a transverse fractures of tho (eft patella, which Wii« attended to by 
litT fainily physician, and was treated by real and bfinduging. It healed with a seem- 
ingly satrrfaotory ligumentoust union, whicb, however, gave way a few weelcs after 
the completion of tlie treatment, resulting in a wide ^ap between the fragments. Mea»- 
iirenit'Ut gave a hiatus of two and a half inches in extension, tive inelies in flexion at a 
ri);ht nngle. Her jjnit was rather uncertain, caasins many falls, one of which pro<liicod. 
May 2, 1887, a transverse fracture of the riff/d patella. This recent fracture was treated 




SPECIAL APPUCATIOX OF THE ASKPnC METHOD. 7s» 



by approximation with tvo broad euip» of adhe$iT« pI*A«r. bdadaec*! co ai>l 
the limb resting on a T-6;^ict. Mmf 35CA. — ^Tbe <M potcfiajy fr jtfi e w^ united bj 
operation at the German UosiHtaL The fimb bsTiiie b«cB re a d * red aBwnie bj ct>o- 
striction, the joint was laid open bj a truksvene ibckwci. awi tLe cincicxal R^arae 
investing the fracture-planes ct the knee-pan wft» ««t awaj. a»l thie Immm- !*rrtp«*! ar«« 
from all adhering connective tissoe. until the correepoodin^ <arfKv» «l the («tc-Ila 
were clean and smooth. After this four eqiddijtanE hoie» wcf« diiSied throng each 
fragment, while the bone under treatment was b«4d imtaoTablT fixc«i bj an assiftact 
in the grasp of a li<m-jaw forceps. The drilling ol the aptrtmre* in the cpper frafmecc 
was much easier than of those in the lower one. Bt the aid of a flexible alrer probe, 
a double thread of thick catgut (Xoi 4) wa» drawn tfaruogh the ccrreepoodinj; drill- 
holes, the ends of each Miture being temporarilj' secured in the grip of an arterr for- 
ceps. The most diflScoh part of the operatkni eooBSteii in the approximatioD of the 
fragments. The quadriceps tendon was exposed bj a longitudinal incLaon of <ix inches 
in length, and. the upper fragment being foreiblj drawn downward with boDe-forcep». 
a number of alternating lateral notches were cot into the muscle and :end<>o, until the 
fragment yielded to moderate traction. The first suture nearest the edge of the patella 
was tightened — ^not tied — by an assistant nutfl the fragmenu were broa2ht in ccotact, 
whereupon the second suture was firmly knotted, .\fter this the fourth suture was 
tightened and the third one tied ; finally, the two outermost sutures were attended to. 
The ends of the catgut were trimmed, and three short drainage-tabes were in^ierted in 
the three angles of the wound. During the whole operation a stream of a 1 : iJi*p* 
solution of corrodTe-subHuiate lotion was played on the exposed tissues. Before the 
closure of the wound, it was finally flushed with a I : 1.000 mercuric solution, and the 
application of a number of external catgut stitches completed the process. The knee 
was enveloped in an ample dry dresring and a plaster-of-Paris splint, enforced by a 
few lateral strips of white-wood veneering. Finally, the constricting elastic liand wa-t 
removed, and the extremity suspended in the vertical positicHL. which was abandone<l 
twenty-four hours after the completion of the operation. Jum 3d. — Splint removeil : 
dressings changed; drainage-tubes withdrawn. Jvne 17th. — Woand healed throngtj- 
out. Silicate splint applied. June KHh. — Patient commenced to walk on cnitchen. 
Julff Sd. — She was discharged cured. July 13th, — ^The union of sutured patella wa.t 
found firm, the operated limb much more useful than its mate. Flexion coald be car- 
ried to a right angle. The course of healing of the case was feverless throughout. 

3. Arthrotomy for Inedoeible or Habitual Dislocatioii, and for Deformity 
doe to Fracture. — Dislocations that are irreducible from the oatset, or have 
become so through neglect, can be corrected by meaus of aseptic ar- 
throtomy. 

Case I. — Henry Kdhler, aged nine. Dislocation of basal phalanx of thumb upon 
dorsum of metacarpal bone, of six weeks' standing. Jjemnher 2iK 1S70. — Rej»cate<l 
unsuccessful attempts at reduction under chloroform. Immediate artlirotoiny. I)i>- 
section of abnormal adhesions, and excision of a shred of interposed capsular tis>iif, 
followed by ready reduction. Suture und catgtit 
drainage. Primary anion. Jan. 10th. — Patient 
discharged cured with improving function. 

Cask II.— John Becker, aged twelve. Fresh 

compound dislocation of terminal phalanx of the 

ring-finger on the dorsum of the middle phalanx. 
tr X fflrt 100I -Cii- 1 • • i J ^ Ai f^'"- *5!^-— Kxplaiiiinsr nlation of parts 

March 29, ISS^.—YXhar was admmistered at the ;„ j^^n Beckcr'.s case of plialangtal 

German Hospital, and, after careful disinfection dislix-ation. 




i^O 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fi... 



-Arnij»i;f'ini'iit ol' ruliUt'r Hliwts for oiKTBtioiif* 
ubont till- upper cxtreuiity. 



of tlie putienl's hand, ntrluction was repeatedly attempted without aacceas. The mian 
transverse laceration at the iiiteguitjeiit ttf the votar iispect of the fSiiirer did nut gire 
the leost advantage as to exaniiiiiu^ the iuterior relutioiis of the displacenjent, hence x 
htteral incision was made on the radial side. It was then ascertained that the tendon 
of the flexor difiiti profimdus was dinplaced upon the dci^rsiuu of the middle phalanx, and 

was interpt»9<'d lietween tlie ar- 
tii-iihiting surfaces. An addi- 
tiiinal lutorul inoisiou on ti>e 
ijppoHite .side of the finger wa» 
necessary, and rwhietion eould 
only he net'omplished after a 
free divisinn of all resisting 
lianda of torn eiipsalar li;j:aiiient, 
caui-ht Itetweon tli" tiexor t^L-n- 
diiii and tho articidutinj; surface* 
rLspeetivelv. Suture and rat^tiit 
drainage; fixation of the tinker 
on A sriiajl volar <:plint. April 
:jtb. — Firnt eliauffe of dressing^a. 
Primary union. In May the 
function of the injured joint oc- 
cnine nearly nornial. (Fig. «'«»,) 
Cabe hi. — loseph Jeretzky, aired eijfht. Old, irreducilde dislocation of basal pha- 
hinx of iudtsv upun the dorsmu of the metacarpus. May It', I8S4. — Lateral incision. 
iJivisinn of the new-formed cicatricial hands; removal of an interposed shred of the 
tapstdar lifjatnent, Reduetion and primary union with perfect restoration of function. 

CoiitijfJar fracfuretf of the clbtiW itu'fh posfcrior or lateral dinplaceiripnt 
of thit forearm are a common injitrff irifff rhUdren. What witli tlio great 
difficulty of an e.xact dia^^o- 
fis in the prcsrnce of x\ large? 
effluxion, anfl the great differ- 
erjet'S of opinion of the aii- 
HiorH aa rc^furds thu proper 
manner of treatment, no won- 
der tliut. after id bow- fract- 
ures, cases of gun-stock de- 
formity and partial dislooa- 
tion with inability to flex the 
elbow are not at all rare. 
Some of the antliors" advise 
putting up of the friictnre in 
extension, others in Ilex ion ; 
w)niie recommend early [Miss- 
ive motion with frequent change of the angle of the elbow ; others condemn 
altogether early passive motion. 

The authors eonvietion is that in many instances exact reposition and 
retention are utterly itnpossible unless the fragment is cut down upon and 
sutured or nailed to its origiiuil seat. The in.«ertiotJS of the muscles of the 




Drefihihi: lur wouiiiJi* of httitd and lurt-ann. 




SPECIAL APPLICATIOX OF THE ASEPTIC 3[ETHOD. 



81 



forearm aboat the epicondyles mo^t exert a great inflnenoe npon the dis- 
placement of the fragments, hence it seems that flexion wonld be the better 
position to counteract the tendency to displacement. Bnt all assertions 
made to that effect, that, in spite of the presence of a large swelling, redac- 




Fio. 72. — ^Anterior view of guD-«tock deformitr doe to eltow fncture. 



tiou can always be accomplished and retention maintained, have appeared 
t4> the author as a hollow pretense or self-deception. 

A very guarded prognosis in elbow-fractures is, on the part of the physi- 
cian, a sign of wisdom and discretion. 

Where very limited motion and an unfavorable position result in spite 

of careful treatment, the only means of 
correction is arthrotomy with sab??e<|UC'nt 
partial or total exsection. 





F^o. 7S« — iMenA vieir of Bernhsril 
Lceber* elbow. 



Fio. 74.— Xonnal a>.pec-t of lower end of hiirne- 
nw. A A. Tnuuiveive diaioeU-r. b b. Line <>f 
fracture. Id Bemluirri I>xrU-l'ft catte. 



Case L — Bemhard Loebel, aged two. Oct<^)ber 27, 1886. injure<l tiis elbow by fall- 
h^ off a chair. The arm was put ap by a phjsirian in tbe tiexed pobition in plaster 




J.J 



Fi«. 75. — Showing relative poj^itions of troff- 
ments in Bemhard Loeber^ au-s. 




Fio. 7^. — .\ntfrior view of 
lower end of hunierus in 
Bemhanl Lmljil's case. 



of Paris, and remained in this dres-iinjr for a fortnight. Jjec 7, 1S8C. — The elbow- 
joint showed verj marked gun-stock deformity. It wa.s lieUi at an angle of uboiit 



82 



EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



one hundred and forty degrees. Flesion ooidd he luirried to ahotit one bandred tad 
ten degrycs; txteneiou not heyond the angle firat nientiimed. Tlie fureariii was dit- 
placed inward and backwttrd, and the tendon of iho triw[>s described a well-pro- 
nouDced concave line. Au ahuoriiml ujass <»f hunt- could he- felt m tlie bfnd of tb« 
elbow externully, behind and below which the head of the radius could be made out 
with some diflSctdty. A posterior incit^ioa midway between the abnormal nisj^ of 
buoo and the olecranon opened the joint, and the periosteum wu» raised by tnesui!) of 
the knife and elevator on both sides of the Incision until the lower eml of the hunierm> 
could be turned ool for inspection. It was found tliiit the deformed callns consisted of 
the external eiHcondyle, cHpitelhuu, and a sinall portion of the trochlea that had l>een 
broken ofl*obIi«[ue]y. and ivuh tilted and pulled forward by the action of the flexors so 
an to present ity Jirtioular ast'*^ct forward, part of the fnictured surface looking back- 
ward. Tq thiH position bony anion had taken place. The elongation of the oater half 
of the articular end of the huraerua aceoanted for the gun-stock deformity : the |>re*- 

ence of the lnr(!:e insit's of bone di*- 
placed forward by tiltinjf of the frag- 
ment explained the inability to flex. 
The lower end of the humerus was 
pared olf horizontally with the knife, 
t-arc heing taken to remove a httle 
more from the external than from 
the inner half of the lower end of 
the humerus, in order to preserve 
the *' carrying point," The capsule 
and Bkin wero nnite<] bj sntnre. 
One drainage - tube was inserted. 
The arm was put up in extension in 
a couple of lateral jiasteboard t>plint«. 
No lever followed. iJec. J^M.— First 
chanjje of dressings. In ame^the^s 
the tube was removed, and the uroi 
was flexed to an aeute angle and put 
up in this position in two lateral 
pastebojird sjdiiits. />cr. I9tf).—¥ii- 
nive mntion was practieed in anees- 
thema, and the arm was fixed in the 
straight position. Dw, 23d. — Paasive 
motion without ether. Fixation at 
an acute angle. Dee. S9th. — Free 
passive motion to normal liinita. 
S|ilints abandoned and active move- 
ments commenced. March 3d. — 
Outline of elbow almost normal. 
Flexion and extension normal. 

Cask II. — Willie IL, aged elev- 
en. Very pronounce<l gun-stock de- 
tVirmity due tu fracture of the elbow- 
joint sustttiued two and a half yean 
ago. The treatment had been conducted by a surgeon of good repute. Flexion could 
be carried to a right angle, oxtonsion to about one hundred and thirty degrees. Fig. 
Y7 ahowa the boy's arm in full extenaion. Jane J7, 1H87. — Arthr^^to^ny done at Mount 




Flu. 77.— tjiin'-stock dv.\'"n»\'.y duo tu T-t'nn luiv of 
the lowor end of the liumurut*. WilUi' H.'m ease. 



b. h_ 





Sinai Xlospital rerealed a rerr carious oaodttaon of ihtn^ Tbe broken-oir external 
tdyle and capitellam occapi^d a poation siniiUr to that observed in tfa« praccding 
Tbe ulna was dislocated hackward and 
Inward from tbe fragment representing tlie tro- 
cbl&a, wbich was attacbed bv i*al]u$ to tbe an- 
terior osfK'cl of tbe lower end of tbe bumenUw 
Apparently a T-shaf>e«l fracture of tbe lower 
end of tbe bainerni^ biui taken place. Tbe ar- 
ticular $)tirf:ice bad a nio^ grotesque sbape. 1 la- 
eartilajfinous surfaces of tbe irocblea au<l ^1;l'- 
inoid incisure were coated witb a dense m:i->> 
of connective ti!«ne. Tbe broken-olf corai .>i.l 
process was attached to tbe fra^jruent of ; 
trocbleo. Tbe articular surfiace waa pared ot^' 
to approximate tbe sbape of a normal bnme- 
ni», and tbe wound waa drained, satured. ao'l 
tbe ami put up in a pasteboard splint. Nonnui 
anion by pritiiury ndbe&ion of tbe wound to<jk 
place, but an annoying couipltcution, cousistinp 
of parahfuU of thr forearm ami haml, was noted. 
Tbis untoward event was probably caused by 
the fact that tbe pnil of Martin'tt bandage, u^ie<l 
for proibicing artificial anffimia, bad been place<l 
ortT the inner tuptct of the arm, exerting undui- 
preasore over tbe nerves. Jwui J9th. — Th*.- 
compressive dressings were removed, the drain- 
age-tube waa withdrawn, and tbe wound re^ 
dreaeed. Julff id. — The patient was discharged 
from the hospital witb healed wound. Local 
treatment of paralysia by galvanisfmi and maa- 
9lgs was commenced. July SSd. — ^Fiexion and 
atension of forearm and fingers re-established, 
cotning normal. 



Flo, 7!*, — Result »ftcr exst^tjon ol\ll>i»w- 
joint fi«r ^run-htock deformity. Willie 
IL's case. 



be- 



Aug. 1st. — Function oi elbow 
Aiiff. 19th. — Muscular power fully restored. (See Fig. 78.; 

Habitual luxation of the tihmhhr-joint, a very annoying and rebellious 
cotnj)laint, may also be cured by artlirotomy and partial exscctiou of tbe 
redundant capsular ligament. (See case on page 8, Note %.) 

V. OPERATIONS FOR DSFORMITma 

1. Knock-Knee and Bow-Leg". — Operative e-tposure of tbe medullary tissue 
of the long bones is a dangeraus procedure unless suppuration can be ex- 
einded from the wound. By the successful employment of tbe aseptic 
'netbod the danger of osteomyelitis can be virtually excluded. 

McEwen's osteotomy is one of tbe safest and most useful procedures of the 
tiewer surgery. It baa almost entirely displaced purely orthopedic methods. 

For knock-knect after division of tbe soft parts by a short longitudinal 
incision, the canceDous tissue of the lower end of the femur is divided by 
a pr«5perly shajKid chisel, called osteotome. For bow-leg, the osteal section 
ie carried through the upper end of tbe shaft of the tibia and fibula. The 







Si 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



SK^ 



operation is doue under artificial aniBraia ; and the dressings are applied, and 
the limb is jiut up in a contentive dressing — preferably plaster of ParLs— 
before the removal of the couf>triet,ing clastic bund. New-formed bone in 
thrown out into the gaj) caused by the corrcction of the jiosition of the bones, 
and by the end of three or four weeks lirm union in a normal position it 
the result. 

Gkak. — Leoiiold ilejmann, clerk, (igetl nineteen. Very marked bow-lefrtv, tbtfdi»- 
taufu bt't wi't'Ti tlio internal r-oiidyles uf tlie fftuorn being tbieu uiid ii lisilf inrhes. .Vo- 
Temher 15, J}^Sd. — Double osteotomy of tlie thiyli-s jit Mount binai Hospitul. Plaster- 
of-Paris ^plintit. Dec. IJifh.- — i'hange of dreasinfi;*. Woiauls tioiilcd by primary niiiiiiiT 
boiioH firmly ronsnlidatiHl. The knees were in pontiict, but the (.'urviiture of tbe tii>iiB, 
wbieh re[)ron(.'dtt'<] a great purt of tlif defuriuily, H-a» still very uiurkcd. Uadoubt^^llv 
os*t<?iitomv uf tlic sliin-bones would Lave giviia a better reaulL Tb© patient decliued 
further operative interference. 

2. Bony Anchylosis in a vicious 
position. 

Oase I. — Linn Frieberger, aj^ed fif- 
teen. Bony anobyloHia of riglit and pseud- 
anchylosis of left ina.villary joint, yruh- 
ably duo to actite osleoruyelitis of ri|a;bt 
ascendinf^ ramuj*. The teeth were in ab- 
solute apposition, and no solid loud cotdd 
be taken. Markeci facial lieniiatro|>hy. 
In diildhood a Huppnniting atleotion nf 
tlie ri^bt cheek wu^ uoted. April >>, 
JHHil. — Exsection by chi-sei aud mallet uf 
the k'ft laiixillary joint (liemiatrophy of 
tbe same side). 
Tlie operation did 
not relieve the 
functional trou- 
ble ; tl)« joiut 
was found i)seiid- 
aiiebylosod, tbe 
cartilages gone, 
andtbecupitelluin 
nearly alt.-^orbed. 
The wniind healed 
by primary iJiten- 
tion. April 29tA. 
— E.\rteetion of 
ripht tivaxillary 
joiut, which was 
found firmly nn- 
cliylosed. Tlie 

seindunur inciHion was obliterated, the capitellum, coronoid process, and temporal bone 
funning one fmlid mass. Immetliately after ita reiaoval tbe teelb could be scparftt«J 
to tbe distani-e of an ineb and a quarter. Primary union. Perfect restoration of fane- 
tiou noted in Jnuuury, 1887. 





Fio. 79. — ATTaDKi.'ment 
of naiU in MaiJiifio 
J^diweizi-r's eaht. 



Fio. so. — Fiiuil re:*!!!! ill M;ii:i.'ii> SchwviftT'** 
wise, rnjss-uiarkd intliouU- places wln-rv 
iiuUa were driven in, i I'ligv S,'>, i 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 85 

Case II. — Maggie Scbweizer, aged fifteen. Bony anchylosis of kuee-joint at a right 
aDgle. in consequence of infantile acute osteomyelitis of tibia, with sujipuration of knee- 
joint. January 22, 1886. — At the German Uospital, excision of the {latella and of a 
wetlge-8bape<l piece of bone, with preservation of the epiphyseal lines of femur and 
tibi.'i. Transrerse cataneous incision, as for knee-joint exsection. Division of the 
bone:^ by the saw, after peeling off of the periosteum. The sa\ve<l surfaces were brought 
t<»gether, and their fixation was secured by three steel nails, which were driven diag- 
onally through the tibia and femur in the horizontal plane — that is, from the lateral 
aspect of the extremity. The locking of the femur and tihia was so firm that the limb 
conld be raised and bandied like a solid staff. The application of the dressings was 
thereby made a very easy procedure. Full plaster-of- Paris splint. No reaction and no 
fever were observed. Feb. 23d. — First change of dressings. The nails and two drain- 
age-tubes inserted at the operation were removed. The bones were found firmly 
united. Over a small aseptic dressing a light silicate-of-soda splint was applied, and 
the patient was directed to walk on cratches. March 1/ith. — Discharged cured with 
ligtit silicate splint. May 10th. — Presented herself to author, walking excellently with 
the aid of a raised sole. IShortening, two and a half inches. 

3. Deformed GaUus. 

Cabx I. — William Paradies, laborer, aged thirty-eight. Deformed callus of the 
lower end of the tibia following a supra-malleolar fracture of the leg. Radiating pai:i 
issuing from the site of the deformity, due to pressure on the in- 
tegnmentf which was tightly stretched over the protruding edge 
of the npper fragment. March 7, 1887. — The deformed bone was 
exposed and chiseled away on a level with the surface of the dis- 
tal fragment. Sature ; no drainage. Primary union. March Slut. 
— Patient discharged cured from the German Hospital. 

Cask II. — Ernst Langer, carpenter, aged forty-five. Deformed 
callns of fihala. Avgu*t 29, 1885. — At the German Hospital, in- 
cision and exsection of the callus by chisel and mallet. Ap[)0>i- 
tion and fixation of the fragments by a strong catgut bone-suturi'. 
Prtmarj anion. Discharged cured, September 2(i, \%HTi. with firm 
consolidation. 

4. Glnb-Foot and Pes Valgus. — On account of its Am- Fi«.Ki.-i>(.r(,rmc<i 

CHllu.S of low- 




plicitj and the excellent results reported both from cr tmi of tiWa. 
abroad and at home after its practice, Plielps's operaticjn uEI',""" '"'"''" 
seems to deserve extended trial. It consists in the com- 
bination of tenotomy of the tendo Achillis with a free division of all the 
soft tissues situated on the mesial side of the planta pedis, tlic inoisi()n 
jienetrating down to the bone and, if necessarv. into joints. The idea of 
dividing all resisting tissues underlies the plan ()f ]>roc(<lure. The iiuis- 
ion includes the tibialis auticus tendon, the tendons of tiie tibialis ])ostieus, 
flexor digitorum communis longus, llexor hallueis lon;,'-u>, the belly of the 
flexor digitorum brevis, of the abductor l:allneis. the ]>lantur fascia, the Vn\\i 
plantar ligament, the deltoid ligament, the nerves, and, if unavoidable, the 
vessels. The incision need not be a very long one. It eommences just in fr()nt 
of the tip of the inner malleolus, and extends downward, according to the 
age of the patient, for about an inch or two. All the ])arts named above 
can be easily reached from the wound with a tenotomy knife, unless thev 




tm. 6^.— Uroup illuj«tratin|ur an operation nliout (be foot .ir iinkle. 

operation being done with the aid of Esmarch'js band, all the tissues can 
be readily identified as they are gradually exposed step by step. The internal 
plantar artery can thus be seen and doubly tied. The main trunk of the 
artery sweeps in a long curve outward to the ex- 
ternal Bide of the «ole, and is out uf the line of sec- 
tion. Should it be divided accidentally, and the 
blood soil the dressing-s at once, it is proper to re- 
move them* to reapply Esmarch's l»anil, to enlarge 
the incision, and to find and deli- 
gate the cut ends of tin; vessel. 
In, extreme cases of aduUs, where 
the bones have acquired a definitely 
vicious shape, osteotomy or wedge- 
shaped excision of the neck of the 
astragalus must be added to the 
teno-myotomy performed in the 
phitita. 

The antlior was f5urprised to see 
the ease with which even great de- 
formities could be corrected after the division of all tissues mentioned above. 
Of course, the wound is a wide gap, which is wideiiod still moj-e by the cor- 
rected position. Its healing is accomplished by tbn " organization of the 




hie 8:1.— I)iPs>"inB for woiinda of ankle and f«>l. 



J 




fio. 84. 

Kk'Viili'iii i-jf the feet 

.(ik-r i'lu'lps'si opiTHtton. 



y an assist- 

t, the 8ur- 

on applies 
ver the asep- 

ic dressing 

silicate-of- 
oda spliut. 
nd over tint- 
: plaster-of- 
'aris 8plint. 

Jhile the phister is scttiiitj. tlu' 
|k)t is held with force in :i 
)mewhat ovcrrorrcetcd pos^i- 
ion, which will allow for tin- 
light giving way of tlio it^^eji- 
Ic dressing. Tlieti Esmarch's 

nd is removed, uiid tlie feet 
held in the %'ertical po.<ture 
br an hour or two after the njieration. After disiippcaraiiee of passive 
lypcrieniia they are placed on a pilluw in the horizontal posture. 

In n fortnight or so the jil its lcT-(>f- Paris t^hell is cut away ; t!ie silicate 
plint thus exposed is finished i>fl by a few turns of crinoline bandage soaked 

i^ilicate. and as soon a'* it in dry the patient h allowed to walk with the 
id of crutches. In about four wt*eks after the operation the silicate ^lioe 

split oei top, and the dres^sings are removed. In many cases the wound 
ill be fonnd cicatrized over by this time. Should this not be the case, 
lowever, the aj?optic dressing and silicate shoe must be reapplied. When 
he wound is perfectly healed, the silicate splint can be replaced by a well- 
tting laced shoe. 

XoTK. — The silicate shoe must not tnctude morp tban atmut one tLird <»f the lei, in order 
M to prevent treatruent of its debilitated musclea by massage and t;lect licit j. 

The fear that the severed tissues will not grow together properly is un- 
[>UQded. Schede had the opportunity of ascertaining by auto}>By the exact 

eatuhlisliment of the physiological relations of the cut tL^sues. The best 
iroof of tiie fact is, however, the restoration of t!ie function of the cut 
ftrts. 

The results exhibited by Phelits at a meeting of the New York Htate 
fedical Society at Albany surpjL>?s everything (be author has seen accoin- 
ilished by any surgeon for the cure of this deformity. 





88 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY, 



/ 



I i 



^^ 



\ 



Fio. 66. — Appcuranco nf woubIh i'nnr wet'ki* ailor Phelps's 
oiH!rati'>n. Harry Eiisteiu's. car<>. 



Casb. — Harry EpHtein, scliool-boj, aged twelve, siifteriiuf from chronic interstitiiil 
ne]»liriti!* ail « coDsciiiU'iicc of !?ii"url»tiii«. Ofntrul i-ninliliou poor, on uecount of lack 
nf ex erf be, duf to ili-Hubilitv (n>m i'liil>fi'Ct. TIil- patteiit wu:^ walking; on the oi!t<-r 

Gdf;<-' of the piautiv. Tiie 
urinu t-uuluincd {irriuiultir 
and hvalino nisis and 
t M cnty per c^-ut <if alb«- 
laon. JIureh IJ^ ISfTJ,— 
At Mount Sinai IJcMpitMl, 
(kMiitlc I'holps''g opemtinn 
wus clone under ch!«iro- 
form, wltieii \vtt^ borne 
exci'Ilentiy, th« u])vrali(m 
histing lorty-five n:itiuu-ii. 
No fevor, no reaction 
f..lhjsv«<l. M,trrl, 28th,— 
The phujtcr »iiell wuti cut 
awuy, and tliv patient 
coiMtuencod to Uobhle 
about in tbe wanl uo 
c?rvitc}«es. April U>tk. — 
The old watcr-glus-> splints 
were removed, and wiTc 
replaced by a now *»<, 
which wero worn tiatil 
Juno, After thia the patient wjia fitted with a pair of laeinf; shoes. 

Case II. — Aaron Meyer, oysterman, aged twenty-nine, tar pnne and very painful 
pjs vulf^usofboth feet. Oct. 12^ 18S5. — At Mount Sinai Hospilal, exsei-tion uf a Im»ii» 
wedge by chisel and mallet i'roiri the internal a-ifiect of the head of the astragalus 
the scaphoid, and eaktineuni of the rif^ht foot. Area of the batve of the werlge al>i>nt 
one square inch. The remnants of tlie neck of the aslragahis and ealeuneum were 
divided entirely by the osteotome, and the fo<tt whs broken into shape by mununl force 
and put up ill an rtHe[>tie. dressing! and ijIaster-ttf-Paris splint. Stip. Ut, — Drc^ings 
removed, wound prcseotin^i n strip of siiullovv pranulatious. Dec. M. — Discharged 
cured. F<-b, J«f. — Foiilias operation on tlie left foot, which showed a lessor de(fr« •>! 
deformity than the right foot bofore oj)enition. The tHlo-n.-u'lnihir j(Hnt was iuciiH'd, 
and its entire cartiJaginoas coverinjr was removed by serajiing with a scoop. Feh.SM. 
— First change of dre^sinps; priiiinry union. Feh. 27lh. — Patient discliarjred cartd. 
In March, 18^7, patient presented hiinaelf for exnminutinii. Finn anchylosis of the 
tajo-naviciilar jointt* of both aidea, and very good fimction Imd been s>ecure<l, the 
patient lilteudiiig to his accustomed buMness. 



VI. PLASTIC OPERATIONS. 

Aseptics liavo ]i]freatly impfoved ihu results of {►lastic oi»cnitions. an"! 
especially erysipelas hva been iilmost entirely baiii!?hcd from fsicial wounda 
raude for pla.stic purposes. In performin^i; any operation about tbe face it 
ia necessary for the sur<;eoii to jtrotoct hiinself and ihe patient from two 
sources of infection. One is tlie oral and nasal jJCcrehoiiH, the other the 
patient's head, notably his hair. The latter should alwayjj bo enveloped io 




3 



I 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



39 



a cap exteniporized from a gCHxl-sised lowel or compre^^s wrung out of cor- 
rosive-sublimate loiiuti. The acconipaDying illut^traiions show the manner 
of folding the towel about the head. It s^hould be firmly fa«-tt?ned by a 

narrow ruller-bandage encircling the forehead 
and occiput. Whenever vomiting occurs, a 
careful cleansing of the t^oiled skin and a 
change of t^weLs are indicated. 

Where there is no great tension to be over- 
come, line catgut {So. 0) maketi excellent sut- 
uring material for facial wounds after plastic 
ofwration*. 

Where the tension is great (which, how- 
ever, should be reduced to a minimum by the 

proper shaping of 
flaps and free dis- 
sect ion), silver wire, 
or silkworm - gut 
well soaked in car- 
bolic lotion, will be 
well employed for 
retentive purposes. 
Sutnres of coapta- 
tion are best made 
with Hue catgut. 

llarc - lip pins 
were never used by 
the author, as they are unnecessary, and offer no advantages over the sutur- 
ing material more generally employed by surgentis. 

Where the wounded surfaces can be completely closed by suture, no 
dressings whatever are needed. A tliick layer of iodoform dusted over the 
line of union will soon unite 
with the oozings into a paste, 
which on becoming dry will 
form an excellent and nn- 
n-ritating protection to the 
wonnds and .luture- points. 
Daubs of collodion, or the 
application, after hare-lij> 
operations, of strips of iid- 
hesive plaster to the face, 
are especially unpleasant and 
irritating to infants. They 
create uneasiness, and excite 
the little patients into crying fits, and the distortion of the face resulting 
from fre'juent crying is certainly not conducive to the uninterrupted rest 
and union of the wounds. 




Fi», M.— Applv'; 



■ up, Flral step. 




Fi'i. iJT. — Applj'iug a»eptic aip. Second «t«;p. 







\>( jiii'- rii[i in mill, i 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Ketentive sutures should never be removed txio soon — that is, before the 
seventh duy. The smaller catgut sutures will bo absorbed by that time. 

Where an uncovered de- 
feet is unavoidably left be- 
hind, on account of lack of 
iutc'giimeiit or some other 
reason, Schede's procedure i^ 
the best mejiti!^ of preventing 
sU))|mrntion. A ttrip of rub- 
ber tijjsue is laid over the de- 
fect, and is 6uiliihly inclosed 
in an aseptic dressing. The 
bhMid-clot, which will form 
under the rubber tissue, will. 
if it be well protected from 
dc>-iccatt(>n and decomjwj;!- 
lion, rapidly become orf^an- 
iiicd. 
In pia-s/ir o/nrtifiotis pfrformni nhnut ihv mff ant! hard palate the con- 
dition of the teeth :?hould be well attended to [irevious to the uudertakin«r. 
Decaying teeth should be removed, and an nnwiiolesome state of the gums 
and mucous membrane sliouM bo 
corrected by the dillji^ent use of the 
tooth-brush and a 1:1,000 solution 
*jf pennanganate of potash as a 
month-wash. 

i^rethrttphtsiij will fail almost in- 
variably if amnion iaeal urine is per- 
mitted to pass over the line of union. 
Acid nrine is not deleterious to the 
wounds. Where chemical examina- 
tion has established the presence of 
atnmoniacul decomposition of the 
urine, fre<"|uent wa;shings of the blad- 
der and the urethra with weak so- 
lutions of [wrmanganate of potash 
(1 : 4,000 or 5,000) aud the internal 
administration of borsicic acid will 
suitably prepare thoi^e organs for the 
operation. To pre%'ent the soilinjf 
of the wound by ummoniacal urine, 
a soft N^'lnton catheter should be 
passed into the bladder and tixed by 

a proper bandage to prevent its escape. Daily aiitisei>tic irrigation of thff 
bladder should be continned all the time wliile permanent catheterism i* 
used. As soon as the wound is firmly united, catheterism may be etopped. 




-Drt'ssing for cxciBion of th* 
upper juw. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



91 



Perineal plastic aperafionjt od the female require a preTion?! thoronpU 
disinfection of the vnWa and vagina by mercurial irrigation, which fshould 
he kept up during the entire time of the operation. Here, too, dressings 

fare annoying and unnecessary- Cathetcrism, temporary confinement of the 
bowels, and frequent irrigation, with subsequent dusting with iodoform 
powder, will afford all the security neede<l agaiutt infection. 

» Aside from the care for the production and maintenance of the aseptic 

condition during and after the operation, another important requirement 
must be fulfilled, lliis i/< a thorough and comphlc apponition of the entire! tf 
of the wtntndud j*urf(ices by several tiers of cntifut tiuturea, and a correct 
■ union of the mucaua membranes of the vagina, and of the rectum if neceinary. 
A slovenly mimnor of suturing will lead to the formation of hollow spaces, 
which will bt'couie tilled by blood-clot ; and, if the sutures of the mucous 
membranes be ali^o inexact, contact of the vaginal or rectal dizschargoa with 

I the unjirotected clot will lead to \i& inevitable putrescence, and to partial 
or general suppuratioTi. An exact, deep and .superficial suture t> the best 
protection ff perineal uperntive wounds against infection. 
Note. — The stitclies holding ibe caucoii^ membnine together shouM never puf-t^ through the 
epithelium. Tbey Hhnuld bv i-ntere^l and brought out ju.xt Mow the epitholiul lining. Thi» 
will prevent Inversion of the edges, and the stitch-holes will b<- also protected from infection br 
the ridge of pmtniding mucous membmne. 

On account of the great vascularity of the face, facial wounds will often 
heal without suppuration, even if very indifferent asepticif^m was observed. 

Xot so in other parts of the budg, notaUg about I hi' extremities, where 
suppunttion ii* much more easily produced, and is generally followed by 
sloughing of tlif llu|>8. Strict usepUcism, avoidance of tension by sutures 
and of pressure by dressings, are imperative conditions of success in plastic 

at ions done on the extremities. 




Kio, !)0.— Miuis's opemlion. Primary f>lusl«r-»r-I'jiri:i drc-s«uii,'s. lln thu jiglit leg, the defect 
to bo ooven-d ; on the lell le^, Hup detacli«xl tVom coll". 



Case I. — Abraham Strecker, aged seven. Circular, extensive akin defect of tho 
right leg, due to old comjiound fracture: extonsive ulceration of frontal imrt of the 
cicatrix ; (edetna of the foot, caused by contraction of Ibe circular cicatrix. Dee. 7, 




9-* 



RULES OF ASEPTIC AND ANTISEPTIC SLTRGERY. 



1885. — At Mount Sinai nospitiil, plastic repair of the frontal pfirt of the defect by Mam^ 
procediirt'. Each thtpli and foot was first inens<?(l in a pliijiter-of- Paris splint, then thel 
cicatrix was disinfected witli iin eight-per-eent sirlutioii of ehloride of zinc and p.'ired off 



Klo. in, — Mii:l- 



■|nnitin(i St-(^p|i(iiiiv |.|:i--ter-r)t-Puiii4 <lr<'S»ia)j;s fixinjr rt'lutivt^ position of 
exiri--mltie5i. ¥\n\> wlUvchtsi to itn r»fw Imbitut. 



with tljti scalpel. After this a properly shaped, generous skin-flap was rniiied from the 
posterior asfiuft wf the Ictl U'p. Now tfio extreiuities were MiperimpoHtnl in bucIi n ninniior 
ns to bring the llup over tliti vivified surface of the right leg, wherewith it was brought 

in contact on its raw surface. A secoud- 
tiry plftsti-r-of-Paris dressing npplic^i over 
the prinuiry filaster sp!int> so«'iired the 
limbs !ind the tlup in tlieir new relative 
position, Tlie exposed raw surface o( the 
pedicle of the flap was wrapped in bq| 
envelope of rubber tissue to prevent ita 
desiccation ; the flap was lightly attached 
tu its new habitat by a few catjurut sut- 
ures. The eitges of the flap were dust- 
i-d with iodoforuu and the defect of the 
r:df was inclosed in an aseptic dressing. 
With the exception of a small portion 
of the end of the flap which necrowd. 
priraury union throughout was ucliieved, 
I/fc. ^I^f. — Tiie pedicle of the flap was 
cut, und the iiiiibs were released fmin 
their contineuient. Kiipid cicatrization 
of the remnant of the original and of the 
defect ni' the calf ffdlowed. and, January 
.1(1, [f*8>i. I lie Viy wiis discharge<l cured. 
The <L'deiiia of the foot bad disappeared. 
Ca»e H. — Ad<dpli Carhtens, school- 
boy, aged eleven. Feb. 17, 1887.— At 
the German Ilo8j>ital, Maa>'s o[ier.'ktion 
for a large skin defect of the anterior 
a8[>«tft of the tibia, due to severe Iraumatism. The ca*e was managed exactly like the 
foregoing one, with this additional circuniHtance, however, that it becatne necessary 
to pare off an area of tlio liUterior aspect of the tibia l>y chi.>ie[)ng, corresp<iudiDg to 



Flo. 02.— Miuia'b iiti- 
iTittioii, rtntd malt. 
Cienuix i* niarkcJ 
with ink. 



Flu. 93.— View ol ci- 
nitri^ of itie plnee 
wlietJCu the!>kio-flti|i 
wi»« t4tken. 



I 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 93 

:he size of the flap, in order to remove the condensed cicatricial tissue uuderlying tlie 
extensive elevated nicer. Thus, a well-vascalarized base was secured for the skin-flap. 
March 3d. — The pedicle was divided, and, April 10th, the patient was discharged cured. 

VXL ABBPTIOS OF THB ORAIi OAVITY. 

Long after the principles of the aseptic treatment of external wounds 
had become recognized, the proper management of the wounds of the nor- 
mal openings of the respiratory, digestory, and nro-genital tracts was still a 
mooted question. It was a comparatively easy thing to produce in these 
regions an aseptic condition for the time of the operation. But how U> 
protect the wounds from the inevitable soiling by the continuous discharges 
pertaining to these several apertures, was first shown by Billroth, who suc- 
oessfally employed iodoform as an effective preventive of putrefaction in 
the oral cavity. 

If a fresh wound of the oral cavity is rubbed off with iodoform powder 
and packed with gauze saturated with iodoform, this dressing will become 
matted together with the tissues of the raw surface, and will form an 
effective protection against infection by septic influences. The secretions 
will innocuously pass over the surface of the gauze, and the penetration of 
active germs to the wound will be prevented by the air-tight and closely 
adherent packing. 

The course of oral wounds treated in this manner differs widely from tliat 
observed under other forms of treatment. Diphtheritic and phlegmonous 
processes, formerly so common in wounds freely communicating witli the 
mouth, have become things of great rarity. The teiTible odor which could 
not be kept down by however frequent irrigations with any kind of deodor- 
izing lotion until the necrosed layer of tissues was cast off, is now generally 
absent. By the time that the packing of iodoformed gauze becomes loose, 
healthy and vigorous granulations will have sprung up, and the woinid will 
progress toward its uninterrupted healing without pain and without fever. 

As long as the packing is firmly adherent, it should not be disturbed. 
Its forcible extraction would certainly cause a good deal of pain, and would 
be followed by hsemorrhage and inflammation. The superficial layers of 
iodoformed gauze, becoming soiled by secretions or food, can be daily 
renewed. 

Another important point to be observed in operations about the onil 
cavity is the control of haemorrhage. The abundant blood-supply of tliis 
region is apt to be the source of copious luemorrhage, danjjorous in itself, 
but especially perilous on account of the possibility of the entrance of blood 
into the air-passages. 

This accident may, on the one hand, cause instant deatli from suffoca- 
tion : on the other, it may produce catarrhal or septic pneumonia by decom- 
position within the bronchi. 

Haemorrhage from oral wounds can bo controlled in two ways. They 
may be employed separately or combined. 
U 






The author's tracheal tunipin cannula. 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



The first one is by preliminary ligature of one or both liugual arteries; 
the second, by the exclusive use of the actual cautery and galrano-cauatic 
wire loop. 

Where the operation must ueeds extend to the floor of the mouth, deli- 
gation of the lingual arteriea will bo insufficient, and the use of the actual 
cautery point or loup often impracticable. In such a ease, preliminary 
tracheidomy and the emiiloynieut of a tampan t-annula will be the only safe 

means of preventing 
the entrance of blood 
into the bronchi. 

Although White- 
head's speculum is ao 
excellent instrument 
to render the oral car- 
ity accessible, yet it 
will be unsatisfactorj 
in operations to be 
done on the floor of 
the mouth. Here sec- 
tion or even partial 
excision of the lower 
jaw may be miuvoiflably necessary to nfTord ample spaee for complete excis- 
ion uf a malignant tumor, and to make accurate hsemostasis practicable. 

Where most or all attachments of the tongue to the inferior maxilhi must 
be severed, a strong loop of silk should be drawn through the stump of the 
tougUG uear the epiglottis, to be brought out by the mouth and att;iched 
by a strip of adbesive plaster to the cheek. This precaution will enable the* 
nurse or attendant to instautly clear the epiglottis should tlie stump of the- 
tongue ever Bli]> back upon and occlude the entrance to the larynx. 

In the more extensive cases of oral surgery, especially after removal of^ 
the tongue, nutrition will have to be carried on for some time by the stom — - j 
ach-tube, which can be left in for several days, or eun be daily introduced— i 
by the mouth or nostril. ] 

Early operations for cancer of the tongue will give better results in every" "i 
way than late ones. But even of the latter it can be said that, as a rnle^..— J 
the patient's life will be prolonged by them, and will l>e made more tol^ — ^ 
erable. 

Every oral operation should be preceded by a careful preparation of tb«S-^ 
mouth by t'xfcraction of carious teeth and frequent washings with a gemii-- — ^ 
cide lotion, preferably a 1 : 1,U00 solution of permanganate of potash. Pres- — i 
ent stomatitis should bo tirst got rid of by all means. | 

Cask 1. — Mr. David S., whole.'^alt' butcher, ajfed tifty-four. Strong smoker. On th- 
inner aspect of tlie right ohoek, opposite a curioas nntt aharp-edged molar, where «i 
opuliiie mucous pntch had existed for some time, an elovatcii nleor of the size of 
sih'ur (l<tlliir liftd established itself, and was steiidily extending. The snbmasillarj^ 
lymphatic glunds wore intuniescent. April SO, ISSJ^. — Extirpation of the growth frow-* 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



95 



S tniASTerse iDcinioii extendiufi: backward from the an^le of the nioutl). The outer 
skin was s^nived and brought togetlier hy a line of stitches. The intnmostsent suhinaz- 
illttry pl.-inds wore also reni()ve<J. Unintfrrupted recovery followed, but a small tistulft 
reintiinod behind, corresjionding to tb« niiddk* of tlio iiioiaion of the check, which, how- 
ever, olostMi after a few applicationn. of the thLTJiio-ciiutery. The <'Oiitraction of the 
cheek wiis successfully overcome by the insertion ami wearinii of wiHxlen wedges, whieh 
were almndoned in the fall of 1^84, Unrins the wnimier a relapse of eancer had 
developed iu the deep-seated Huhmnxilhirv irlandn of the rijjbt side and in the Hulmien- 
tal gland. September S5, 1884- — The glandular L^welliiiga were extirpated from both 
mentioned re^oaa. The complete reujc>val of the isubTnu.\illary jrlandw necessitated 
exciHion of two inches of tfie deep Jugular vein. The wound healed by the firBt inten- 
tion ; the patient took Ida first walk twelve days after the operation. lie remained 
free froro the disease until September, 1885, when a rather rapid swelliug of the sub- 
maxillary glands of the Iti/y side was obs^:■^ved. Apparently the infection had extended 
to the opposite side of the neck by way of the diseased submental gland. The original 
site of the epithelioma in the cheek remained intact by relapse. Ortober SS, 1885. — An 
nttem(»t was made to remove the ulaudular swelling of tlie left side of the cheek, but 
it hatl to bo abandoned on account of thy wide extension and iofiltrating character of 
the new growth. January 31, iS56'.— Patient died of extension of the ilii^euse to the 
cerebnun. 

Had the first operation beeu uudertakeii at an carlipr date, the respite 
secured to the ]>ationt would huve boon much longer. 

Case II. — Katie Johs, aged titirteon. Mucous cyst of the left under side of the 
tongue, deeply imbedded in the lingual tissnes, and extending back to the hyoid b*ine. 
March 24, 1883. — Deligation of the left lingnal artery from an csleraal iucision above 
the hyoid bone. Whitehead's specuiuni being inserted, the tongue wasi transfixed and 
•ecnred by a strong fillet of silk. By this it was withdrawn, and the cyst was easily 
cxtirfj-Hted from it.s bed by means of scissors and forceps. Care was taken not to grasp 
tbe cyst with the mouse-tooth forceps, which served only to hold aside the rauseular 
tissue of the tongue. Mininral hannorrhage was idiserved. The wound was stitched 
with fine silk throughout its entiro leugtb, a few tliroads of catgut being inserted into 
ite upper comer for drainage. Hfjth wounds healed by primary union, »ind, April 7th, 
the patient was discharged cured from tlie (tcrnian Hospital. 

CA.8K HI. — Adolph Bottger, cooper, aged forty-two, a strenuous smoker and bard 
drinker, had contracted an epitheliuina of the right iinterior margin of tlie tougue, ox- 
tending well forward to the gums of tbe canine tooth, and involving the intervening 
ptrt of the floor of the mouth. No intumescence of tlie lymphatic glandjj could be 
mftde ont. Augvat i?*\ 1883. — At the German Tlrtspital the right Ungual artery was 
deligat«d. and the right hulf of the tongue was excised by the aid of forceps and scis- 
•ors. A morphine injcctiun had been adrainlBtered befont tlie operation, and anes- 
thesia by chloroform v!a» not i;arried to insensibility. Ilicmorrliago w ils very moder- 
Rto. In excising the tloor of the mouth tbo bleeding was somewhat profuse, and a 
large number of spurting vessels had t«i be tied. T!ie resulting wound vviis packed 
with iotloformized gauze. No fever or inHnmmation ft)l!iiwe<l, and the power of degUi- 
titioD was re-establr.'shed i>u the third day. Tbe patient left the beil on JSeptembcr yth, 
and October 9th was discharged cured. In February, 1884, the disease returned on 
the inner aspect of the gutna. Mnrek 10th. — Three inches of the idveolar proceas of 
the horizontal part of the lower nmxilla were excised, together with the entire <:icatrix. 
Cure was delayed by nec^oB■t^ of the remaining portion of the body of the jaw. April 
90th. — Tlie se«]Uvstrum was extracted. Mitp £0, I884. — Patient was discharged cured. 



S>(> RULES (3F ASEPTIC AND ANTISEPTIC SURGERY. 

Maij 17, 1886, — The patient relurncMl with a far-gono relajise. starting from the left 
sabmaxilhiry stnrup. Maif IDth. — ExstH-tioii was porfuniied. Violent delirium trertienii 
«et ill innnediateiy aflL-r the mptfriititin, t'olluwed hy denth in rullupse. 

Oase IV^. — Fritz OattTwald, slmi'maker. a*:ed sixty-three; strung smoker ; «'aiK'er 
of the right margin of the tongue well buck near tije anteritir pillar of the fauces witli 
considerable involvement of tfie floor cf the mouth. Fcbrwiry S, 1886. — Deligation 
of tile left lingual artery, followed by excision of the corresponding half of the tongue j 
and floor of the luouth in morphine-chlorofurni anjesthenia at the (Tennan UoHpitul. 
Aroesa was gained to the nnd cavity by a semicircular imi^ion following the andeC 
sifln of the lower jaw, from which the attachments of the muscles were raised togetbei 
with the [teriostetim. The rinieoii* membrane was cut through, whereupon the tongue 
and floor of the month rould be drawn out from under the maxilla and turned out apon 
the front of the neck. Ilamorrhage wa.s rather free in spito of the iirelitniuary liy:rt- 
tiire of the lingual artery ; and, though the patient was not fully ana?sthetized, alarm- 
ing asphyxia suddenly took place, apparently due to the occlusion of the glottis h_v a 
Ulood-tlot. Efforts to dislodge this were unsaccessful, therefore hasty tracheotomy 
hud to be performed, resnlting in re-estahliflbnicnt of respiration. After this the excis- 
ion was completed without further mishaj). More than half of the tongue was re- 
moved up to the epiglottis, together with the left side of the floor of the mouth and 
the uiiterior fanciul pillar. The wound was packed with sodoformized gauze. Nutrition 
was carried on by stomach-tube. No fever foUowed, but, February 15th, Hymptoms of 
iodoform mania nece!>dilated the removal of the original packing, which was replaced 
by corrosive-suiblimate gauze. Ftfi. 18th. — The restless patient was taken to his liome, 
whence be was transferred to Bcllcvue Hospital, where he died a maniac on February 
28th. 

The foregoing case illustrates the dangers frotn tlie entrance of blood 
into the larpix, and the greatest diiiwbuck of iodoform when Uf^ed on elderly 
individuals — namely, its tendency to produce aeulo nnmia. From this 
instance the author learned the lesson of never risking a rather bloody opera- 
tion in the oral cavity without preliminury tracheotomy and the use of a 
tampon cannula. Tlie auxioii-^ moments spent in oiieuing the suffocating 
patient's trachea will never be forgotten. 

Case V. — Victor Jeggi, silk- weaver, aged trfty-three. a very moflerate smoker, 
admittuil August 2n, lH8i>, l4>the GernTan llospittil with lingual cancer, involving nearly 
one half and principally the right side of the tongue. No glandular swelling. Avg. 
22, 1885. — Both lingual arteries were deligated, and two thirdit of the entire length 
and width of iho organ were excised with very little hjEmorrhage in mixed (mor(»hiTie- 
chloroformj anai'Stheaia. The wound was packed with iodofontieil gauze. Deglutition 
returned on August 28th. The wound healed very rapidly, so that, Se])teniber oth, 
patient could be disw-harged nearly cured, lie presented himself. February 21, 18^6, 
with a relapse iu the floor of the raoiUh, but delayed ojteration until March :iOth, when 
the disea.se had assumed formidable proportions, rreliuiinary trachoutomy being doue> 
the author's tampon cinuhi waB inserted. The middle portion of the lower jaw was 
excised, and the remnant of the tongue was removed together with the entire tioor of 
the mouth by means of the thermo-caustic knife. The .stumps of the severed arteries 
ilid not retract (atheromatosis), and were successively tinl. The wound wa** |>acked 
with iodofonuized gauze, and nutrilinn was carried on by the stouinch-tube. April 
ad. — The patient vomited, and nodonbtetlly some of the ejecta found their way into 
the bronchi. April Sd. — Catarrhal poeumouia net in with a chill and n temperatare 




104 Fabr. April 6fh. — The critical condition chunt?e«I for thv better, jm«] hy April 
tb the patient leH the bed. To moid vomitinfj produced by the frequent intnxlup- 
>n o( the 8toaiHch-tube, tliis was cjirried in tliroiifih the nostril and left in »itu with 
evident comfort to the patient. Tlie wound contracted rapidly, ixit in the niiddJe of 
May relapse appeared in the pharynx, which ended the putierit's exit-tence in June, 188(1. 

If The presence of the tampon cannuht in the tmchctt, effectually shuttiiiji: 
off the possibility of tljc entrance of blood into the air-passages., inatle this 
otherwise very bloody and formidable operation comparatively easy and safe. 

Cask VI. — Mr. Joseph T., wholesale liqnor-dcaler, aged sixty, u smoker, had "been 
suffering for twelvo yenrs from oi»idiiie piitehes of the tcjiiffiio, two of which, witiuited 
ou the left side of the organ, developed, toward the end of lH8ft, into epithelioma! a. 
The otherwise wcli-aoxiriished patient saflfered also from chronic interstitial nephritis, 
as evidenced by tb© presence of alUumen and hyaline nnd tine praniilnr casts in the 
urine. Feb. 10, 18S7. — The left lingual artery was delifjated under clilnrofonii ansiA- 
theaim The tongue wus fccored hy a stroujir dlletof silk, and was vvitlidruwn from the 
moutii. A straipht f'eijslee's needle was then carried into the bottom of the tlelipation 

I Wound, and was thrust through the Jiiiddle of the bane of the toiipue just in front of 
the epiglottis into the oral cavity. One end of a platinum wire was passed through the 
•je of the necfJle, withdrawn through the wound and disengaged. The siuue needle 
»a» reintrodaced hy the wound into the oral cavity, emerging this time just alnngside 
>f the left anterior pillar of the fauces. Tlie other end of ihe wire was bronght ntit 
Ay the needle through the external wound. Tims, one half of tJie base of the tongue 
'^'iis included in a loop, and, the wire being connected with a galvanic battery, wan 
•inged throngh without loss of blood. After this the tongue was divided longitudi- 
**allj by the thermo-cautery in two unequal fialven, and tinally was severed from its 
Oonnections with the floor (»f the mouth by the same instrument. A few spurting 
•Arteries had to be tied otiMuring this lant step of the operation, which was coni|deted 
"^rit-hin the time of forty nilnute.s. Ttie hjemorrhjige \\n» really insignifieunt, to which 
<^ircani«t«nce i-* to be mainly attributed the rapid recovery of the |«iticnt. The 4iral 
"%«"onnd was packed with iodolbrmized gauze, and the estornal incision was dressed in 
'•ibe normal manner. Tito temperature remained normal throughout^ and feeding hy 
'^nbe was discontinuetl on the third day. The mouth was irrigated every hour with h 
T : 1,000 permanganate of potash solution, until February IHth, when the packing cnnie 
^^iway. The wound appeared clean, urul rapid contractii'n wati mnnife^^t. Feb. '^Ijlh. — 
The external wound was tirnilv healed. Mtireh Sfh. — Tlie oral wound was cloced. 



XoTB. — In preparing iodoformized gauze for m^c in wounds of the oral cavity of elderly 
bjecto, care must he taken not to sprinkle too much of the eheuiical upon ihe gauze. The 
irploA of iodoform bIiouU lie rinsed out of the meslicB of the fabric, wbi«'h should be tinged just 
▼ery faint yellow color. 

VTLL LABTNGXJAL OPERATIONa 



H 1. Tracheotomy. — The belief that tracheotomy is an easy operation is by 
no means jutiti lied by the author's experience- Occasionally, on a slender 
neck, and wheti there is competeirt assistaiiee to be had, it is a simple 
enough procedure. Bat in most cases, especially on children, it calls for 

■ the l>est <iualitie3 of an experienced and cool surgeon. 
The necessity of tracheotomy having become manifest, three require- 
menta are to be fulfilled. Firsts infection of the wound has to be avoided ; 




UNE LIBRARY. SUWOWi mmV."2iX\ 



J 





RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 





secondlif, unriceessary haemorrhage has to be guarded against ; and, tfiirdltf^, 
the trauhea hm to be pi-operly iuoised, and the cannula properly introduce^^ 
and secured. 

The risks of the operation are not inconsiderable, hence intubation o -=* 
the larynx, a much simpler, easier, and more physialotrical proeednre, mus "^ 

be deelared to be far [ireferable to trache<.)tom '^" — y ' 
wliere its apjdieatiou is proper, as in croujwu-. -^Mi 
hirynj^fitiij. 

For the I'l-nioval of forei;:;;n bodies and in caj^o. -^^ 
of tumor of the larynx, tracheotomy will remutu^^n 
the proper mea>iure. I 

Avf/idance of infection oz^ "^1 
\ ^'J ^'^^ wound from witbtu oi 
withfuit is an ever importan 
matter in all laryngeal o] 
enitions. But it is especial — 
ly important, and also moi 
diflicult. in cases where ihczZ3 
operation in done in the pres — • — 
t'neeofan infectious proeess,;^^ 
as, for iiitituncL", dipbtheritics^ 
croup, where the extension^e- 
of the septic condition t<^^ 
the external wound signal — 
izes a very grave complication of the otherwiije precarioa« state of th»- 
patient 

The aseptic rules laid down in preceding parts of this work obtain to- 
their full extent in laryngeal oj>erations, Iiifeetion from within must be- 
guarded against by careful cleansing of the external wound and rubbing' 
iodoform powder into all its recesses before incising the trachea. As soon 
as the cannula is inserted, the external wound mut^t l>e well mop]>ed out with 
a sponge soaked in corrosive-sublimate lotion. Then it is dusted with iodo- 
form^, and lightly packed with iodoformized gauze. In all cases of croap» 
the external wound should not 
be sutured, as sutures favor re- 
tcntion. A small ^lit compress 
of iodoforniized gauae isslijjped 
in under the flange of tlie can- 
nula before ils fastening by the 
two lateral pieces of tape. By 
slipping in over the gauze com- 
press a slit piece of rubber tis- 
sue or oiled silk, the dressings and the patient's shirt will be protected from 
soiling by the sputa. A narrow roller bandage passed several times over and 
under the outer opening of the cannula will give additional security against 
iiccidents. 



Kii.. !t5. — Arrangftiitrit <j1' the putitut lor trucljiHitomy, 




Fia. t»6.— ;!, Slit comprecH. b, Sune in »it». 



J 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



NOTK. — I'rvruly rhiMren will aometimes ftttompt the fordbla retnovol of the cannula. In 
1880 the amiior [x<rfoniio<J tracheotomv «»n a boy twelve years old, who, on rogainitig coiidciou»<- 
wss, at onc-e ton* uut the esuimila fmiii ilic wimnd, breaking it.-* fastenings to Ibo llangc, which 
remained alUeheii to lus neek. The family attcndiint, an elderly gentleman, attenipted th*? 
re-inlrvKliiclion of the indtniment. Finally, during the violent stnif^les of the patient the 
omoiila slipped into place, whereupon respiration, which had been iaboreii before, ^^iddenlj 
ceased altogether. The author reachetl the bedside by this time, and at onee removed the 
cannula from the asphyxiated child's neck, restoring reHpiradon. It was found that the cannula 
had been introduced upward intd the oral wivity, instead of downward into the trachea. Another 
tracheal tube was properly introduced, ami peace was onee more rest<iretl, but the boy died sub- 
leqnentlj of septicaemia, due lo the widu extent of the diphtheritic affection of the pharynx. 

Hwmorrhmje, iilwuys fhuratjteristic of an overliasty luul bundling opera- 
tion, can be guarded agaitjst by obf^erving the rule.^f laiil dmvn in tbe chapter 
on thti tecbnique of surgical dissection. Nothing will retard the perform- 
ance of truclieotomy as effectively its the disregard for baeniorrhage. And 
every drop of blood spilt untiece8.sarily will proportionaU'ly diniini.sli tl>e 
chances of recovery, not to mention the danger of suffocation from the 
entrance of blood into the lungs. 

NiiTB. — Tiie autlior once fu^sUteil a collengiie who io his anxiety to open the tnichca cut 
the isthmna of the thyroid gland. The formidable hiemorrhagt- following this step only inereaflcd 
the doctor'? ho^te. lie plunged the knife into the pool of blood and fortunatelj opened the 
tradiea. The patient a.spiralcd a large quantity of blood, and would have snrcly been suffocated 
but by the tiiuely turning of his bcxly face downwai'd. The patient, a boy of seven years, recovered. 

As 80on ti« the ukin, plutysma, and superlii^ial fajscia have been amjjly 
divided, the two groups of longitudinal muscles situated in front of the 
larynx are exposed. Sharp retractors are inserted and the bleeding vessels 
are attended to. A faint white murk indicating the median line where 
the muscles meet, is incised, and the mu&cles are taken up and raised by the 
retnictor.s as the wound dee|)eus. 

Thus far everything is easy. The most difticult part of the operation 
consists in the projier treatment of the isthmus of the thyroid gland. 

The surgeon must decide whetlier to approach the trachea from above or 
below the isthmus, and this decision depends ujion the length of the neck 
and the *ize of the isthmus. In long, slender necks, the trachea is easily 
ex|HJsed below the isthmus : in short, fat necks, with a massive isthmus, the 
upper o{H>ration is more fiiipro|iriaie. 

a. Sl'PEKIOK THAr'HEttT<jMY. — ^Ilaving chosen the upper operation, tlie 
surgeon must lind his way to the upper part of the trachea, situated just 
behind the isthmn.s. without injuring the thjroid capsule and its compli- 
cated jilexus of large and turgid veins. To accomplish this, Bose's method 
affords an esisy way. 

The deep cervical fascia divides into two layers jast above the stiporior iiuirgin of 
the thyroid gland, the^e two layers t'onuirig the niuiu body of the thyroid cnpaulo. 
The point of divifion correspondn exuctly with the npper itnu-pin of the friroid carti- 
lage, which can be easily tdentilicd by touch. The nail of the left index ()Dger is 
plact?«l n^ninift tho margin of the cricoid, the palp of the finiter looking downward, 
whereby the thyroid gland is protected, and tlit> fascia is opened by a nhort transverse 




Miu 



RULES OF ASEPTIC AND .ANTISEPTIC SURGERY. 




Fio. V7 — Difi^riirii bIiowIij^ rt-latuiiis 
uf du*!* ccrvk'ul ik-'i-m. *, Thy- 
roiil liody. .Itirtt ttbovt! it, cf>rre- 
>[Mit]diti;j; t<i cricoiil itirtilajfc, bi- 
furcwtiou (if dec'it oervtwil Ikscia. 



incision dirui'ted iipiiti St the upitor t'dizv of tli« ciirtilagt', A8 soon u? tlii> ia dotie. A 
I)tiitit hook can be )ntro(Itu-t?d through the Transverse slit iMihind the thyrn'ul gluniL, 
vvhirh thon iMin hi- drawn down with si>inc tbroe, expomug the two or three npper rinjr* 

of tlie tnicheii. The author never wiw this iiicthu*^ 

/fail, and, iu tniployiiijr it, never was conipfUiHi t-^J 
p,.,^^ cut tUii cricowJ i'iirtil;i;r« for want of space to limi.'* 

"^ vj\ the incision U> the trachea. (See Fig. 97.) 

L In'ferior Tracheotomy. — When tb- «< 
lower ojieratioii is decided mi, the two layer" * 
of the deep cervical fascia are successively^ 
incised t/fftt'irn (wo forceps, and thus tli -^ 
trachea will bi- readily exposed. 

Jncision of Ihc trachea t^hould be don ^ 
by the scalpel used fur the firt<t part of th « 
ii[wratioti, and rather by enttiug than b ' J 
piiuctnre, as the latter may injure the jx>8t 
rior wall of the cylinder. Before cutting i 
the trachea should be allowed first to adjas 
itself in its normal position, so that the in 
ci^^iou should be placed exactly iu the me- 
dian line, 
(ftuspino- of tile trachea wliile the incision is being made, but esj)Ociall« 
haste in openin*;; the orgati, may lead to very serious mistakes. It mai 
bnpiK'u that the trachea is not incised at all, or, what is still worse, tbi 
incision is placed laterally or even posteritH'ly on the tilted wind-pipe, 

C'ahe f. — Mary K., aited tivo. Mfty 4, 18S2. — Traoheototny porforuK'ii \tj a col 
league for laryngeal croup. The cannula could not Ih* kept hack in the woimd, and ibf 
patient was Couud hy the author suffocating, t!ie iustruinenl lying on the outside of th 
nwk. Kxuiniiiiition showed that the tracheal ineisioa was plaecd to the left side ant^ 
posteriorly, the traehea being twiited and bent wldle the cannula was in silu, Af^ 
anterior trarheal inei^ion wa-* made, and in this the lul>e was retauie«l without Irouhlc.- 
The child died of pueuinuuia. 

Cask II. — Ilorinaun Molleahauer, aged two aud a half. Croupous laryngitisw 
March 27^ 1881. — With the assistance of the family attendant, Dr. Ilase, superior 
traeheotoiiiy, on account of iiniiiiuent suffocation. The trachea was exposed without 
Irouhle, liut ia cutting it open too hastily it tdted around itn. axi;*, and the point of tlje 
kiiile nliavod off a segment of the first traeheal ring. The tilting of the tra<-bea wu 
not nolit'od at tirrtt on account of the neceHsarj* haste ; but, as soon as it was discovered^ 
Die trachea was properly incised, and the child iilliinately re<iovered. 

As soon as the proper number of rings are divided, the lij>s of the in- 
cision should he taken up by two small, sharp retractors. (See Fig. 18, 
page 39.) Hasty crowding in of the cannula is rei>rehensiblc, and may 
cause serious or fatal mischief by detiicliing imd pushing membrane down 
into the deeper parts of the tracheal tube. Itrawing a.^imder tlie tnicheai 
wound will afford amjUe opportunity for free brcatliing. for ejection of blood 
and menibranc or mucus, and will give tfie surgeon a welcome chance to 
ius|teeL the traeiiea and to extract 6emi-<letaclicd membmue or a foreign 




SPECIAL APPLICATIOX OF THE ASEPTIC METHOD. HH 

body. Il Will iiLso soJvc tlie question whotlier tracheotomy htus accoan^lished 
its end or not by the relief from dyspnoea. 

The apiuea, or seeming cessation of bivathing, often oWervurl imme- 
diat«»ly after the incision of the truehea, is apt to uhirm betfiuners. Jt is 
due to the habituation of the patient to exii^t ou a very small jillowunce of 
oxygen. The hrst deep and free breath taken through a newly-made 
tracheal incision gives the patient more oxygen than ten or (ifteen lahored 
itLspirations could give before the ojneration. 

As soon as the cannula and dressings are in place, the patient is brought 
to lx*d, and a sponge, hollowed otit in cuji t^hape by the curved scissors, is 
attached with a safety-pin or two to a suitable piece of bandage, is wrung 
out of hot carbolic lotion (two per cent), and is tied down loosely just over 
the orifice of the cannula. It should be cleansed at frequent intervals 
in the same lotion. Close attention to the cleanliness of the interior of 
the cannula is a constant duty devolTing upon the nurse. It should be 
done by chicken or pigeon wing-feathers dipped in carbolic lotion. The 
little patients should be encouniged to drink as much as possible, prefer- 
ably milk- 

Tbe first dressings can remain undisturbed for three days ; on the fourth 
day tboy and the cannula are changed. The patient is laid out flat on a 
table as for tmcliootomy, and everything possibly needed should be at hand 
and readily arranged in a pan. Two sharp retractors, thumb-forceps, scis- 
Bors, a clean cannula, and aebange of dres-i^ings will be needed. The bandages 
are cut, and they and the cannula are simultaneouijiy removed with the outer 
compress of gauze. The deejier packing should remain unchanged till it 
beci»raes detached. The fresh cannula is slipped in at onee, and usually with- 
out much ditticulty if the procedure be not unduly delayed. 

The packing of iodoformed gauze will become loose on about the fourth 
day, and should then be removed. If the wound is found clean and granu- 
lating, no repacking will be re<piired. 

As soon aa the patient can breathe freely through the fonestrum of the 
outer tube, the external opening of the cannula being occluded, the instru- 
ment should be removed, as it is apt to cause ])ressure-sore8 and trouble- 
some granulations within the trachea. 

The author's t'Xi)enence erabniees thirty-eight tmcheotomies perfornu'd 
for various reasons. Twenty-two were done for croupous laryngitis on ehil- 
dren. Of these, five recovered ; seventeen died. The superior oiJcration 
was employed seventeen times ; the inferior, five times. 

One of the children died of suffocation caused by the ill-advised action 
of the father. wh() infljited the patient's bronchi through the cannula with 
a large quantity of burnt ahim. The others died of extension of the jtro- 
oeas to the lungs, or of 8eptica?niia. 

i)f the remaining sixteen tracheotomies done on non-croupous cases, two 
concerned ciiildren, fourteen referred to adults. 

The following table will elucidate the causes for which the operation was 
jierformed : 
in 





102 RULES OF ASEPTIC AND ANTISEITIC SURGERY. 

Asphyxia from cntrnnco of UIockI into trachea 1 1 

" " Tnalt(;iiant guiire 2 

" " arterial liiEinorrha^e into a cervical abaoesa ] 

" *' chloroforra. ,...,.,.. 1 

PytpnoM from cicatridul giteuosis of bri>nchui« 1 

" " " pliarynx 1 

** " foreign \Kniy id trachea 1 

'* " " tarynx 2 

" " latyngeal tumor 3 1 

Preliininnrj' tracheotomy . , 1 

Total 9 7 

Of the two cases operated mi for the entrance of blood into the larynx, 
one recovered (see Case IV on page 96) ; the other, where haemorrhage came 
from a wuicidal gunshot wound of the base of the skull, died of the ccrebrdA 
injury. 



In two cases the operation was done for threatenin<^ asphyxia bvgrowiu 



^ 




malignant goitre. Both died : one from collapse ; the other from comw-- 
produced by acute alcohohsm or traumatic delirium (see Causes I and II o*"* 
page 109). 

In one case asphyxia caused by hajniorrhage into a cervical abscess neces^ — ' 
sitated the operatiou. Patieut recovered (see Case III on page 217). 

In two cascf? tracheotomy was done without success for deep-geated ate — - 
nosis of the air-ducts. 

One concerned a man of fortj, in whose left bronchus post-mortem examinatioc 
revealed a sypliilltif ricatricial stenosis. Tlio other bronchns was found compr 
by aeiito swelliug of a bronchial lyinphatic ^Uiiid. 

TIic otber ease was that u( Fred, Pecknry, jiged one, who eihibitod syraptoras of i 
^rovTini; tracheiil ^lunosh^ priitrijjullt/ ofigtrHrtintj expiratiim. The case came, Marcb.^-^* 
6. 18H0, under the iinthor'a cure by the kindness of Dr. Boldt. Tracbeotoinj was don«^ 
ut the nennan nosjdtal witbtmt rt-lief. The cbild died of pneumonia March 10th. Oiu 
uutupsy a bniss trouiicrs-button was luund imbedded in uld cicatricial tis^«^c between 
trachcu jtnd tcsophnpis, midway between the cricoid cnrtilajje .tnd tlie bifurcation. An 
open communicntiun existwl between the two tubes. Ttit* button wits budd in place by a- 
rim of ciciitriciid tH«iic in the «i"Bophjigns, tuid projected downward witli its free lower 
murgin liken vulvc into the lumen of the trachea. Thus iiiaidration found no impedi- 
ment, but on expiration the valve was raised, and expiration-stenosis was the rt-^ult 

In one C!i>;e syjihilitic stricture of the fauces indicated the operation. 
Piktient survived. 

In four ciises the trachea was opened on acconnt of the presence of lar?n- 
gcal tumorj*. Three survived, and one died of BCptic pnenmonia, duo to 
aspiration of the intensely fetid secretion of the uleeratcil tumor. 

Preliminary tracheotomy was done once successfully before extiriwtion 
of t!ie cancerous tongue (;-ce Case \' on ]ingc Of)). 

In one case the trachou was opened on account of acute asphyxia occur- 
ring during chloroform anassthesia. 

Cabe. — Undersized boy, aged nineteen. Norrmhrr /-?, ISSo. — At Mount. Sinai Uos- 
pital removal of an enormuua congcnitu) terutouiaof the occipital rei^on under cbloro- 



SPECIAL .\PPLICATION OF THE ASEPTIC 3IETHOD. 



103 



I 



I 

> 



form. Tlie growth hftd becume >arci>matoas, and extensive involvement of the cervical 
gland-s of both sides was pren^nt. The patient hud to be placed in the prone position, 
&nd this and his generally weak -ttate, together with the encronchiuent on the trachea by 
the glandular swellings, pro«luce<3 asphyxia toward the end of the operation. As arti- 
ficial respiration did not seem to produce any effect, irncheolotny was performed at 
oDce» and respiration waa reiiiored. While the pedicle of the tmnor was being de- 
titched, it was note<I that re^^piration had again ceased. The cannula was found outside 
of the trachea] wound, froui which it was allowed to slip by the n^istant intrusted 
with the narcosis. It in fair to state that deiith was very likely due to exhau>tion or 
coliapeie induced by the shock of the forruidalile o[>eration upon the much emaciated 
patieot. He was a lad of nineteen, hnt looked like a very sickly child oi ten. 

In one ease increasing stenosis, caused by the presence of a dispropor- 
tionately £imall tumor, iudicated the operation. 

Cask. — Julius Meyer, peddler, aged thirty-nine. Previous history pointed at the 
lodgijient of a foreign lifMly in the «iesf»phapu8 with dysphagia, wliicli spontaneously 
disappeare*]. (Gradually, however, increasing dyupnfea sny»ervened. The laryngoscope 
demonstrated the presence of n small irregular tumor in the larynx, the size of which 
did not seem to explain the intense dys|ina»a. Tracheotomy was done December 18, 
1886, at Mount Sinui Hospital. On incising the trachea above the thyroid b«»dy, a 
granuloma occupying the posterior iind lateral aspect of tlie larynx fust helow the vocal 
ehonis was exposed. Surrounded by tlii" mnss was found tlie point of a irooden xketPtr, 
one inch in length, its ends being inibedileJ m the miicotis memlintne. The cricoid 
cartilage was divided, the bttdy was extracted, and the granuloma was oxcisod. Bee, 
27th. — Tracheal tabe was removed. (Fur continuation, see Case III on page 104.) 

The followinof history of the removal of a foreign body from the larynx 
of a child concludes the series of tlie author's iiutj-croupous cjises of trache- 
otomy : 

Cask. — Clara V., aged five and a lialf. Mnii 22, J^/f7.— A foreign bmiy entered 
the larynx of the patient, causing intense fits nf coughing and transient attacks of chok- 
ing. A number of unsuccessful attempts at ciidoluryngcal removal of the body were 
made the same daj*. Finally, the IkmIv heeame liMiged iu the right 
bronchus, where its presence was made out l»y the sil>ilant noise 
beard near the bifurcatiDU nud the absence of normal respiration 
Rounds over the entire right lung. A short, hacking cough, moder- 
ate dyspn<va, and noisy respiration served as constant reminders <if 
the impending dunger. Jitur IJ^th. — During a coughing s[iell, sud- 
denly an alarming asphyctic attack set in, followe<l I>y dys|ih(igia, 
■phony, hoarse, cronpy tough, .and distressing dyspnoMi. Marked 
larnygeal stridor and diminished respiration sound:) over both lungs 
pointcnl to the lodgment of the foreign body in the glottis. Inferior 
tracheotomy being performed, tlie dyspnnpa at once disappeared. The 
fori-ign body, a headless and nnuless mmiature doll of porcelain, dvo 
eighths of an inch long and three eighths nf an inch wide, was found firmly wedjred 
in the glottii^ wlience it was extracted through the wound without diltieulty. The 
wound WHS treated openly, iiiid the child recovered. (iSeo Fig. 98.) 

2. Laryng"ofl8SUre. — Fis^^ion of the hirynx for the removal nf tumors or 
a foreifrn body was- jjcrfonncd three times by the autlior. In one case of 
iwurrent diffuse papilbma a very good final result was eecurod. In another 



IJ- 



Fio. W.— Min- 
inftm'iloll. rc- 
m<ive<.l from 
Ittrj nx by tra- 
cliC'tlOTiiy, 
Exact Buo. 
iriHrn V.) 



KU RULES OF ASEPTIC AND ANTISEPTIC SURflERY. 

one, done for epithelioma, sjwedy rolapse followed. In the llnrd case th(> 
prc:*eiice of a foreign body iindl inflammatory ;2:r!vnulomrt roquired the step. 
The body and neiv-growth were removed, but the ])erichoiHlrilic itiflumma- 
tion maintained f or a very lon^^ time .such an intense swelling of the laryngeal 
mucous membrane that the tracheal cannula had to be worn until June, 188?. 

Case I. — Mrsi. C. LeltmniiTi, tvvi-nty-four, t'i>ithoruimii (if iHith vucal L-urfl*. April II, 
18S^. — At the GeiJtiati no.s]>itai, Iiirynjrofissure and estlriJtitioti nl' Wth vocal i"ordi» imd 
the ndj.-u'ent miicrHismetubmiu! were? done. April 15lh. — t'muiu I Ji removed. April -ioth, 
— Wound healed. Relfip.HO nianife-^ting itself soon tiftorwurd, excision of Iht- Inrytis vms 
dono in the Hiiraracr nf tlie smne year by Dr. F. Lanj^e. who took t'harge of the service 
at the Geriimti Huapitul after tlic eX[iir«tion of the siuthor's lonii. 

Cabe It. — thivtd Popplewcll. iiiu<'hini!*t, a^red forty-two; recurrent papin«>ma of 
the larynx, that had been treated endohirynfreally by l»r. (Ileitstnann, who kindly 
directed the putietir to tiie niithor. Jtjftf 0, JHK5.— LarytigoJlrtsion at the Gemian 
I[oH[iirid. lieiiioval of the posterior h.ilf of riirht vocal eord; excision of several 
dissetuirmted pupjjhjinulu utid searing of their base by the tLcrmo-cjiutery. Augutt 
5th. — External wrmnd healed; voice ranch improved. 

Cask III. — .Inliiis Meyer, peddler, ai^fed ttiirty-nine; recurrent stenosis jifter tracLe- 
otoitiy (see case on page 103j doui.-, December 18, 188«5, forttie removal of a foreign body 
and gratnilonin fruin the larynx. Jtnnuirt/S7, l8S7. — Larynffu1n:i»nre. Moderate retnm 
of the new-prowth about the defect of ilio niaeonH laenihrane in which the end of the 
wooden splinter had been found imbedded. The |irobe was introduced into this aper- 
ture, and {lenctrated downward iirid backward tit a distance of three fourths of an inch, 
thin \nw ezndint; from the riinui). Intens^a Hweilhig and hyperiBinia of the entire niucoos 
membrane and submucctus tisfiie were noted. Ferichondritia was diagnosticate^l. and a 
tracheal tube was left inserted in tlie wound. The patient readily reeovereil from the 
operution, but Hubaetinently obald not get along without a cannula till June, 1887. 

To prevejit Hic entrance of blood into the bronchi the author tried the 
itse of a tampon eannula in each one of the preceding eases. It liad to bo 
abandoned, however, as, taking up too much space, it cramped the operator. 
It was found rjuite gatisfactory to press into the lower angle of the laryn- 
geal wound a small spongo, leaving enough space below it for the adtuissiion 
of air. 

3. Extirpation of the Larynx. — There is no doubt in the author's mind 
that partial or total extirpation of the larynx for malignant new-growths, if 
done mrli/, is the correct treatment, and will be successful in direct proiwrtion 
to the readiness and thoroughnctjs with which it is done. This view is in full 
accord with the accepted i>rinciplesof the treatment of malignant neoplasms 
of all other regions of the body. The large rate of mortality recorded ao 
fur after extirfuitirm of this organ ia due in a great measure to the fact, thai 
the step was resorted to mostly in otherwise hopelp.s.s and desjierate cases, 
in which endolaryngeal therapy liad utterly failed to give irlief. 

The earlier the operation is done after due establi.sbment of the diagnosis. 
the less mutilating it need be. Unilateral extirpation of the laryox is far 
lesis dangerous than the total removal of the organ, and. n.>* a number of suc- 
cessful ca-se-s testify, even a fair degree of phonation, together with unim- 
paired deglutition, may be preserved by it. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



105 



I 



^ 



Case I.* — Paiil £Iu1id, bjtrlwr, aged filty. i^otemhcr, 1879. — Tncreueing dystpliagia. 
l>r. E. Ciriit'ninp'liiifcnosticatwl iiii elevated iilicr of tliti .-izc of a lialf-dollar coin, o«-upy- 
in^ the dej>rt«A!iion boundetl by the ri(rht side of the hasu of the epiglottis, the ri(jrht side 
of the base of the tongae, and the rijjht wnll of tlic ]ihni'ynx, n site correspotidini; to 
chat of the glossji-ijpigltitti*.' and arytouo-epiglotlic folds, and more particularly to that of 
the siniia ityriformiH. The mucous covering of the epiglottic was soeu to W thi<^Tkoued 
and congested. The cervical jrlanda did not appear to be aiiected. No evident^© of 
syphilis could be elicited, either from the history or from the physical exanii nation of the 
patient, exeeplJHg n tnodi'rate decree of onychia, ♦•haracteri/.ed by rongheDing of the 
fingcr-miils. In the course of the treutiiioiit it became evident, Jiowevor, thot this bittor 
truubk' was due only to the fact that, iu pui-siiing his trade, his fingers wore niueb ex- 
posed to the action of »oa[i-lather. 

Anti-syphilitio treatment w its iuatitated and continued for some time with ap[>arent 
benefit, the patient regaining to a certain extent the ability to Hwallow. Tlie iuipruve- 
tnent was, however, merely temporary ; the dynphagiu returned, and the patient soon 
begun to suffer from the inanition thus engendered. 

Preliminary tracheotoniy was performed January 18, 1(^80, at the Gerniaii Hospital. 
March 'j^ 1S80. — rnilatera! exse(5tion r>f the larynx w as done witli llie able assistance of 
Drs. Ciruening, Bnp[i, Lefferts, sind l>r. Degner, tlie houBe-surgeoii, to whom great 
cre«lit is* due for the ^kill and patience exhibited in the dillicalt and tedious after-man- 
agement of the cji.se. 

An incision was carried from the median line of the hvuid bone idong its upper 
margin outward to the extent of tliree incbe-*, exposing the right lingual artery, which 
was ligated. A second incision was carrie*! downward from the starting-point of the 
first, in the median line, to tlie opening for the cannula, exposing the anterior surface of 
the hyoid bone and larynx, and the (lap thus foruitHl wiii* dis!*ecte<l up with all the 
nnderlying soft jmrtn and turned outwur4l. Tretiileleii burg's tampon-oannnla had been 
fitted into the trachea. The right half of the hyoid bune was then exnected, a double 
ligature placed around the .superior laryngeal artery, and the same divided. The crioo- 
thyroid ligament waa cut acroas, u pair of bone 8cis.-ior.s inserted into the larynx, and 
the thyroid cartilage divided in tbo tnedian line. Trendelenburg's tampon canimla did 
not fulfill the requirements nwing to a leak in the intlated bladder, so that blood iiian- 
nged to tind itn way into the trachea. An attempt to make it Herviceuble by winding 
layers of moistened iiauze around the cannula was unsuccessful, and daring the rest of 
tlie Ojteration it became necessary to fill out the lower part of the larynx with rimall 
sponges. The interior of the larynx was now exj^osed and showe«l an oval tumor, of 
about the size of a pigeon'H egg, nituated in the sabstauce of tLe right false vocal cord, 
involving the posterior half of th« true vocal cord and the .HToall cartilages belonging 
to it. The right half of the thyroi<l and the whole of the arytenoid cartilage were 
Ho «r dissected up and remove<i, together with the whole epiglottis. The pharynx being 
thna exposed to view, its entire right ."iido was seen to be diseased, and was removed, 
tugether with the right tonsil and the lower half of the right pillars of the ptJate. The 
bflM of the tongne, likewise involved, was dissected up on the right »ide with the 
flOftlpel, on the left with the thenno-cautery. The hannorrlirtge was insignit^cant, and 
the patient rallied promptly after the oj>eration. 

One of Tiemann'a excellent soft-rubtK'r tiibes was introduced into the <r soph agns, 
the wound thoroughly cleansed with a ten-pcr-eent solution of zino chloride, and the 
whole cavity packed with motatoned balls of oarbolized cloth. The wJgea of the hori- 
zOQtal iocietioD were then nnited by catgut sutures. 



•** Archive!' of Laryngology." vol. i, X«. 2, June, 1880. 



lOG RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The (BsoplmgeoJ tabewas remurkably well tolerattsd, and the patient^s aoiirishmeTit 
wa^ sntiflfftctorilj effet-ted through it during the whole course of the treatment. 

The dres^^iinp was i-liMnpeil onoc every twentv-four hours. 

On the tiftli day after the ujnTiititm fhe patient was well enough to sit op in n 
chair lor an hour. Three days Iut<er h*i could ii^ceud a flight of Htairs in being removed 
to atiollicr room, and a week later he spent most of bis time oat of bed. By the Ist 
c»f April, twontj-mx days after the o])erat)on, lie took a walk in the garden, and his 
weijilit had inrreased by 61 poonde. 

Tho large cavity contracted rapidly, and fin;illy became a canal, bouin!e<l «»n one 
side by the remaining half <if the larynx, on tlic urlior by a siiiouth cicatrix uniting the 
skin with the mucous membrane of the posterior wall of the pharynx. 

On tiic 21ith of April the patient made a Hrst attempt to speak. When the tracheal 
tube was closed, lie could converse with a hoarse, dull toil^, <)aite audible, and easily 
andcrstood at a distance of frura two to three yards. His ability to swallow has in a 
measure heen recttvered, but he [(referred to use the cpsophageal tube, to which he had 
become accii!«ti»nied. liy the hl\\ of May he hfid g:iiiued 1 4 J poundn in weight. 

The patient continued well until February, IHHI, when he contracted an acute 
pleurisy, to which he succumbed rather suddenly on accimnt of fatty heart. The speci- 
men of the larynx gained at the [»oBt-mortem examtnatiua ^^howed absence of any sign 
of a relapse. 

The tumor was found to be an adeno-sarcoma. 

Case 11.* — Uenry O., porter, aged fifty -seven. Rebellious hoarsene»9 of five 
months' standing, with increasing difUculty of deglutition. Marked loss of flesh and 
power. Murrk 16, 1885. — When the patient was directed to the author by I>r. S, W, 
(ileitsmann, a deup-.wated, nearly immovable, hard, ginndular swelling of the size of a 
hen*s egg was noted in the left submaxillary triangle. Endolaryngeal inspection 
revealed the presence of w jjmooth, pale tuiiiur^ the size of an ultmmd, commencing in the 
left ghjsso-epigbittidian fuld and extending through the subfltaneo of the left vocal 
cijtril into theary-epiglottidian fiild, to lertMinate in the aryteunid cartilage with a knob- 
like protuberance. March ISth. — Chlorofurni heiag administered, the diseased glands 
were removed. The sterno-mastoid was found partly involved, and thii*, together 
with a piece of the internal jngular vein of about one and a half inch in length, whs 
removed in one mass. Then inferior tracheotomy wa«i performed. The wuund healed 
kindly, except where the truchoal tube was bjcated, and April •JVth, under chloroform, 
the leiY half of the larynx was removed. A tamptm cannala, made by (Jeorge Tieniann 
& Co. after the author's directions, wjis inserted and .suitably distended so as to pre- 
vent the entrance of blood into tlie traohe*. After this an incision, commencing at 
the upper notch of the thyroid eartilago and extending to the lower margin (^f the 
cricoid cartilage, laid bare the larynx in the median line. To this was added another 
incision, commencing in the upper angle uf the fir>t cut and extending Imrizontally to 
the anterior margin of the left sternf»-ina->tuid muscle. The crico thyroid ligament was 
eplit to admit a strung pair of lione-pliern for the division of the thyroid cartilage ; but 
it was found impossihle to perfiiriu this act, iin the strongly inclined [Hisition of the 
cartilage did not permit an effective Imndltnir of tho im^trunient. Therefore, access 
was gained throngh au incision in the thyro-liyoid ligament from above, and in this 
manner an exact division of the calcined cartilage was snocessfnlty eifecte<l. After 
thiB the epiglottis was cut through lengthwise, the left half of the crico-thyroid liga- 
ment was divided, and tlie superior thyroid ortcry w.is inchnled in a double ligature 
and cut through. The most difficult part f>f the operati(»n consisted of the dissection 
of the lateral portions •>f the larynx and pharynx, closely adherent to the carotid artery 

* " Ammla of Surgery," January, 1886, p. 20. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



107 



I 



by cicatricial tis-^ue, caused by tlie exttqmtion of the BubTiiuxillary glands. Shallow 
iacitiions, running? piiritlU>l with t\\v course of th*.' curotid artery^ were cautiously made 
one nftt-T another, and tlio difficult task a^orjied almost completed when suddenly a 
powerful jet of arterial hlood welled up from the bottom of the wound. The bieedinp 
point waa t*asily eeeured in a pair of artery tbrcepa, and then it was ascti'rtained that 
the ti'unk of the superior thyroid artery (drtuldy titrated further below prior to this) 
bad been cut away on a Iwvel with its iuosculation into the carotid. A catgut iipa- 
ture was applied c'lroiind the main trunk .-ihove, another heloiv the iirtery fi>rceps, nnd 
when tho instrument wns removed n round hole in the side of the earotid became visi- 
ble. The remaining adhesions, L'orreKpimding to the hiteral portion of the pharynx on 
the \6t\ side, could now he ea.'<ily dissected out. The tampon cauuuhi was remove*!, and 
it was found that no blood whatever had entered the trachea. A sotlt tube was in- 
serted into the msophaiijuii, the wound w.is loosely packed with iodofortned ^atize, and 
an ordinary tracheal ciumiila wha left in the lower atii^jle of thetnu-henl wound. Finally, 
the Ijorizoiitid incisirm was chwed hy a number of catgut sutures. The duratton of tho 
operation was one hour and three (jiiarters — the antestheHia throufihnut undisturhed. 

Mieroseopictd examination of the new-growth by Dr. I,, "tt'aldstein gave the diag- 
nosis of alveolar sarcoma. 

The sttbsecpient course of the wound waa very satisfactory and free from fever or 
suppuration, the patient's* only cornptuint being a rather profuj^e secretion of saliva. 
Nutrition was carried on by the a-sophageal tube, the patient consuming corisiderablB 
qnantities of milk, eggs, and an emulsion oonnfofied of heef-tea and crushed boiled beef; 
finally, a generous supply of good whisky. 

From May 10th on, the trswiphageal sound was introduced twice daily for puriJO.ws 
of rmtrition. On May 13th the tracbe.i! cannula was abandnned. On the same day 
the innenno*»t layers of the iodoformed gauze packing became detached, and were 
replaced. The entire wound was found tu be in a vigorous jtrocess of granulation, and 
was considerably contrmted. 

May irtth. — The patient swallowed a small quantity of ct)ttee. 

J/oy 27>h. — Sutures were removed ; wound firmly united. Increase of body weight 
four and a half pounds. Mait Sht. — Patient wa.s discharged cured from the hospital, 
gtXKl deglutition being noted. June Wh. — Removal of it small, suepicioiis gland from 
the loft snpracbivieular space. M'irfh 13^ lUHfJ. — Removal of an enlarged lymphatic 
gland from left }*upraIiyoi<l region. Since then the patient reniaine<l well, attending 
to his laborious occupaticm. He cimid speak with a \x*ry audible hoarse intonation. 
Tlio right vocal cunl performed its fun(!lion normally. In March, 1887, relapse 
appeared in the cicatrix about the insertion of the stump of the ei)iglottis, for which 
snhhyoid pharyngotomy was performed, April '2'2. 1887, at tlie (Jerraan Hospital. A 
portion of the ricatrix. together with a section of the base of (.he tongue, was removed. 
The external wound was united by three rows of >uperimpo>ed ralgut sutures. Deg- 
lutition was* hardly disturbed by the operation ; the external wound healed by adhe- 
sion, and. May >M, patient was dischui'ged cured. 

Ill both of the preceding eases decided alleviatioii of the patieuta' 
wretelted coiiditiou uud un undoubted jrrolongutiou of life were uchieved. 

IZ. GfOmUE!. 

The aseptic method and un iinproved technique of dissection have 
tnaterinlly reduced the formidable perils of the aurgical treutnient of goitre, 
justly dreaded by old-time itractitiouers. 




lIXI 



RULES i)F ASEPTIC XSl) ANTISEPTIC SURGERY. 



iticiaion diructLMl jjpihist tlif tipper eiljif of tiie Piirtilaf^t'. Aa soon as tlii- is done, « 
hititit liook cnn be introdnced tfirou|rh llie transverse slit, tieliind the tlivrniU plunA, 
wtiirh tlion I'liii l<c dniwn iluwtj with wmje tbrce, exposing tliy two or tlir«e apperrititT^ 

i>r the trueljcii. Tlit' atitbor never saw this iiit'tlt>A 
/ f.'til, and, in c'Uit>loyinjr it, never wha coitipfUod t-*^ 

eiit tlio cricuid oartilitj^c for want of spat-e to limi- ^ 
the incision to tlie traohea. (See Fig. 97.) 

h. IsFEKiott Tii.vcHEoTOMY. — When tk ^^ 
lower operation is decided on, the twu layer s 
of tho deep cervical faj^cia are 8iiccessivcl_^^ 
incised AcVwwh fit'o forcepa^ and thus tli -^ 
trachea will be roitdily fxpased. 

incimUm of fh- tracht'U should he don- <' 

hy the sculpel used for the tir^it part uf th— -<-' 
(>])eration, and rather by cutting than b *" !? 
puncture, as the hitter may injure the jK>stf 
rior wull of the cylinder- Before cutting it 
tlic trachea should be allowed fji>it to adju^ 




itself in its nornuil po.sition, so that the in- — ^ 
cision should be placed exactly iu the me — "^•l 



Fio. or. — Diu^'niiii «ho;Yiiitf rt'lutimia 
of doef> cervical fjvscia. a, TIjv- 
rold l-H(dy. .Just ub<>ve it, C'lrrL-- 
Bjioridiut^ U> orioii.l <iirtil«t^\ bi- 
furcation of dif [1 oiirvicjil tusL'ia. 

dian line. 
<Jmspin<r (if the trachea while the incision is being made, but especially 
ha«te in opening t!ie organ, may lead to very serious niititake.s. It ma 
happen that the trachea is not incised at all, or, what is still worse, tb 
incision is placed laterally or even posteriorly on the tilted wind-pipe. 

t'AsR I. — Mary R., ji^ed five, Mnij j^ 1882. — Traebeytorny iicrfurtiK-d by a col— 
Ica^ne for laryngeal oronp. Tim caiinuta voidd not be kept liack in tht* wound, and iXxG^ 
patient was found by tlie author suffutatiu^, the inatrument lyin;? on the ont^ide of th^ 
neck. Kxaiinnation showed tliat tlie tracheid iru-ision was placed to the left »ide aaJi 
pustoriorlj, tlie trat-hea beiufr tutsted and bent wbili* tlie cannula was in gitu, Ai» 
anterior tnicliL>al ini'ittion was rnadu, and in this the tnlie was rt'taitiod without trouble. 
The child died of pueuiiiouia. 

Case II. — Hermann MoUenhawer, ajjed two and a half, Croupons laryngitis. 
Miiirfi 27, 18S1. — With the iis^istance of the family attendant, I>r. Ilati*, superior 
truidieiituniy, vi\ jH-count of iunninent snffocatinji. The trachea was* exposed without 
truubk'. hut i,ii cutting it open too htuitily it tilted nrouud ils axis, and the point of the 
knife ahavud off a sefjment of the first traolieal riuij. The tiltinjr of the tracbea was 
not noticed at ilrnt on aceount of the necessary biuste ; but, an fwwn as it was discovered, 
the trachea wan properly ineised, and the chihl ultimately recovered. 

As soon a-* the jiroper number of rings are divided, the lips of the in- 
cision should be taken up hy two email, sharp retractors. (See Fig. 18. 
page 39.) Hasty crowding iu of the cannula is rc|>rchensible, and may 
cause serious or fsttal mtsehief by detaching and pushing membrane down 
into the dte[>er ]iarts of the tracheal tube. Drawing asunder the tracheal 
wound will afford ample opportanity for free breatbiug, for ejection of blood 
and membrane or mucus, and will give the surgeon a welcome chance to 
inspect the trachea and to extract semi-detached membrane or a foreign 





SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



lo^+ 



I 



drawn u-ide. Ifrmntigo, Niiture, Htid asejttic drossinjfs. Tlic woiiiul heiik-d, witL llio 
exception of ihf (Iraiiiafic-trucks iindtT the flr!?t tIreHi»intj, which whs chttiitfL«d on Oolo- 
Iwr lytli 8oriit) huarseueas Jtie to paresis uf thy right vucal t-ord persisted for live 
months, but ultimately diaappeureil. 

Trnr/anfomif for (/a if re is one of tlie tnost fortniilaljlo tasks the .surge<m 
may l>e eulletl ui>uti to perform. It was twico tlu» author's duty to umk'f- 
take this procedure for extreme dysi>ua^a crtitsed hy mulifrnuiit tiiinur of tlie 
thymid glund. One case wjiscutujilioated by mitral iusiiRiyicnL-y and acute 
bronchu-j)npumouia, and endoil futally. In the other one the ^iipra-stenial 
jiortioii of a ^ery large fibro-isaicoma of the thyroid ghitid liad to be lirst 
extirpated before access could be liad to the traehcii. This case also ended 
lethidlly. 

Came I. — Rosa (iuttraunn, widow, ugetl thirty-six. Lnrge and frrowitig ori^inalJy 
p.ircnchyriiiitotiij, later snrrumiitoii!*, ftuhsrtTniil <;foitre of tivf yonrs' -tjind)ij<r. Mitrul in- 
sufficiency and scvtM-e acut*' hroncho-pricmiionia. [>r. S. Kohn, who relvrred the jmtient 
t^ the autijor, diiignosttcated paralysis of the right vocal cord. Ntrtnnher 11, 1S79, — 
Patient was adoiittcd to Gertnan Hospitfil in a very exhausted conditit'n. After copioiiB 
simulation tracheotomy was performed. Unly a very small amonnt of ether wan adniin- 
istert^l txxr the ciilttncoiis incision. Division of tljc |/oitre by the thermu-caut^'ry was 
trieil, hut liad tt> he given up on account oJ'the «In\vnes.s of the [irocess and the preat 
hit'niorrha;rt" Iroia the enormously liiisLended veins. Tlie expedient of at once tnkin); 
up and firndy retracting the divided ti*<i*ue^ by lar^e, fuor-pron^reil, sliarji hooks, proved 
more efficaciona in checking hfemorrhftjtre. With a few rapid atrokca the trachea was 
exposed aud opened, and, a lari^e-jsized soft catheter hetn^ intr<i<hieed, respiration be- 
came well estahSislitHl. But a few minutes afterward patient espired. 

Cask II. — Klizaheth K., agc<l Mixty-two. A very fat woman, withafiuiall pulse, 
BnCferinj? from extreuiu dyHpnom due to the presence of a very lar^e and Lard supra- 
ntid infra-sternal fihro-tMircoiiiMlons goitre. Aug'iMt M^ 18S2. — Extirpation of the 
soprn-st^rnal part of the swelling with suhsetpient tracheotomy, for which a specially 
constructed cannula with a lony tube was used. Relief of dynpnoja. Co|»i(Hi.-« stionila- 
ti"n was ernfdoyed by the family attendiiut to such tin extent that in the night of 
An^^uHt 24ih the p•^tient !>e<*ame htiisteriiiisly drimk, and died in a soporous condition 
under the symptoms of uonte alcoholism. 

X. AMPUTATION OF THE BRBA3T. 

In preantisieptic practice the rate of niortalitv observed after amputa- 
tion of the breast, miiinly due to accidental wound coniplicationa, was nearly 
ss hijrh as \\\\\i of major uniputution of the limbs. 

The notable depression <if the deatb-nite that bjus taken phice f^ince is 
dirertly due to cie'^nlier methods. 

The absence nf a pro|Hirfionatc decretive of Ihe deidh-rate. caused by re- 
lapw of tlic malij^niant growths for which the oj)eratiou ia performed, is to 
l»e attribtited to tlie tardim-s.'' of the fjeneral jinictitioner in advisinp and 
urging early removal, and the nnwillingnes.s tjf the patients to heed timely 
advice. 

Fn view of tlie fact thiit over ninety per cent of nil mamnniry tumors 
are carcitiomatoiis, the benefit of tiie dcniht belongs to the view which urges 
K. 




110 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY 



to removal. -1 prohalury incL<ioii at ira.-if shoufii be insisted on in «vry 
case of solid chronic intumeHcencf of the breast that remains uninJlwwM 
by pntpt-r hirtfl anil f/rnfnil hradueut directed against MyphHia or chrmv 
i ujitt in I n ff/ti rif tn ay/ if * .s . 

Partial operations are admissible only where the youth of the palienU 
the smoothness and imibility and slow pror^ress of the tumor jiL<tify tk 
Ht'jinni]>tic>n of a Ifenij^ii (growth, Kuch as utleiiomii or udeno-tibroma, »»r 
where probiitory puncture leaves nt» doubt of the iirosence uf a simple in- 
tention cyst. ^m 

In these cases the operation proposed by T. fJ. Thomas is very app^^'^l 
priate» and gives satisfactory results both as to the completeness of the rt*" 
moval and ttie cosmetic effect. The incision is laid iu the poctoro-niammt*-- 
fold, and the breast-gland is raised from the pectoral fascia sufficiently t* * 
enable the surgeon to incise it on its posterior asjiect. After the cnucleutiot'* 
of the tumor the breast is rephieed, and, the wound IxMUg drained. th« 
skin is united by an exact suture. The cicatrix ix-mains hidden under 
the overlapping breast. 

Cask I. — Mias C. L, governess, ajced twenty. A<lcno!iia of left Itrca-st of tbeiiiiiki 
of n hen's ejrf?. Decfmher 12^ 1S8J^. — At Mount Sinai lla«j)iial, Thomas's operntiu 

Thefm}*er 2Jd.~~Tu 
*-h:in^' of dreseiini 
JJrcemfxr 2J^th.—U 

larged cared. 
crmbfT JS, 1886.— i 
relaptM? ; verj fine lin 
ear cicatrix. 

Cask II. - VI 
Tilhe G., aged 
teen. Adeno-fihm 
wt' J eft breast of 
of u yuinll ap! 




1 

I 



Fio, yjt. — The (iiiniirriftrv claiiit iM-itit; tli-Uu'tifil trutii lifluw, tlie siirj;i-'iii iiisiTt- 
uitder ttic lirooiit to LMimpk-to tliL* upper s«3cti':«ti. 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. HI 



I)eeemfter SO, 1886. — ThoratLs's operation at Mount Sinai IlM'-iiitnl. Jkc-embcr 30th. — 
l>re»siti^'s fluingod. Janmtnj jf, 1887. — Wonml firmly uuiled. 

W bene vtT amputation of the breast is performed for nmliguiiut tumor, 
tite operation muM be radical, w at least as radical tis possible. No regard 
ichatevrr shouhl he pnid lo rnniiit'tir considerations, th»' ohjed of the mvnyure 
being the extirpation of a dvadly disease ^ which, if not dintinuted, is sure 
to kill. A wide bertb sboiild be given to the visible limits of the disease, 
and the knife t^hoiikl take* fiwuy at lea.st aiv inch aud a Iialf of apparently 
healthy ^ikiu. The axiUunj fat and (fhtnds must he invarialily retnoved in 
masSf whether intumescence is to be felt or not. 

If the axillary vein be attached to de^^eneraled lym[)liatic ji^lands, the 
attacbed segment muHt l>e ineliided in two ligatures^, and t!ie intervening 
piece cut owt together with the adherent mass. 

The tecbniqno of breast amputation i;? simple. After marking by a 
shallow cut the extent of (he two .-^enii-elliptic ineii^ieyns that shouUl include 

the part to be removed, the infe- 
rior margin of the brea,st-gland is 
exposed. The jicctoral fascia he- 
ing incisetl, the mamma is gradu- 
ally dissected up from the thorax 
till its upper limit is reached. 
The surgeon's hand is slipped in 
under the breast, and the upper 
incision completes its detachment, 
excepf where the lym- 
phatic vessels, pars- 
ing along the pecto- 
ral fold from tbo 
brea.>^i to the arm- 
pit, form a sort of a 
pedicle. The bleed- 
ing vessels are secured 
a.-* they are cur, and 
the ]K'Ctoral wound is 
covered with a towel 
wrung out of corros- 
ive-hublimute lotion, 
to remain under its pri»1eeti<»n during tbe removal of the axillary contents. 
The incision is exiendetl well U|> the arm into the uxilhi, and the ekin is dis- 
sected up forubtnit an inch to eat'b side of the cnt. The fascia is divided 
where the incision can be nuide boldly upon the edge of the pectoral muscle 
anteriorly, and the latisHijuns dor^i posteriorly. Proceeding from this hitt-er 
iiKMsion. the IttoHe cojinective tissue is divi<led by blunt dissection with a 
thiimlj-forceps and the handle of the scalpel, until the axillary vein is 
expc»scd to view. With this the most, important step of the o]>eration is 
accomplished. Seeing the vein will prevent ius accidental injury, and from 



Vv 



F^'^ 



s> 



i>< 



aiil 



ii". I'Hi, -Kciuovjil ijf axilliirv ootiU^nl.i. The sur^ton liuliliu 
Uie <let«ub<xl brvuHt. 8ervku|f ust ii hundlc. 





The vessels und nerves which travei-se the adipose tissues can be distinctly 
felt and Been as they are supcessively approached. If necessary the long 
thorueic artery and vein, and soniL'tinies the sub^ca|iular vessels, simiild he 




Fio. 102. — CoinplL'teil <in.-«fiinf after bn-a-it amputution. 

taken up and cut between two forceps. The nerves ought to be preserved. 
During' the disseetion of the axillary contents, the breast servua as a snitjthK- 
hundle. Brejtst and axillary contents are removed in one mass. Thus the 
intervening lymphatic ducts are certainly taken away together with the 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



113 



mamnifiry gland and the axillary lympliatic glands. After due irrigation, 
u countcr-idci^'ioii is madp on tlie exti^rnjil ns^ect (if the lati.«Rimiis-dor,*i 
rau-^clo. Tliu knifi- should divide the skin and fascia only ; then a dressing- 
forceps is thrust throngh the mnscle into the most dependent part of the 
axillary wound, when it is made to gra-^p the iMid cif a f^tout dntiiiage-tiihe. 
which is drawn out through the eouutcr-incisiou, to be traaf«lixeil wjtl> a 
safety-pin and clipped off even with the skin. 

After this the pectoral wound is united. Lister's button suture, ur a 
quilled suture, or any (iiher of the known forms of retentive suture, is 
applied to relieve tension. After another irrigation, the fine catgut sutures 
of coaptation are put in until the w<»nnrt is closed. The wound is once 
more thusbed out with mercuric lotion, mid is covered with the dressings, 
care being taken to make tliem the thickest about where the drainnge-tubo 
issues forth. The dressings are secured by roller-bandages, and the arm is 
either included in the turns of the bandage, the ulnu lirst being well padded, 
or, being left out, is sujyported by an extra sling. 

Ordinarily, the dressings are changed and the tube is removed on the 
tentJi day after the operation, when the retention sutures are also extracted 
should they not have been absorbed by this time. A smaller <lressing secures 
the parts against injury. Five days later another change of dressings may 
take place, when the drainage opening will be found closed by a plug of 
gnmuluiions. After this a covering of cerate or lead plaster, with a little 
pad of cotion secured by a strip of adhesive plaster, will be all that is neces- 
sary until cicatrization is complete. 

It is remarkable how soon the arm regains its power of abduction in cases 
that remain free from sujipuration. 

Of Kfty operations for tumors of the mammary gland, forty-eight were 
done on women mostly past n)i<hlle life ; two were jierformed on men. The 
male cases were as follows : 

Cask 1. — A. B., iif,'i'i! «eventet!n. tirowing adenomu of riglit ummmary gluini. 
Auyitat Jf, i.»?A?.— Exiir|iatu>ii of the tumor; axilla wii» uot, ioterferuJ with. Uniuter- 
nipte^l pririiury uui<iii. 

Cask !i — Gt'or^jc Eckert, ttlarkHttiiHi, u^M nixty. Uir«e, very Imnl u|iit.h*.'liouia 
of the riirbt tnjimmary nljunl. ^tartiiij; from tl»e nipple, which wti# uiirt'cujiiijzjiliie iu 
the ulcerated ma*s. .\xi!liiry glands mvolveil. April 27, 1886. — Aaiputation of Itrejwt 
und evacmitloii of .ixdln iit the Geriiiiia Hospital. Ijargv portions of Hkhi aiid of the 
poctorulb umjor itn«l luinur musdt's Imtl to be roniovcil. Primary iiniim followed, 
«lcept where tlie sikiu could not be brouj^ht together. June 7th. — Discharged cured. 

In two cases of adenouia of young girls, the tumor alone was removed. 

In five instances (Mary Kauser. adeno-cystoma : Rninni Hockhold, cysto- 
[iftrcoma ; Albert Baron, adenoma; Sarah S., cysto-adeno-fibroma ; Frida 
Meisisner, adeno-fibronia), the nirtnimary gland alone was amputated, the 
axillary space remaining ititaet. 

The remaining forty-three cases consisted of thirty-eight cancers and tive 
sarcomata. In each of tlie.se the entire breast and all the axillary contents 
were removed. 



lU RULEH OF ASEPTIC AND ANTISEPTIC SURGERY. 

Cttncor . 38 caw» 

Sarcoma 6 " 

AdLTuiriia 8 " 

Adoio-filirDiiia ,♦..,... „. 2 " 

Aderio-cv" stoma 1 cas* 

Total 50 cue* 

Of this number, furfif-one fitnes healing b\f primary union was observed. 

Fitff ra.'^ps xuppnratM iu consequence of infection nf one or another kit^^ 

at tlie time of tlie openitiun ; three cases healed by graiiuhttion, a^ it ^^^ 

impossible to cover the defect caused by the ojx-ration. A fourth granttl*^^' 

in^ case died of erystpolsis, contracted outside of the author's care (Jol»* 

Sehmalz, scirrhus) while the wound Wiw not yet healed. 

Of the eases healed by primary adhesion, one died of continuous thro«**' 
bosis of the axillary and iniiominate vein, with .mhscquent embolism of tl"** 
pulmonary artery. The .sudden change took jdace shortly after the fi**^^ 
change of dressings, made eight days after the operation. 

Oahe. — ( 'Irirn Ufilin, spinster, ji^jed tliirty-tvvu. Xott'mhet 30^ ISf^S. — Anipatat**^' 
of k'ft bruiirtt, witli evaeniitiun nf axillu for Htimn-ceried iideno-cfircinoma : suture; **** 
drain it<i;t\ fjfcember llffh. — Kirft cliniigi; nf dreissiiigs; entire wotinti ab^olulelr hcaJ^^^^" 
On Cliristnms eve the (xitieut wus? !»C'lling cn>ckt'ry over the counter. April 4, 188^"" 
Typical mnputation of ritjht breaat sit tlie German Hospital for the same affeoti*^^^ 
lX)^et)it'r with excision of re]fii«)nji: cancer in the sUfifie <if »i snmlt node in the cicat^*"*^ 
of the lt>ft side. Patient was doing exrelleiilly till A[iril llilh, when the first dre«isi *'*^^ 
were chjintred, and the wound wa^* found faultlesf*ly liealed. Immediately after "^^ 
dresMinj^s vrere etanpleted, tiie palii-nt heranie faint and cyanoBed; breathing lab«'ii'^='^ ^ 
pulse scarcely to ho felt; the left deep jui»ular vein was penuanently distend *- 
llydniperienrdiuni and hydrothorax developed with a?<lemn nf hoth arms, and ^'^ 
[>atient died April 2tJtli, sixteen days after the operation, having had normal and laC^ ^^^ ,, 
Bahiiominl teniperatiiren thronfjhont. Autopsy revealed continuuns thromhonin of t^^^ . 
axillnrif awl aiionijmiii rt'iu, the tliroinhtis extendiiiij intu the rii?ht auricle and t.J*^ 
pulmonary artery; bilateral liydnithnrax, liydroperirardiinn, and a hteniorrhngie §i* 
I farotion of the conueetive tissue in the poHterior uiediastinurn. 

The only unusual circumstance that attracted the author's attention 
immediately before the second and fatal operation was the fact that, a hypo- 
dermic injection of morphia being atlmiiiistercd. extensive ecchymosis ap- 
' peared .shortly sifterward at the site of the injection, suggesting a morbid 

altcnition of the patient's vascular system. 

Thrombosis and embolism were observed in another case, which, bow- 
ever, ended in cure. 

Case. — Mary Lier, school-teacher, a^ed fifty-seven. Suffering from old pahnonarj 
einphyaenui and chronic hrotjchitts. FaeeHliyhtly eyanosed. Seirrhusof right breast: 
nipple retracted, disi-liurj/in^ dark, tar-like serinn. yorf Fufier 14. 1878. —With the kind 
ftasistunce of Dr. F. Lange, amputation of ri^ht breast and evaeuatioii of the axilla were 
performetl. Aniesthesia by etlier Wius very bad, Feverless course of healing. Xorem- 
&*r /9/A. — Dniinag»'-tube wa» removed. X»rcmhfT 23<l. — .\])0[»leet.iform sei/urts, fol- 
lowed by aphasia and agraphy. wliicdi, however, gradually disappeared. Dee.tmher 
S9th. — The wound was entirely healed, and patient could again speak Iloheinian, her 



J 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



115 



mother tongue. Gradually slie res^ained her Gernmri am) Knglii^h, uml in 1882 uiithor 
heard from bcr as being able to write again. 

One of the suppumting caws died of acute cahirrhal |HH"umonia and 
carcinosis of tlie lungs. iwGnt3'-two days after the opiM-ation, the woiiud 
doing well at the time under process of granulation. 

Cask. — Mury Volkmor, linust'vviff, iigeil forty-seven. Sttft tideno-cancer of both 
breasts, thelarjife tutiKjr iff tlio li-ft niauirua caiisiiifj tiiut-b Jistress. March 17, ISSl. — 
At the German Hi>spitiil ainputution vf left brejist ami evacuation of tlie axilla were 
done. Wound was united in part only on account of extenflive loss of integiuia-nt. 
Suppuration of axillary spaoe followed, but ttie fever residting therefrnrn subs^ided 
directly after drainage was re-established. Xevertlielcss, jiutient appeared to bti very 
ill. April 8(h. — Catarrhal pneumonia set in, to whioli Khe MiceiimbcHl. Apriil iHh. — 
On piiit-niorteni oxiuniimtion general oareinosts <»f lungs and liver and cuturrbal 
pneuiuouiu were found. 

In computing the three fatal cases, that of Jnlie Sehmalz, who died of 
erysipelas contnicted under the care of another phy.siciau before perfect 
cicatrization had taken place, can justly be excluded- Accordingly, of the 
remaining forty-nine cases, two died directly iji cousequence of the opera- 
tion, none, however, on account of rfcptie processes established in the wound. 
Thus, the author's rate of mortality from accidental wound infection in 
amputation of the bresist would he ; from other causes beyond the in- 
fluence of the surgeon, u trifle nmre than four per cent (4'08). 



k 



• 



XL ABDOMINAL. OPERATIONS. 
1. General Remark.'^. 

The relation of aseptics to the surgical treatment of the peritoneal cavity 
is in some fjuarrers a subject of hot controvensy to this day. On one side 
we see the advocates of a more or less coniplieuted antiseptic apparatus, 
including the s])ray, achieving very good results, and basing success upon 
the strict enforccnient of their cautela*. But, on the other hand, we notice 
a most successful la|>arott)niist maintaining that antiseptics are unnecessary, 
or even harmful, and that he is aceustonied to flush the jieritoneal ciivity 
with *' water from the laj)," teeming with mJlliuns of bacteria, and yet his 
results vie with those of the most scrupulous Listerian, 

Both .-ides to the controversy have abundant and incontroveHible fact.a 
to support their jiositions, and tlie contradiction seems to be hopelessly in- 
surmoun table. It certainly is e.xtremely bewildering to the student and 
begiimer. 

Yet this contradiction is unreal, and let us say, on one side, also disin- 
genuous. 

The physiological peculiarities of the peritonapum, most notably its enor- 
mous absorbent power, endow it with the quality of neutralizing thedelcteri- 
ons effects of limited quantities of pyogenic or septic micro-organisms, u 
quality not possessed to such an extent by any other part of the human 
organism. 




116 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

fJrawitz* has brought experimeutnl proof r4 the fact that the normal 
peritonaBum will at once absorb into the circulation moderate quantities of 
active pyogenic eocci, where they will be widely scattered through the blood 
and perish. 

Note. — This fact goes very fur to t»xplaiu Lawson Tail's position, who, however, althnuirb 
fliHi.'laimin^ aiiti.*i'ptic,s, duvolts miwt scrupulous can li> cmc/ViVt«hj — that is, to the clean^inp M 
bunil-t and iriHtriiiiitfUtt'. [Us laftviuiiont^ iirc few, und KokH:te<i wit!) » y'wvi to siiaplidtj. //« 
tp<t)i<frn tin put hifn ctirbofjc Mini for dixinfftlon. The w[i(<'r iiff4 for the imraemon of hn 
Instpuiiipnt-* is sterilized by boiliiip. .Most of the hsicteria t'ontaincd hi hU " wnlor from llie 
lap^' lire innocuoii.i — that is, nim-pyngenTc : and those that have tht' power to cause suppuntioo 
are too few to proiliiee Kcriouslroulik". Thoj are simply ahsoilied and killed off hv (he ctml 
gertnicldc, th<? blood. 

The limit of the quantity of jiyogenic cocci required to produce acute 
purulent peritonitis raries with the size and state of health of the animal 
used in the experiment. A largo dog's i>erit<.ina?um would resist a much 
greiiter i(UHntity of infectious pus than that of a Mmall dog or rabbit. An<l 
a healthy anitnal would neutrali/e more septic material tliau a debilitated 
one of the same kind and weight. 

The presence in the j)eritoneal cavity of a larger (|uantity of stagnant 
bloody sei'um than can be readily absorbed within an hour, will suffice to 
produce purulent peritonitis on the addition of a very small number of 
cocci. 

If tl]c fluid is absorbed or artificially removed by drainage before the 
cocci have a chance to vastly multiidy, no peritonitis or only adhesive forms 
of the inLlammation will develop. 

Therefore, it is rational to employ drainage in cases where large surfaces, 
denuded of peritoniinim, have to be left behind in t!ie abdomen. 

Denudation of the s^iirface layer of the jicritoueal endothelium bycaloric* 
or mechanical or chemical inllucncey, is also conducive to the development of 
puruleiit peritonitis. It favors exudation of iserum, ancl diminishes or de- 
stroys the power of aV.soi"|ition inherent to the normal iJerilontenm. Should 
even a minute quantity of pyogenic cocci be introduced into the {)eritoneal 
cavity imder these circumstancej*, purulent peritonitis may readily develop. 

The practical conclusions to be tlrawn from the ])reeeding facts are a^ 
follows : 

1. Although the normal peritonaeum will tolerate a greater quantity of 
infectious material than most surgical wnund.si. yet all precautions regarding 
the cleansing of hand?, instruments, sponges, and other apparatus used for 
laparotomy should be employed, aii septic infection of the peritonajum is 
much etusier to prevent llum to cure. 

2. Unnecessary dentulatitui of the u]jperraost layer of the peritonaeum 
should be avoided as much as possible. 

3. Corrosive eolutions, as, for instance* of carbolic acid or mercoric bi- 
cbloritle, are not to ho used on tlie peritonaMim, As soon as the peritoneal 
cavity i« opened, Thiersch'ij solution should bo employed for rinsing the 

* " Charity Anniilen," xi. Jahrg., page 770. 





SPECIAL APPUCATION OF THE ASEPTIC METHOD. 



11 



gurgcon's Imtids. immersing the instniraeiita, sponges, towels, and, if 
necessary, for irrigation. 

4. A careful toilet, that Is, ri'moviil of ull exudiHl ^>rum or hlood, shoiihi 
precede closure of the abdominiil wound. 

5. Where large denuded surfaces luive to he left Ix^hind, and a good deal 
of oozing is to be expected, drainage must be employed. 

XoTK. — If the draln-tubv i» hroupht out from a liciwndent pari *if tin- ]^c^it^>n•'al cavilr, 
&a, for instance, Uirough Dodgla.'^'i* enl-ik'-sac, th« seeriitidn.'* will t-srajie spojitaneously li_v the 
opcrntion of thf law of pravitv. Whi^nmer the drainage-tuhe is broupht out ubore the ifympliyj^is, 
the acTuiTi ctjllectin;; nt the botlom of the cavity must be reniovi-d eithtr ii}' htniriy mopping nut 
with a stick, amiwJ with a pad of ulisnrhent liorated cijlton, or by eshauntiiig with a long-nuzzled 
syringe, introduced to the bottom through tbc huUow of the drain-tubi'. 

(L Should it become evident that the tnoiie of drainjige employed is in- 
Bnfficient to remove a ce>i»ious gathering of secretions, febrile syniptoma, 
tenderness, and tympanites developing on the first few dtiy^ after the opera- 
tion, a saline purge nuiy be employed in preference to the aecuatomed 
opium treatment (Tait). Its object would be to favor rapid absor|>tiou of 
the effused serum in an analogous manner seen with the administration of 
cathartics for the rapid removal of hydropic accumulations from the abdomi- 
nal cavity. 

7. If purulent peritonitis be undoubtedly established, reopening and 
irrigation *)f the ]X'ritoneal cavity with a hot 1 : 5,01K( solution of corrosive 
sublimate may be taken into consideration, provided that the patient's gen- 
eral condition should warrant such a procedure. 

2. Hfrniotontf/. 

In the main, the success of herniotomy depends upon the condition 
of the strangulated gut at the time of the operation. With aseptic pre- 
cautions, as long as the gut is not necrosed, herniotomy is fraught with 
very little danger. From the nnHiient that intestinal gangrene has set in, 
the preservation of ase])ticisni becomes exti-emely difficult. Contact alone 
with the decayed gut is infections. Laceratietn of the friable intestinal wall 
ia very likely to oc«'ur on employment of the least aniuunt of force, and 
usually leads to further contamination by escaping intestinal contents. 

In addition to this, the general condition of patients with intestinal 
necrosis is mostly wretched. Systemic intoxication, and tlie teuLleney to 
heart- failure induced by constant vomiting, vastly increase the perils of 
anipsthesia and hemorrhage, and the prognosis is thereby rendered all the 
more doubtful. 

The free exhibition of anodynes, especially in the shape of hypodermic 
injections in the presence of strangulated hernia, is very often followed by 
fatal consequences. The most acute synijitoms are blurred or blotted out 
entirely, and a false xense uf si'tmritu /.s npf to lull thf apprehejixioni*, and 
jl to betray patient and ]ihysiciau into undue procrastination. 

I Out of the thirty-one eases uf herniotomy i>erformed by the author both 

L for strangulation and for the radical cure of the complaint, eight died. 



118 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



Six oat of this number exhibited uecrosis of the gut, and all of the** died. 
Of the remaining two, one, whose gut was soiiTsd, died of acuto nephritis, 
presumably due to tlie use of ether as an anffisthetic ; the other one of 
general tuberculosis of the peritonaeum. 

Cask I. — A. Sohlesinger, aged seventy-three, Btrun;jiiliited left, inguinal hernia of 
twenty-four hours' stumlitig'. April 12, 1S85. — At Moant Sinai IIo.s|)ital>tbe bernial »«c 
was exposed uinler ether iiusustliesiti. A knuckle of gut could be felt within the sac, eon- 
tiiining a cubic, friable body tbat was easily cruHiiet], wJu'reupon the gut wns replaced 
in tht' abdominid cavity without any diflitnilty. The wound was Hutured and drtsssed. 
Diirution of the operation, twenty minutes. The wouud healed by |>riinary adLe^iiio, 
but uraeuiic ayinjjtoms., with suppreseiou of tbe renal secretion and vomiting. develo{»cd 
on tbe second day. I'he scanty urine was found cuntuiiiing blood and a large amuant 
of albumen. April 22d. — Tlie patient died in uraomic coma. 

Inquir}' elicited the fact that, procoding the day of the patient's illnea^^ 
he had largely consumed of a dish of potato soup. Tbe toothless old nifl^| 
had bolted some of the potafai, a piece of which having made its way into 
the hernia eau.sed strangulation. 

The other fatal case, not due to necrosis of the gut, was as follows : 

Oass II. — Mrs. nenrietta 60I2, honaewife, aged sixty, an ill-nourialicd, etniiciated 
person, who said tliat she had been fiiiffering from beUy-iiche and conatipation for two 
months, and that !<]ie Las had nievoro and continuous fever that rau!*ed her present 
emaciation. She also noted that sht^ bad lost most of lier hair. Forty-eight hours pre- 
vious to her admission, irretlucible feiitoral bei'nia of tlie right side was diagnosticated 
by a medical man. Vomiting, no fever, and great tendemesa over the abdomen weiv 
found, and it waa deemed projier to explore the hernia. Accordingly the operation 
wftH done, Muy 7, 1887, at the (leriiian lluspitid. .Alter incision of the sac, this wr* 
fouiul to I'ontain a portion of a<Hjerent. onj en tuiii, together wiih a very uineti congested 
knuckle of small gut. The strangulating band vins ineit^ed, tbe gut withdrawn, aod, 
being in a viable *-ondittou, waa replaced. The proiniding portion of onientani «•• 
liberated, tied, and eut off. In replacing it, extensive adheitions of the !$tunip to tho 
p.iriettd peritonfeum could he felt inside of the alKloiiiioal cavity. The sac was excised 
and tbe wound closed and dressed in the usual miLUUcr. Mtnj 12t}i. — Change of dreasii 
The wound was found uniled, but the general condition of the patient had remjui 
the same aa before the o[ieration. (rnidually conHiderahle iiJirites developed, tbe 
patient continuing to complain of much colicky pain ; the vomiting and lack of appetita, 
together with rehellioiiH constipation, »ceiiied to jurttify tbe assumption of a general 
morbid condition of the peritouajum, namely, either tiibcrculof<is or a neoplasm. Maf 
iGtk, — Tbe peritoneal cavity was reopened at tbe site of tbe cicatrix left by hemiotoniT, 
and extensive tubercular degeneration of (he entire peritoofeum, with dense infiltratioa 
of the otiientum and almost univer^jd agglutination of tbe intestineR, were foand. The 
parietal ]K.Titona?utn and tbe gut w ere literally covered with a mass of miliary white 
nodules. With a view to relieving the obstruction caused by the multiple adherenee 
of the bowels, a protruding part of the thick got was attached to the wound bj a 
nnmber of catgut stitches, and the external incision was packed with iodofonnized 
gauze. Mfty2Sth. — Tlie bowel was found well united with the parietal |>eritona>nni, and 
an artilicial anus was estnblished hy incising the gut and sewing tlio mncoiis ni«?in- 
brane to \\w sikin. Sufiicifnt stools followed, but the patient died, Miu-ch Slsl, of 
exhaustion. 



laed 



i 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



119 



iteresting on account ol the coincidence of tubeiculosia 
of the peritonaeum with istrangulatiou of a femoral heraia of old standing. 
Of course, successful horniotomy could not avert ini]>endi]ig death. 

Twenty-three (inclu(Jin<; those subjected tq the mdieal ojKsration) of the 
anthor^s total of thirty-one heriiiotonnzod patients recovpred. 

a. Herniotomy for Strangulation. — If gentle and not too jurolonged 
effort,s at reduction, first without tiieu with anaesthesia, do not succeed, 
herniotomy should be done forthwith. 
The mode of procednre is m^ follows : 

The patient's inguinal region is shaved and scrubbed off 
wilh soap and hot water, and is disinfected with niercuric 
loiion. Towels wrung out of corrosive-sublimate solution are 
arranged about the field of operation, and a free iuciaion is 
made over the hernial swelling down upon the nic. Tlte in- 

citiiiin xhtiuld fxtrnd 
wpU above the ingui- 
mil Of femoral ring, 
tt jnf s/iim hi free Ii/ ex- 
pow ike place where 
th r he rn ia em e rgt's 
from the. abthmimtl 
nmU. By doing this 
the surgeon will be 
enabled to divide the 
constrict ing band un- 
der the guidance of 
the eye, and without 
the necessity of in- 
tiug the probe-pointed knife into the inguinal or femoral canal, a cir- 
enmstance that may, even in the hands of a cautious and expert surgeon, 
lead to cutting or laceration of the intestine, especially if it bo very brittle, 
or necrosed, or adherent, 

tCASE HI. — Philip Truiiiann, ajred two years and three raonthei, waa presented to 
e author Dect'inbor 11, 1881, with a suft, tluctuatjng, sorotal awellififr of the left. i*i(li% 
which, however, could not he hy pri«?*?<iiro rtMhiied in size. Corigt'iiitiil hydrocole Wiis 
dia(;n«>»tirat«.*<I nevorthek'^Hia, as tlu- tiniior nhowod trunspiiruiiuy. Puurture with a 
hypodermic needle hrmitiht unt intt'stitm! contents. There were no sij^us ol" stranpala- 
tioD, therefore cold applieationa were ordered, and the child's mother was told to return 
the next day. By December 12th till symptoms of Btrangulation, with nuher high 
fever and iutlamtuation of the swelling', had developed. Ilorniotoitiy was doiiL' ;it the 
German Dispensary. Iti openin>^ the sni\ tho put was inndvertcnlly incised. It was 
found that local peritonitis. <»f (he sue, with extensive fresli adhosioiisi, presunuihly <]utf 
to esi^-npe of feeul matter through the piinctiire-liole, had taken place. Tho gut was 
detached everywliero hy the finp;er-tip9, the parts were well disinfected by free irriga- 
tion with a two-por-cent solution of carbfdifi add, and the stit in the intestine was 
cIo*e<i with a Lemliert suture uf catjtrat. The tjtrnngulaliiig hand wu!> then cut, iind, 
the intetitine being replaced, tho wnntid was aevved up, ilrained, and dressed. Un- 




(••r uns otlior 




A 




RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



January 12, 188i^. —Thv itutk-ut was 



dW 




Flo. lt'4.— IJi.rtii<jtomy. <*ut*iM!ou.-i itidsion. 



interru[jtetJ recovery fuliowed. 
cured. 

Tlie .1HC is carefully ofwried betwei'u two furcpps, and, if possibU 
place where there is iiu iulliosioii to the gut. AtkT fret' ilivisiou be 

two ihnnib- U 
u eiircful insp 
of \ti> content 
orotntMilum, at 
should be modi 
will be very 
fueilitated hj I 
up the edges 
iticiston mad< 
the sac with a 
her of urtcry fi 
which will aq 
littndles to ual 
to a funnel, 
can be easily i 
over. (Fig. 1 
Generaliv the gut will appear deeply congested, purpli^ih, or br< 
red. Aa long as it is turgid, and is seen to contract on pinching, ,' 
bo lu'^suined to be viable. 

Hut it still remains to be a»!eertjiined whether the |>ointfl of strangt 
Ih? alive or not. To 
do this thf xtrnnifii- 
latlii'j bnntl or kinds 
HI It lit be fir. si cut (n ft 
.siilfivivni extent. 

Attempts to with- 
draw the put before 
tlie strangulation is 
ciympletely removed 
may lead to very seri- 
ous cousetjuenccs, es- 
jK^ciully where necro- 
sis of the strangulated 
jiortion of the inles- 
tine is jiresent. 

CaheTV.— ^T.Svtirsink, 
BftlooD-keeper, ajfed fifty- 
nine. I-oft iu^iunul Htran- 

gulated lifrnia nf five days' standing. Herniotomy, Mftreh 8, 1880, at the lierini 
pjtal. Tlio Stic contained a. larjxe ina.ss of adhcrinK omentum, and a knuekie of 
funirfstt'd small Intei-tine. It was thmifrht thitt ilio stranpnintin;; bwad. corre9| 
to the inteniul flbdotninul ring, had been sutficiently iaei»icd, and a vurj ^eQ 




Fta. 



lori.— Hiirtiiototnv. The o^ieiu-il luTiiiul »ac le hell 
for in»i*wti"ri t>y u tnmilHT <>t' Hrtery ror«:ji». 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 121 

ttiuracce»!!ifal utt«mpt was ituide to withdraw the ^nt. The ti[> of ihe index was rein- 
sertej ms a pajde, and, the ron!;trii"ti<in b«.'inp cniiijiU'tfly divided, the (jnt was easily 
withdrawn. At the same iiitiment a t'onBidorrible quantity of fecal irmtter was seoii to 
««o«pe. It was found that uei-ro<ii(4 of the neck of the elrangulated knuckle of gut had 
taken plare, and that it hnd been t4)rn or vM darinj; the proeedinp eftbrt;* at lihoratton. 
The intestine was still further extrai-ted, and was atta('he<l to the skin by a few silk 
sutures. After careful disinfection, the neck of the sac wa» loosely packed with stri[i8 
of iodofonuiztil gauze, an<I the wound wu^ inclosed iu ii inoist dredsir)g. The collaiakxl 
patient died two horxr^ after the operation. 

In cases hkc tlic procodin^r one, tlic classical practice of iiiva<::inatin^ the 
tip of the index into the inguinal canal or femurul ring, for the purpose 
of cutting the etratiiiulating bund, is dangerous, a^t it may load to injury of 
the brittle gut. 

The author liiis found the gradual divisi(»n of all tissues from without 
inward much safer, although it must be admitted that the division of tlu' 
fibrous tif^ues located above thr plaee of rftrangulatiou is extensive, and often 
practically converts herniotomy into laparotomy. 

With a few exceptions, the author has always employed open division 
of the strangulating bands of tipriue. and never had reason to regi-et it. In 
some of the complicated cases he was tliereliy enabled t<» at once gain a very 
clear insight into the relations of the ht-niia, and iu a great measure the 
nltimate success of the ojieration was attributed to that advantage. 

CiftE V. — Fred. Bormaun. laborer. .«ured thirty-three, had been treated at the Ger- 
man Hospital without success during several days ff»r internal intestinal obstrtictioD 
ruarked by the usual symptoms. On closer inspection, slight »xlenia of and somewhat 
indi^tiurt resistance at the right inguinal region wa.s noted. Janunrif 17. ISftj^, — An 
incision was made exposing the external inguinal ring, which was seen to be normal. 
The incision was further extended, and, when most of the tihrous layers earrounding 
the inguinal canal had been divideil, a small but well-«lefine<l tumor could be seen and 
frit occupying the inner as|>ect of tlie alwlominftl wall near the internal orilice of the 
inguinal canal. The atKlominal wall was completely divided, and then a small hernia, 
located between the parietal perilonieum and the alKltimin.'d wall, was exp<ised. The 
«iH" being incist'd. a knuckle of small gut wa** found containo<l within iL The place of 
Mnuigulation was at the neck of the sac. This was completely slit open, the gut was 
reduced, and, the netk of the sac being clo9c<l by a purse-string ligature, it was cut 
away entirely. The incision in the abdominal wall was cloi>ed by three tiers of catgut 
tntures. Primary union followed. February I6fh. — Patient was discharge<l cured, 

Va»k VI. — Mr. M. S.. aged thirty-six. Left inguinal hernia, that had been repeat- 
wily incarcerated, but was rwluced each time. April ft, IS8.0. it came down again, 
and. atlcr prolonged and very energetic efTort^*, the y>bysician in charge succee«led in 
rvfibcing it, bat the symptoms of strangulation, notably vomiting and absence of alvioe 
e»acaations, persisted. April lith. — Herniotomy at Mount Sinai llimpital. No ex- 
ternal tumor could be seen, but on palpation a dense resist.-int swelling could l»e felt 
in the inguinal region within the aMominal wall. The reirion of the external alxlom- 
inal ring wiw freely exposed by an ample incision, and the abdominal wall was divide<l 
above Ponpnrt's ligiiment. The hernia which had been reduce<l in mjvss was then 
reached, and was pushed out through the inguinal canal. The remaining portion of 
the tnterteoiDK alHlominal wall was divide*!, together with the pbce of strangulation. 



122 



RULES OF ASEPTIC AND ANTISEPTIC SUKGERY. 



and, the aac being tied and cut awaf, the abdominal wound was closed with tltraa 
tiers of stronj^r cutgiit sutures. The wound healed kindly. May 15th. — Patient wts 
discharged cured. 

It miiy be said, then, that open division offers gi-eat advantages, es|ie- 
eiully wilh regard to thf avoidant'C of injury Uv nocrosed or very brittle gut, 
and that, its only dfuvvbac-k — tlie increased size of the iiieision — Is vastly 
overbftlaueecl by the security gained therefnnn* If tlic gut be found ne- 
crosed, it can tje nafely withdrawn from tlie ample aperture, and esUiblish- 
ment of an artilk-ial anus ean take place after t^eeurely packing the neck oi 
the protmdiun; knuckle of intestine with a sort of enihankuient of iodo 
formixed orauze. This jiacking of gauze serves as a diaphragm against infec- 
tion of the peritoneal euvity. 

Out of nineteen cases of herniotomy done for straugnlutiou, undonbted 
gangrene of the gut was present at the time of operation in four. In 
two of these tlie necrosed part of the gnt was injured within the inguinal 
canal by the unavoidable muniitulations in libenitiug the ititestine. In 
those cases where external or ttpen section was used, the integrity of the 
much-decayed gut was preserved. In tlieae latter c:i.ses the gangrene ex- 
tended to the free part of the gut, and was taken notice of before dissolving 
the strangulation. Tji the former cases, however, in which the gut wa« 
inadvertently injnredj gangrene was limited to the exact locality of the con- 
striction, and was diagnosticated otdy after the mishap. 

The practical lesson to be drawn from this experience is that o[>en incis- 
ion of the inguinal eanal should he done whenever very acute stnmgulation 
lias existed for moi-e Ihan four or six hours. 

All the patients nj)on whom necrosed gut was found died cither of col- 
lapse, shortly after the com})letiou of the ot>eration, or of i)eritoniti8 dae 
to jtifection extending fntm the place of strangulation. 

On one of t Jiem reelection of the necrosed part of the gut was practiced, 
with subsequent suture. The patient died of peritonitis. 

Cask VI 1. — Catliaritie Ilile, housewife, ngcd sixty-one, a very fat woman, liavln; 
a Jjirpu ineurct-rated ninhificul AfrnjVi, mus uperntisl September 24, IKHl, ut lu»r room* 
in tJie [iresonce uf the family attendant, Dr. .Vroularius. Open flection of const ri< -tin tt 
bands, circninscrihed necroais of tlii* neck of tht» ]tratrudiug xini»s of transver^^e colon. 
Exst'ction of six inches of thick gut and of a triangular piwje of me^o-colon, and j«ub- 
sequent onterorrhapliy with fine eatfrut; closHro of ahdoniiunl cavity. Peritonitis 
developetl during tlai following' ni^^ht, »nd, Seplemher 25th, patient died with eaorinuos 
tympanites. 

Immediate exscction of the necrosed gut ha^ tittle to commend it. Ttie 
dangers of infection of the peritoTiieum arc almost insurmountable, the eora- 
prebensivc preparations required for enterorrhaphy are usually not made, 
and, the work being extemporized, generally lacks exactitude. In addition 
to this, the general condition of the patients is commonly so bad, that undue 
prolongation of ana'sthesjn itself would be very dangerous. Therefore, in 
thf'KP cases, the estnbiUhmcni of an artijicial anus is the only proper thing 
lit do. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 123 



oniio: physicians the decision of tlie questiun. whether the gut 
be Eilivc or necrosed, niuy offer n goad ileid of diiticiilty. The responsi- 
bility is great, nnd iiucertuiuty about ii poiut of such importiiuce extremely 
perplexing. Where necrosis is fairly established, the shriveled, parchment- 
like appearanee, the yellowish-gray co^or, the absence of reflex motion on 
pinchin;jj, and the great fragility will at once characterize the eonditioii. 
But where necrosis is just developing — that is, where thrombosis of the 
terminal vessels with bloody infarction has. gone su far as to surely com- 
promise the integrity of the gut, but the sign.s of necrosis are as yet unrec- 
ognizable — decision may be very ditticult indeed. 

The causes producing intestinal necrosis are not identical in dififerent 
eases. Local, well-circnmscribed necrosis, limited to the extent of the 
strangulating ring, and very often fonnd in femoral hernia, is due to local 
ana?raia produced by the pressure of the constricting band. 

In other cases the local pressure exerted by the constricting band U}>on 
the neck of the hernial contents may be insufficient to destroy the vitality 
of the intestine in actual contact with the conslrictiug tissues. But press- 
ure that would l>c hardly sufficient to cut off arterial supply, will often com- 
press to such an extent the veins leading (ttPffif horn the strangulated gut 
as to completely arrest circulation. Venous engorgement and gangrene 
of the convex jiortion of the intestinal knuckle are then inevitable. 

The decisi<ni whether a portiitn of intestine, subjected to prolonged acute 
ansemia by local jiressurc, is viable or not, is comjiaratively easy. In many 
of these cases, absent circulation is often restored to the bloodless parts under 
the eyes of the surgeon. As soon as the constriction is relieved, minute red 
Btreaks are scon to spring up across the formerly jiale, bloodless area ; ihe}' 
increase in number, and finally the parts in question assume a rosy hue and 
a normal appearanee. 

Sometimes, however, recovery of circulation is tardy. In these eases, 
after amply dividing the strangulating bund, a catgut tliread should be 
])ai;&ed through the mesentery of the questionable loop of intestine, which 
then should bv temporarily replaced in the abdominal cavity. The time 
required for restoring the cirenhition of tbe gut is usefully employed in 
attending to such other procedures a^ may be indicated under the circum- 
stances. Dissection and removal of adherent omentum, or the dissection 
of the JieruiBJ sac, will thus occujiy some time, by the end of wliich the h)op 
of intestine can be withdrawn from the belly for examination. If the con- 
ditions be found satisfactory, the tliread should be removed, and the oj>era- 
tion finished in the usual way. 

Cask VIII. — Thero.sft Wa^rcngliist, cigAnnaker, npott thirty -nine, contracted, April 
11, 1887, stran^rulntion of a ftitiornl liiTiiia i»f ohl standing, sitiiatwd on the left 
side. April loth. — Adniitteil to German ITusjiitul with inn-ssaiit vomiting, inihiiTCil 
taainly by tbe admitiistriition of cilonicl, Iinuteiliiite licmiotomy. A coasiderablo 
portion of adherent omentum presented, and wns tie*] nff in several |if>rtioiis and 
removed. After itiia a very snuill kniiofclM of gut became visible, which showed an 
uueinio area corretipoading to tlje lucnlity of constriction. Recovery being tardy, a 




vn 



RULES OF ASEPTIC AND ANTISEPTIC SUKGERY. 




thread of cutgut wo!* pus!«e<] ihrough the mesentery, and the knuckle was replaced ia 
the ubdonien through the well-divided feniural riit^. In the mean thne the sue was 
excised. After ll>e euaiidotion of this »tep, re<juinn^' jiboiit fifteen minutes, the jrat 
wasii ro-extnirted for tiXatiiinaliim, and nireulatiim was fuund fully re-e«taldishiHil. The 
gilt heinjj: replaced, the nerk «»f the siac wjis rli>seil with a imirse-string suture, and wa^ 
pnsliw] welt a{> in tlic feiuoral ring. Drainage and suture of tlie external wound. 
April 15tft. — The drainage-tul/e was removed. April 20th. — Patient was discharged 
cured. 

Where impendiug gauajrcno from venous CQororgemeiit is to be feared, 
tho decision is pfenerally more difficult thiin in tlic prcct'dinor class of c 
Where ittnnediatf' sulviiifr of the momentous question is imi>o!5sihle. t 
benelit of the tl*ndjt shouhl always l>clong to the asj^umption that necrosis 
is to Ih? ex|kectcd. In the^e eases the neck of tlie hernial sue should Ijc well 
divided to secure the l>est eircMhition possihle, and the loop of gut should 
be so attached to the i^kin by u couple of sutures pa.^si>d through the mesen- 
tery as to leave the fjuestionahlo spots exposed to view. Thorough disin- 
fection by wiping with sponges wrung out of Thiersch's solution, a light 
jwiekiug of iodoformized gauze around the neck of the knuckle, and a mtiist 
a.<cpfk' iiressiixj (the gut being covered by a protective strip of rubber tissue) 
should be applied. If the gut decay, this will take place outside of the 
peritoneal cavity. Should It recover, the fact will be manifest within one 
or two hours after the ojieration. The gut i*houkl be then well dij*irifecletl, 
liberated by gentle manipulation from its newly-assumed position, and 
replaced in the abdominal cavity. 

Case IX illustriiles the cunseiiuences of the replacement of the gut of 
doubtful vitality. It was the author's first herniotomy. 

Cask IX. — .John F'hilif) lores, waiter, aged fifTty-three. Verv acute strangnlation 
of twelve hours' standing of .mh old, right ingiifnJtl hernia. October 37, HfVH. — Herni- 
otomy in presence of Dr. L. Hop]*, the fuitiilj pliy»ician. Two knuckles of deeply- 
injected small intestine, aggregutiug to the length of ten inches, and a nuisis of dnrlc- 
blne omentuiii were found in the »ac. But» aa tlie gut seemed to ltt> turgid and viable., 
it was replaced. The onientmn was pulled out, tied and cut otT, ami the stuni|i \vm 
re]dttL"ed. Suptk MUifftonis set in itiiiuediiiiely after the operation, with high fever 
and very great debility, (khiher .i'Jth. — L'unjistakable signs of perit;>nitis, notably 
enornioiis nieteorisui, appejired. The restless putietit disarranged the dressings during 
his tossing in bed, and, while vomiting, the adhesions of the muod gave way, and 
a large loop of intestiue prolaj)sed. Necr<wis of a portion of the [irolapsed gut waa 
evident. As uiitcli of it as was normal wnti replaced, the decuyod part <if the 
gut was it'cisi'd, and lixed near the external wound, Tlie patient died shortly 
afterward. 

It must be added that, according to then prevailing notions (1878). the 
sac and its content** were washed with a strong solution of carbolic acid 
(5 : HH)) before the gut was replaced. Superticial erosiou of the intestinal 
peritona'UTu nuiy have bad its share in precipitating both gangrene and peri- 
tonitis. 

Xecrosis of Ihe vcrmij'onn appendix was observed by the author once 
with futid terinitiatioo. 



J 



SPECIAL APPLICATION OF THE ASEPTIC JIETHOD. 125 




Oabe X. — Ik'tirietta BmiliiniJ, aured fort.v-seven. Ri;:ht fcmonil hernia «if forty- 
eight hours' shiiKliiijr. April IS. ISSJf. — lleruii>t**itiy at l\w Gerianu Hospital. Veriiii- 
forni appendix was found attached by its apwx to the side of the stie; a knucklt; of 
small intestine was einhraeed in the loop formed Irj the vermiform appendix, and then 
doubly incarcerated. MuDi[niiation was very difficult, on account of the narrow sjtace 
and the complicated .itate ijf thuig^. The jfut was Hli|j;htly torn, hut no intestinal eon- . 
tent.H esc-aptjil. Two Li-nihert's sutures heiiit; ij|»])lted, the straujjiihitinn jtt the neck of 
the sac was relieved an*l the put was lil»eruted. The iniddle purl of the veniiiform 
appendix was found necrosed, and, a ligature hein^r applied ahove this* part, the appen- 
dix was cut away. The ^ut wu>* returned. The patient {jot on very well until April 
25l!i, when perforative peritonitis developed. April i^th. — Patient died. No autopay 
could he secured. 

However ilesirable thoruiighiiess aucl: deliljenitioii may be in lierniotoniy, 
niidue prolimgation of aiiffisthesiu is an evil fruUL,^ht with especial danger iu 
cases of long-con tin lu^d .strangulation, on areount of the cai*dtac debility 
present. When the patient's vitality has been much lowered liy continuous 
vomiting, lose of sleep, and septic fever, oven a brief anaesthesia nniy l>e 
sulHcieiit to precipitate fatal collapse. Habitnal user.H of alctthol and obese 
individuals are very poor Bubjects to endure auresthesia in the presence of 
necrosis of the gut. 

Cask X(. — Alhert P., drayman, aged thirty-five, nioderate hul steady conHumer of 
r and whisky. Incarcerated right inguinal hernia of seventy-Jive honrs' duration. 
The ewelliug was inLstakeu for acute orchrtia, hernia being tliou^ht of by the family 
»tten*lant only after fecal vomilinp; had set in. March Iff, /i'*S7.— Herniotomy at the 
GeriJiuu IIo«|iital. Extensive gantfreno of the small gut was found. Ether jui.Tstheaia 
wan very bad, the patient strugglinj; aU the wliilc during the operation. If ether was 
crowded, respiraticin hecanie irregular, the face pallid, and syncope threatening. Arli- 
ficinl anU9 wa» eatahlished, and the case was tinir^hed with all jjoHsihle expedition, 
annatheeia lasting altogether for thirty minutes. Deep colhi]ti*e following, the patient 
did not rally in ,'<pite of co[hou!* hypodermic Ktitnulation, and he died two h<iurs after 
the completion of herniotomy. 

It is ]>lausible to assume that in similar case.s henn'otomy |»erformed 
with the aid of local anaesthesia would olfer better chances of success tlian 
If it be done in general ether or ehloroform narcosis. 

The last one of the eight fatal cj»«es died of acute septiea?mia induced by 
diphtheritic enteritis of the strangulated knuckle of gut. 

Cask XII. — Charles Etzler, baker, aged tliirty-five. Very acute strangulation, of 
fifty hours' standing, ofun old right inguinal hernia. The patient had had no inedieal 
care until a few hourn before his adiuistiitm to the (iermun Hospital, when Dr. U. Kudlich 
wns called in. lie was requested to stop the violent fecal vomiting caused by a very 
large dose of R«»chelle Halts takr-n in (he moniingof -lanuary :]], 1884. Herniotomy on 
the evening of the same day. The large scrotal hernia contained a good-sized portion 
of adherent otnentiim and a massive conglomerate of several knuckles of small gut, 
bonnd together by firm cicatricial adlieBionin of old date. Free external inciision of the 
abdominal wall until the neck of the hernial mc was completely divided. The gut 
hniked toleraldy well pvescrved and wiw replaced ; the nnientuni was freed by dissec- 
tion, and, being tied off in .sevenU jjortions, was cut oil'. The stiunp being replaced, the 
SMC was tied ami cut off; then the ubdomiuul wall wa» Hutnred by several ti«rs of 
18 



126 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



strong cutgut in physiological order. Ttic outer wouud was tlraiaed, sew&i, and 
dressed a« luiial. February 1st iia(*se<l off witliom any outward symptom, the vom- 
iting Lanng" ceftstjd iiiunt'dlatc-ly aftt-r tlie openition. February Sd. — A severe chill 
with much hclly-aclie set in, but no nieteorism appeared until February 4th, The 
thermometer indicating all the while 1(>5^ F. The luitient's condition grew steadily 
worse, with deep coma, jaundice, and petechial patches on the legs. February 5th. — 
The sutures i^ftive way during u vomiting s[»ell, and a loop of healthy-looking gut pro- 
lapsed. It was not rejjlaced. Shurtly after the [tatieiit died. Po>t-mortein t-xaniina- 
tion revealed n .slaty discoloratirm of tlie mentioned buneh of coherent gut, which, 
being incised, ap[teiired to be coveretl on its timcous* side with a large nniiiber of round 
and fontluent whitish-^iruy ailheretit pateJies of nveuibrane, which involved the intes- 
tinal wall to varying depths, some of them being visible through the peritoneal 
covering. No peritonitis. 

The author is at a loss for tin explanation of this rare form of diph- 
theritic affection of the bowoL 

Seven of the KucecssfuJ ojiorutions for strangulation were done on in- 
gniual (one preperitoneal, Case V), four on femoral, hernia?. 



Cure<l ,...,., 11 potienta 

Died 8 



Total. 



19 



I 



In dividing the stranguhitiitg band in femoral Iiernia, the inci.siou should 

be directed inward toward < Jim Ix' mat's ligament. But, where the space is 

very narrow or tlio condition of the gnt doubtful, free incision of the 

fastna luta parallel to the large vessels, and preparatory exposure of the 

femoral canal, would be nntre proper. 

To incise the strangulating band.s sufficiently to enable the surgeon to 

withdraw additional portions of gut for examination does not insure faci 

reposition by any niean.s ; and forcible crowding back of the congested au 

vulnerable intestine through an insufficiently wide orifice may lead to i 

rn|rture. Therefore, the dilatation must be very ample to permit easy reposi 

tion without the use of undue force. 

As long as the sac is not closed, and communication is open with the 

peritoneal cavity, irrigation of the wound nm.st sto[i, otherwise large ]»or- 

tious of the lotion may find their way intcf the abdomen. The use of strong 

solutions of carbolic acid or mercuric bichloride on the prolapsed gut is 

not advii.sable and i.< uuuecc'.s.sary. As soon as the gut is replaced, the sac 

should be wiped clean with a disinfected sfiongc, 

and another small sponge, fastened to a thread of 

catgut, should be pui?hed into the inguinal canal 

to serve as a barrier to the influx of blood into 

the |HMntoncal cavity. If the piitient is seen to 

l>car ana'sthesia well, inguinal herniotomy can be 

supplemented by the addition of Czerny's suture 

of tlie inguinal ring, as dc'^CTiln-d under the head- 

Fio. IOC— r*unie-«tr)nk' cut- ing of " Radical Oi>erati(Hi of llerjua,"' 
ure, emploved I'nr rKjonnUnir oi i i i n i . . 

the nock of till- III niiftl istio should, liowever, collapse be present or immi- 



to 





SPECLVL APPLICATION OF TPTE ASEPTIC ilETHOD. 



121 



A.Vl 



E^s: 



nent, and prolongation of aiui^s- 
tbesia iuadvisabic, a throud of 
strong cut^t is passed througL 
the neck of the sac (see cut) as 
hijrii lip US (jossihle. assistants 
holdin^i well apart tlifarLorv for 
ceps by which tlie ed <:(?.< of tJic 
cut through the t^ac are secured. 
Tliis suture rescmliles a purse- 
string in its working (Fig. 10'5). 
It is tightened and knotted, and 
will securely occlude the perito- 
neal cavity* Tlieu the external 
wound is well iiTi^'uted with cor- 
rosive-sublimate hitiijji. a drain- Ll. i , it i , .Miui «.»;inii. 
age-tube is placed well n\i to the 

purse-string suture, and the edges of tlie skin are brought together with cat- 
gut stitches. The dry dressings are ajiplied so as to cover up the scrotum 

and both inguinal regions, a slit 
being left in the nii<ldlc for the 
penis, which should protrude from 
the bandages. The use of a " hip- 
rest" will faeilitalethe ujjjdication 
of the ollierwise difticult dressing. 
In private imictiee, a etmiuion 
liassoek or footstool, wrapped in 
a clean towel or 8lipi)ed into a 
clean ]nllow-case, will make a cap- 
ital hip-rest. 

In female patients the coni- 
presses are held down by a spiea baudagc. The dressings should tit snugly, 
especially about the edges, and should not be too scanty. 

Six or seven days after tho op- 
eration the dressings should br- 
changed, to j)oruiit withdrawal of 
the drainage-tube. Five or six 
days more will eonipleto the es- 
sential part of the cure. 

The patient's bowels should 
bo moved forty-eight hours aftr-r 
the operation by a large enema 
of soap-water. Should fever set 
in from peritoneal irritation, a 
Bjdine purge may he administered 
with good effect. 

As long w* the patient is in 



Fio. lo^. — \'iilkmiinTrs •'■ hip-re^t." 



Fia. ion. 




-SlauriiT ol' H|i|ilyintf droMiiii; for wounds 
ol' sctota-in^ulhui region, 



128 




RULES OP ASEPTIC AND ANTISEPTIC SURGERY. 



bed, nutrition should be t^imple and niodonite. No patient should be jk-i 
mi tied to go about iiis busiiiegs before a truss cau 
worn witlv comfort But there is no objwtion to b^K^ 
being up iind about the room wit — 
i\ well-Gttiug pad and gpica. 




Flu- 111", — llirni«>totity. J*iili(Mit on " h<|>-re>*t," with completed dnses'ing: LatcnU riew. 

Syjittpitiit of KureenKful ptfgc* hit li trio not iiccimnteJ for : 

Ca*e XIII, — Mra. V. Heiiibtirdt, aged fifty-four, left iiigtiinoJ iacarceratiMl htrmi-^ 
of three days' durjitiou. Ojjeration, November 15, 1882. Cured, Decvmlwr llth. 

1'ask XIV. — C'ha*. Ruiro»cI» • 
lt»ur tiiODths old, c-ut]|fenital iis — 
fvireemlwl bi-rnia. Uperntio*:*- 
m nfrnum iMjpciisary, Jana ^^ 
ary 26, 1»83. Cured, Febm— ' 
jiry 22d. 

Cask XV.— (*,. .Tolin. 8e^ 
liistury, ftaire 24. 

CAr«K XV I. — Fred. Uipp.me— - 
rliiitHc, Ji^rtnl sixty, ripht cxIkt — 
nali kigiiitiul liernia. 4)peratioi» 
at (irennaQ Hospital, April (^ 
1884, Ciiri'd, May 1st. 

Case XVI L— Mrs. EmmaT.. 
lined forty-seven, lefr femoraB 
ticriiia. Oporation, March 2r>» 
1887. Cnivd, .Vjiril Idtli. 

Case XVIII — \uni\ Brown* 
a;;tHl fifty, left ibniornl heroi*. 
Operation at MiMint Sinui IIo;^-' 
pitid in Sc|itt'raber, 1880. Di*— 
rlijirfred purt!<l, en«l of October. 

Case XIX. — Martin Thor-- 
tipcration, February 12, 1880. 




i'm. 111. — ComplctcO dri'*!>iriii i>r xcroto-i^iMiiiiul rtLnou. 
Anterior %'io\v. 



wartb, E-onpi^r, fti^ed Bixty, riglit iiijruinal bernin. 
Cured, March 51 b. 

k Radical Operation for Hernia.— In performing lierniotomy for stran- 
gulation on a patient who.se general condition is good, the additional 8te| 
for radical cure may be at once carried out to grcnt advantage. 

In other ea-ses of n on -strangulated hernia, wbc^re retention by truss of A 
very large scrotal hernia is impracticable on account of wide distention of 



I 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



129 



the inguinal cunal, (ir where adhes^ions of the ]u-olup8e<l gut ar omentum to 
the sac reiwh-r hm] not ion impossible and make uttompts at wt»;iring ji truss a 
torture to the patient, radical operation in (iro[>er and justified. Due ob- 
eervance of the rules of asejisis makes this operation very safe as far as the 
production of purulent jjeritonitis is concerned. 8till, some danorer of 
septic infection eun never be excluded with positive coriainty. Therefore, 
bloody radical operation should be discouraged for a hernia tliat cau be 
retained by a properly coustruetcd truss. 

The luithur ha*:, in tlie main, followed Czerny's directions iu jierforraing 
radical operation of hernia, the several steps of which are m follows : 

After due preparation by a laxative, prefenibly cjistor-oil, tfie patient's 
pubic region and t;crotuni, especially on the side tjf the rnjittire, are shaved 
and cleansed the day before the o|>eration, with brush, soap, and hot water, 
and are w-rapped up in a clean towel dijiped iu a three-])er-cent solution of 
carbolic iicid. This wet compress is again covered with a suitalile piece of 
oiled silk or rubber tissue, and fitstened un with a T-bandage, 

On the day of the operation the patient is placed on the table and anfes- 
thetiwi-d, a full and good aua'sthesia being especially desirable. After re- 
peated disinfection, the hernial sac is exjiused by a sutticiently long incision, 
in whicli all bleeding vessels are to be secured by ligature. The n[>pcr 
angle of the wound should be located well above the upper margin of the 
inguinal ring so as to p.-rmtt easy manipulation. 

The sac is incised, tmd its edges are taken up by a number of artery 
forceps, which l>eing held apart, an excellent view of the contents of the 
hernia ran Ih' had. Adhesions of the omentum to the sac will be found the 
most common cause of the irredneibility, the gut iK-ing rarely adherent. 
The author has observed only one case of old hernia in which adhesions of 
the gut were present (case Mau). The fitvorite place of onu^ntal adhesions 
is the anterior portion of the neck of the sac. 

As soon as the sac is open, the use of the irrigator has to be discon- 
tinued, to ]irevent entrance of large quantities of irrigating fluid into the 
|ieritoneaI cavity. The lotions used for rinsing hands, .^^ponges, and instru- 
ments ought to be very mild to jirevent even superficial corrosion of the 
peritoneum. The author hiis generally used Thiersch's boro-s;ilicylic 
iwiutioii. 

A suitable sjionge, fastened to a stout [lieee of silk or catgut, is juished 
well np into the inguinal canal to prevent the entrance of blood into the 
abdomen. Carc^ must be taken not to select a too brittle sponge, as it may 
happen that, on removing it. some portion of it may become detached and 
remuiti in the belly. 

The sac must be split ojien to within ti <|narter of an ineh of the external 
inguinal ring, and the adherent omentum must be detached from the sac 
by preparation. As suon as the distal attachments of the omentum are 
serercd, it is withdrawn a little farther from the inguinal canal, and, being 
doligjited in small portions with reliable catp:ut, it is cut away by the knife, 
or, preferably, the thermo-cautery. After this the sac is wiped out clean. 




130 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



J 



and, the sponge being withdrawn from Uir iiiguinul canal, the stump of the 
omentum is replaced in the abdominul cavity. 

In dissf^otiug u]) adherent gut, «rreat caution murit be observed noi u> in- 
jure it. Where the julliesioiis are very close and extensive, it would 'h 
bettor to excise the attached jwrtion of the sac with the gut, and replace 
tliem together in the pcritonannn. 

Case U — Iloriry Mftu, ehooinakcr, aK<?<3 sixty-two. Vim-v largi? scrotal hernia, con — 
taininj; a<llierent gut. The in^'uinal rinp was so cltlated thitt the lips of tliree (im 
could ea.sily be slipped witLiii ihe uUdoitiitiiil civity. February 23, 18S6, — Radical o; 
(snitiitn at the llerinttii Ilospitiil. Etlicr niiiestlK'siu produotU violent retching am 
cotigIiiu;x, so thnt tlie irre.'^istiblc escape of ^riit from the wonnd rendered operatioi 
impossiljle. Chloroforiii being udniini)«tere<l, quiet iinii».»<tlie8ia was uchievod. Tbe ad — ■ — 
bcront thick gut wns dtisscotcd away, tui^'elliur with the adhering porliuns of ibe sic, .^^n 
and WI18 retarncd to the abdominal cavity. The reEnnant of the aac was ecparateJ^ ^^^ , 
closed at Us neck with a purse-string auture, and was oat away. The wide gaj> of thc^ ^^ j 
in^uinjd rin^ was closed with eight >siitiirca of stout catgut, and the external wnnml -^^^ 
wii-s drained titid He wed up. Uninterrupted recovery. March 25th, — The patient vta 
dincharged ciin-d with instructicjns tn woitr a liffht tms8. In November, 1886, he pre- 
sented hirnsclf with a relaiise. His truss iiad been broken, and he neglected to have it 
repaired. In a tit of violent coughing the rupture reapjifiared. 

The contents of the sac being disposed of, excision of the sac is the next 
thing to be done. ' 

In most cases this can be readily accomplished by stripping np the sac =2^3 
from the surrounding tissues with the fingers, the sci-ssors being only occa- — ^ 
aionally needed to sever resi.sting bands, which generally contain vessels 
requiring ligature. In some instances, however, especially :u eases of con- 
genital hernia, the separation of tlic sac is not ea.sy. The ^ao j>roj>er is not 
well defined, and in some localities consists of nothing but tlie bare peri- 
touteum. Hence it is difliciilt to get it out uninjured and in one piece. 
Another dilficulty is presented by the close relation."* of the cord and its 
vessels to the sac. The greatest care must be taken to properly recognize 
them, as otherwise they may be accidentally damaged. 

Case II. — William bitzehaiter, baker, aged twenty-seven. Left mgninal irreducible 
liorrda. Ftbrunry 5^ ISM. — Radical operjitiinj at ihe Gernian Iluspilal. Liberatioa 
of adherent oiuentiiui, which was deligated and cut away. lu dissecting u\t tbe sac^ 
the rag dfjcrtm was cut across. A sliort piece of stout catgnt wa» introdnee<l into the 
patent ends of its htnien, and the duct was united by four fine catgnt «ntores pa8«e«l 
through its invtihicruni, Tbe sac being removed, tlie oxterual ring was closed by six 
stoat catgut sutures. The external wound was drained and sewed. Fehruary 
7th. — Purulent urcthnil discharge was iiuted ; no ("ever. Fthrnnry iTtth. — ChMige 
of dressings. Wound healed by adhesioji, left testicle somewhat swollen and pain- 
fal. Tube waa removed. Fehntarj/ 27th. — Urethral discharge diiHappeared, t««t$cle 
notably decreased in size. March loth. — Discharged cured, with sJightly enlarged 
testis. 

Congenital irreducihle hernia is comparatively fretpient. Four of tbe 
twelve eases operated on by the author belonged to this class. One was com- 
plicated with undeacended teatide. 



SPECIAL APPLICATION OF THE ASEPTIC JIETHOD. 131 

In two of these cases coitiration had to be performed aloug with the radi- 
cal operation. 

Case III. — Axipns't B., pfiintt-r. ngod twcnty-fmir Amjmt ^3^ 18SS. — Radical 
operation at tlif (Jerman llospitjil. The oinentniii wa-i foumi uilbereut to the Jclt te^ti- 
cle, antl contained near it-s adhesion to tliis urfiun a hard, (ii^jnivnted tuiimr of tlu- size 
o'' a wsdnut. Tbe sue and tlie tunica propria uf tbe testis vv^ru dotttMl with u liirue 
number of pigmented spots. Tlicrefore the ouieutuui, sue, sind teslicdo were all ro- 
jnovetl. CloHore of inguinal riiifr by ratfrnt sutures, Trt'utriient of external wound 
tts usual. Septemhtr 20th. — r)iHobBri,'i'd ciirwi. 

Case IV.— Gt-orge W., »!attif-riiisor, ayod tbirt>-six. Direct inguinal lifiniu of 
left side. contHiniiif^ the undesceudLMl testicle. Attj^unt 2J^, 1S85. — liiidiral tjpenitioTi at 
Mount Sinai IIoi*pit«L Tbo altacbed omentum was freed and removed, Tbe ntrophic 
testicle was also Tjtkt^n uway. Suture as usual, September Ifth. — Patient utratned at 
ftool, whereupon ibe ext^rnul wound reujiened, but subsequently tieuled by granu- 
lation. October 2d. — Patient was diaehar^ed cured. 

In a third east? of congenital hernia, in an infunt, oclfimptic attacks 
caused rc'|ioatt'd protrusion of the iutostiuc, that eaulcl not bo reduced with- 
out the employment of anaesthetics. 

Case V.— Carl Schliobter, eiglit imnitli* old, AprU fft, /S-W.— Prolafiee of the 
pit during a convulsive seizure, I>r. Mt'ltzcr, thu fauiily att*.iuiiuit, nduiiiiJstcred eliloro- 
forni, whereupon (be author reduced the trut with (?unie diffioulty. The accident bad 
oecnrred the fntirth time in spite id u truss. Radical operation was nt once performetl. 
Mnj/ 5tA, — Patient discbartrt-d cured, 

Case VI. — Franz F?iulhabi'r, lalmrer, age<l twenly-two. Left congenital omental 
hernia. .Mi/ 2S, 1SS5. — Radical operation at tbe IJerruan Hosplta!, Omcntuni adber- 
inp: to sae treated as usual, Sao was cut away bebjw from its reflexion u[ion tJie testi- 
cle, and above close beneath the purse-string suture. Treatment of inguinal ring and 
external w<»und u» usual, Uninterriipted cnre. S/'pftt/thtr Jut. — Patient was discharged 
t^iCared. 

" The closure of the aac is to be done b^^ the purge-string sntare, depicted 
l>y Fig. 10(}. Rather stont catgut mu?t be used for this, t<> withstflind the 
powerful tension required for elnsing the circular suture. The sac is cut 
away below the knot, uiit] any hleediiiE; vessels must he .sojwrately do- 
ligated. The stump \» pushed well up within the internal abdominal 
ring. 

fn applying Czermfn sniurt' of thr iugmtMl ring, the left index-linger 
is intruded as fur as poasible. its volar ns]iect being directed dawnward and 
inward to protect the cord, wtiich slioukl bo kept near the inferior and iuner 
angle of the slit of the ingtiinal aperture. A strongly curved needle, armed 
witii stout catgut, is passed first through one, then through the other pillar 
of the ring, and the pnds of the thread arc secured in a jiair of artery for- 
ceps, and reflect^^d upon the abdomen, where they are received by an assist- 
ant. This first suture .should be placed n-s high up the inguinnl ring as 
possible. In intervals of a third of an inch from four to seven stitches are 
applied in the matiner indicated ; then they are tied firmly by surgeons' 
knots in the reverse order. A small-sijted drainage-tube is placed in the 
wound, and the integument is united by liner cutgut sutures, the tube being 




133 RULES OP ASEPTIC AND AXTISEPTIC SURGERY. 

brought out through the lower an^le of the incision. An antiseptic 
dressing is next applied in the mayner shown by Figs. 108, 100, 110, 
and ill. 

The first change of dressings should be made on the tenth da}', when 
tlie tube is also removed. As soon as the woniid is coaipletely closed, the 
patient is permitted to get up with a spiea bandage or trus8. 

The patients should be directed to continue the use of a light tru^^s. as 
this U the only reliable security against recurrence. 

In one case a tihromatous node in the adherent omentum was the chief 
source of pain complained of by the patient. 

Case VII. — Jucoh Cliristiuanii, hiborer, uged thirty-nine. Auffuitt 15, ISSS.—'iintVi- 
cal operation at. the Gt'nuaii Muspitd. A luirLJ, irregular node was occupying the uiid- 
dl(? of the prolapst'tJ and adherent omuntmn. It was rtinoveil with the satne. Dis- 
charged cured, 8iiptomber lUth. The node was tibromatous in character. 

In another case a subserous fibro-lipoina was located outside of, and was 
closely connected with, the neck of the sac. 

Cask VIIT. — Carl Dillo, laborer, ngetl tliirty, SoUHeroiia fibro-lipnina and left 
jitllierent oinentnl hernia. Mttrrh 1^\ 1SS7, — Radical operation at the (.Jerni.in Hos- 
pital, lienioval of omentum and sac, together with iteopliism. t^atares as usual. Aj/iil 
itth. — Distchfirged cured. 

The remaining four cases presented nothing unusual, and all re-covered 
without mishap : 

Case IX. — Ohnrles Niemann, locksmith, aged thirty, .\dherent left omental hernia. 
February 19, 1887. — Kudical operation at the tieruian Ho.Hpil.'iL .Utirrft IJth. — I)i- 
charRfd I'tired. 

Cask X. — Martin Ilussmaan, baker, aged twenty-five. Adherent right onientnl 
hernia. March 3, 1S87, — Radical o]ieratioQ at the German Huspitul. April 7th. — 
DtsMiharjred cured. 

Cahe XI. — lletiry Mehle, barber, aged twenty-five. Adherent riuht omental herniji. 
Jnnimry H, 7^AV;.— Radical operation at the German Tlospital. Februart/ 12(h. — Dis- 
I'lmrged cured. 

Cask XIL — Mr. M. D., inerchantj a^ed thirty-nine. Very tnassivc, growing, adher- 
ent omental hernia of tlie ri>?lit -"ide. Mity 20, 1887. — Railical npyratiou at Mntint Sinai 
lliisjtiutl. Jianf 16th. — Patient discharged eured. 

It has been urged, notably by Weir and Abbe, of New York, that, after 
radical operation, healing of the external wound by granulation is preferable 
to primary union, cm account of the larger nias.s of cicatricial matter result- 
itjg from the gmnulating pntces.^;. To the author this advatitage seeni.'^ «»f 
doubtful, certainly of only pas!?ing. value, as the ma.ssive cicatrix, first bard 
and resi.»iting, must in the course of tinn? l>ecome atrophied, soft, and yield- 
ing, and will not be able to withstand for a long time the constant impa<'t 
of the intra-abdominal pressure. The analogy of this fact with the ex]>eri- 
enccs gathered about the wounds resulting from laparotomy can not be gain- 
said. These regidarly terminate in ventral hernia when tiie healing of tlie 
abdominal incision was not by primary union, and the cicatrix produced by 
a long process of granulation is very wide and massive. 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 13:3 

3. Laparotomy. 

«. Exploratory Incision. — Although the aseptic method has very mate- 
riallj reduced the dangers of erploratory laparotomy, its wanton and un- 
necessary practice must be deprecated on several grounds. Fin^t of all, 
no surgeon is absolutely secure in his practice against accidental and un- 
eipocted, often unexplained, wound infection. Secondly, the dangers of 
anaesthesia, and of conditions indirectly caused by it, as nephritis, pneu- 
nioriia, thrombosis, and embolism, are ever present, and usually surprise 
the sxirgeon when least expected. 

^Exploratory incision is only justified where, in the presence of a disorder 
thi-ea.tening life, all known means for establishing a diagnosis have been 
exli.a,visted without positive result, or where the extent and exact relations 
of a mechanical disturbance can not be estimated without ocular inspection 
att<J <3.igital examination. 

t^ ne observance of the rules against infection will exclude suppurative 
l^eri tonitis with great certainty. The detail of the procedure is treated in 
tae c^kapter on abdominal tumors. 

C?^8E I.— Fred. Kahn, aged eleven. Intestinal obstruction of seven days' duration. 

^caX vomiting, very great tympanites, and threatening exhaustion. No fever. June 

' -^S82. — Laparotomy ander ether. In the right iliac fossa an immovable convolu- 

'ou ^^f small gut coald be felt. The incision was sufficiently extended to enable the 

'*ot to inspect the locality. It waa found that the tip of the vermiform appendix 

. ^^ attached to the parietal peritonseum. A large loop of the ileum had slipped through 

L^^ ** latus thus formed, and was there incarcerated. The vermiform appendix was cut 

^^"^en two ligatures, and the loop of intestine became free. Reduction of the enor- 

**^ly distended intestines was impossible. At the suggestion of Dr. A. Seibert, an 

**~*a was administered, and it brought away a large quantity of gas, whereupon the 

*^^ what collapsed gut could be replaced, and the abdominal incision closed. Tlie 

J **«ation lasted thirty minutes. Deep collapse followed, in whicli the patient died 

^■■■'Ve hours after the operation. 

~^ery likely an earlv operation would have been followed bv a better 

ct^.„^ ^A8E II. — Philippine Pahler, aged thirty-five. Pyloric cancer of stomach. Febru- 
T^^^^ J*» 1886. — Probatory abdominal incision at the German Hospital, with a view to 



\ 



j».| ^^^ible resection of the pylorus. The extension of the disease to the retro-peritoneal 
f_^ *^d8, the pancreas, and omentum put the contemplated step out of question, wiu-re- 
*-, ^^ the incision waa dosed. March 11th. — Patient discharged with tirmlv healed 
^^^nd. 

1 Casb ni. — Albert Schroeder, painter, aged thirty. Large retro-peritoneal tumor 

-tfc^^^ted behind hepatic flexure of colon, causing intestinal stenosis. Aiujmt S, 18S^\— 

^■. ^^batory incision at the German Hospital established the fact of the inoi)t'rability of 

-j^ ^ swelling — a sarcoma of the raesocolic glands. Closure of wound. August Oth. — 

^tient died in collapse. 

h. Abdominal Tumors : 

(a) General Remarks. — Avoidance of infection from without by scru- 
*^^lou8 cleansing and disinfection of hands, instruments, sponges, and other 
19 



lU 



RULES OF ASEPriC AND ANTlSEPnC SURGERY. 



utensils slioiiUl render unuecessary the application to the peritoueal cavity of 

disiofoctaut lotions, which, by their corrosive properties, may produce mischiefs 

Tlic Uisuiil measures adopted for protecting the body of Ibe patient a^aiit^t 

wettinjLT and undue eoolintj off, as the w]"a|>pin*,' up of the extremities iu 

llantiels, and the sinvudiog of rubber cloths over 
I he triink and Iowlt limbs, leaving ex{>osed noth- 
ing but tlie abdfunen, demand special care and 
utteutioti. Ejrrfssim lus.t of budif heat is a (jri-at 

fnrtor in tletermining 







I., I IJ.- -A(<C'ltfH iinil itvuridii lutivir. I',>tii,-ii1 
rciKly for <4H.-ration in thv l!itti;il i-siurf. 
Ciia« 01" Dr. W. L. K-u-j^, <»f JVtIil. !■ , i,,. I';i. 



rollapse, and should bt 
Ijuartled ayainsi most 
sctlulon.sl^. 

The principle of non- 
cT/toftu re appl ies equally 
to the contents of tl>e 
abdominal cavity. The I 
greater the incision, tlio 
uunu attention must be i)aid io the | 
nun-exposure of the intestines. Hot. 
fiat Hpniifji's <tr towflx nhould hidf 
from view everythinif except flit -^ 
vert/ ."put Hubjecied to surtfiail ma ■ » 
nipukdiun. ' 

The use of the spray apparatua during abdiuniual operations is harmless^B^i 
but unnecessary. Certainly it forms a very objectionable feature of tbi^^ 
original Listerian metliod, 
and has been abandoned 
in general as well as ab- 
dominal Hurgery by most 
opemtoi's. The author has 
not used the spra\' appa- 
ratus since 1H81, 

The control of htemor- 
rfi(ff/e is of the utmost 
importance to the succeiis 
of abdominal operations. 
This and the former re- 
quirements can be best 
liilHlled by an intelligent 
observance of the rules laid 
down in the paragraphs on 
the tjechnifine of surgical 
ilissoetion and tlie rpmoval 
of tumors. The principles 
tliere explained remain unchanged, their application to abdominal turaor"^ 
only bein;f somewhat modilicd by the peculiarities of the locality. 




Fia. 11.1. — Protcotion of tho intcHtines by flat nponftt 
:irra])^-d about llie tumor. 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 1:^5 

An ample incision is the fir^f cnmHiion of the mf'e removal of an abdoini- 
maltumur. When a unilocular, non-adherent cyst is to be exsecte<l, a small 
incision will be ample, because the cvst, howerer krge. can be emptied by 
tapping, and is thus reduced to the elonfrated pro])ortion.s of a flat bund, 
which can be extracted throuojh the small inciniou without much force until 
the pedicle comes in view. 

Multilocuhir cysts that can not be emptied readily, or solid tumors, or 
growths witJj many adhesions, must be freely exposed, to enable the t>ur- 




Vm. 114.— Protection of the i!it< fiin. - In <>viiri(Jtotjj}' by hot tDvvelj^. 



^eon to Ht'c what is to be done. Aeeidentiil Inrcration of the gut, bladder, 
■or large veins will not easily occur while the adhesions binding the tumor 
"to these organs are exposed to view, 

Disrejrard of thip plain and rational rule is the cause of rajiny an accident 
*nd mishap that rai^jht be ensily avoided otherwise. 

NoTS. — However important the incision and fitml suture of ihe abrloinitial wiills may be, it 
n)U5t not Im? ftipgottpu tlinl titev do nut Tcprcaonl the critical part of raoai iihJoiiiiiial opcLutiims. 
The abdominal incision, hcin? a preliuiiiiary nieaHui-e. should not occupy too mMcli time. Of 
OCXRVe, it must be done h-fjt arUs, BmvrrH kxi-editjon. Blee<linp ve»s<?ls need not bo ti<?cl here, 
m» the pressaure of the liemostatic forceps, cxcrttd for ten or tifteon minutca, will offeutually 
«rrert hnfmnrrhajre. Here, na elsewhere^ eutling between two forceps will be more eipcdJiioua 
and safer, than the «i!>e of the ^ooved director. 

Tlie skillful and unstinted use of mass ligatures by means of Thiersch's 
spindle appjiratus will render the dissection even of extensively adherent 
alidominal tumors remarkably bloodless smd safe. Stronfj catgut is prefer- 
able t(» silk, an the latter is knowji to have been the cause of suppuration in 
a good many cases, although the silk was prepared in a seemingly proper 
fashion. Extensive masses of tissue, especially if their shape approncliea 
that of a membrane, should not be includerl in a single ligature, as they are 
very ajjt to slij) at the edges. It is Siifer to divide them into a number of 
snmller portions which should be separately tied. This rule applies to the 
omentum es]>eciaUy. 




1;>J BCUa? OF ASEPTIC AND ANTISEPnC SURGERY. 

Adhesion.^ or pir<l;cle: of a mon:- ejILa<ihcaI »iupe can be safely tied in 
one TD^iR wii:b>at riikia^ the jlippiitr of the ligature. Eyerr maas shoold 
be iaclaiei in nro ligatures, betw^eea w^hich it can be severed with the knife 
or, better, the therm«X!anterT. 

TnmsdxioQ of fieiiele^ with a sharp P^a^Iee's aeedle is not ad viable, as 
larze vein« pti~ing iiit«> the ma.-*g mav thos be cat open and cause tronble- 
i>«>ine hsmorrbige from a poiac not incladed in the ligature. It ia better to 
u^ a blant ia*trument. such as Thiersch** fpindle, or a dressing or artery for- 
cefis, which will pa.-w thn>agh any pedicle easily without injuring the vessels. 

Where the adhesion or pedicle is too $hort, and the tumor too large, to 
admit of easy manipolation ander the guidance of the eye, the nseof a 
temporary elastic ligurure. with or without preliminary transfixion to pre- 
vent slipping, will }>e found a welci>me expedient. To this, a rather gtoat, 
solid band of {not rottifn) pare gum-elastic, and one or more ronnd probe- 
pointed steel nt-edle» are necessary. The pedicle is first transfixed singly 
or crucially, then the rubber band is thrown around the needles beyond the 
place of transfixion. The ends of the tightened rubber are crossed and 
secured at the crossing by a stout pedicle-clamp. After this the tumor can 
be cut away, and the pedicle, becoming more accessible, can be divided and 
tied off with catgut in several {K>rtions. .\s soon as this is done the clamp 
is loosened, the rubber is removed, and the tied-off masses are trimmed and 
seared with the actual cautery. 

Close adheition.< of the out require tpecial care. Recent adhesions are 
easily separated by blunt preparation, but cause a good deal of oozing. 
Much wiping and sponging of the oozing points is apt to prolong haemor' 
rhage, for reasons explained elsewhere. It is better to cover th^e points 
with a flat sponge, and to let them alone till hsemorrhage ceases spontanea 
ously. The blood that found its way into the abdomen must be sponged 
out at tbe final toilet. Old adhesion.i of the intestine are very dense, an<S- 
efforts at their blunt separation may easily lead to injury of the gut. Dis- 
section by the scalpel, the line of section being well away from the intes- 
tine, will be found the most expeditious mode of proceeding. Spurting' 
vessels must be tied, and as soon as the adhesion becomes less close and- 
the formation of masses by blunt separation possible, mass ligatures should 
be applied. 

Forcible blunt preparation in the vicinity of large veins, more especially 
of the largo plexus regularly encountered in the bottom of the small pelvis 
near the uterus and its adnexa, is hazardous, on account of the hsemorrhage 
often caused by laceration of the delicate walls of these vessels. Careful 
isolation and double deligation, with subsequent cutting between the liga- 
tures, are the best safeguard against dangerous haemorrhage. 

Blunt dissection, preferably by the tips of the fingers, is, however, emi- 
nently proper where the peritonaeum is to be stripped up from underlying 
tissues. It is, in fact, the only safe way of separating tumors that are 
located between the folds of the broad ligament, in the mesentery, or in 
any portion of the retro-peritoneal space. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 137 

Exploratory punctnre and aspiration of exposed abdominal cysts of un- 
known contents with a fine, hollow needle is very advisable, as the exact 
knowledge of the nature of the cystic contents may materially modify sub- 
sequent steps of the operation. 

If the cystic fluid be bland, its escape into the peritoneal cavity does not 
signify much, provided that careful cleansing be employed before the clos- 
ure of the wound. But when the cyst contains purulent or fetid serum, 
accidental soiling of the peritonaeum by it may effectually destroy all chances 
of recovery. 

Whenever puncture of an exposed tumor is determined on, whether by 
a small or large-sized instrument, good care must be taken to prevent, dur- 
ing and after the act, the escape of cystic fluid through the puncture-hole 
into the abdominal cavity. To do this it is necessary to surround the 
needle or trocar with a number of flat sponges laid on the tumor. As soon 
as the piston is withdrawn the nature of the fluids appearing in the barrel 
of the syringe will become manifest. If it be clear and limpid, no further 
precaution need be taken. Should the fluid appear to be turbid, or mani- 
festly purulent, the barrel should be emptied and refilled and emptied again, 
until the tension of the sac becomes so far reduced, that its transfixed portion 
may be raised in a fold and secured by a large clamp. The sponges used 
for this step of the operation should be at once discarded. 

To prevent laceration of the sac or capsule, the utmost gentleness and 
care should be practiced in handling the tumor. The use of sharp re- 
tractors and vulsellum forceps, or forcible traction with or without blunt 
force of any kind, are extremely ill-advised. Not only may the sac be 
torn, but large veins spread out over the surface of the tumor may be in- 
jured, and give rise to uncontrollable hsemorrhage. The aperture of a torn 
Tein can not be easily occluded by any kinds of artery-clamp, first, because 
of its irregular shape and extension, and principally because the tension of 
the capsule of a solid tumor precludes the formation of a fold that could be 
conveniently grasped. 

NoTB. — ^The author recalls an instance witnessed by him where, during the removal of a 
large uterine growth through an inadequate incision, sharp retractors were used in forcibly 
dereloping the mass from the abdominal cavity. Several large veins being torn, profuse hipni- 
orrhage set in. The incision was somewhat, but still insufficiently, enlarged, and, more force 
being applied, the tumor was finally brought out of the abdomen. But very soon it became evi- 
dent that, in consequence of the forcible manipulation, the transverse colon, which was closely 
adherent to the posterior aspect of the tumor, had been extensively torn. Enterorrliaphy did not 
save the patient's life, which was forfeited by the injudicious management induced by super- 
stitious fear of a " large " abdominal incision. 

The tenet of making small incisions for the removal of abdominal tumors 
had its origin in the justified disinclination to expose a large peritoneal sur- 
face to the contaminating and refrigerating effect of the atmospheric air. 
And unnecessarily long incisions arc certainly to be avoided. But the sur- 
geon's discretion must decide the question of the size of the incision, the 
principle of safe dissection under the (juidance of the eye being herein of 
the first importance. 



138 RULES OF ASEPTIC AXD AXTKEPTIC SURGERY. 

Undne cooling off of the peritoneum h a very undesirable thing, on 
account of the eollaps^ it may induce ; therefore, all portions of the abdomi- 
nal organs that are not actually under dissection should be carefully covercii 
up by large flat sponges or clean towels wrung out of hot Thier^h*8 solatiun. 

Son. — ^To alvBTB liKf« a adBdoit lopplj of want ■poqgeB and UnMih > the folio viai; 
Miai^ e i et will be fooml coavodenk: A 6n paa or faaniv «w—iai a g A* i po ap w or towda 
iif M u f wMwi in TUendi's Botutioo, is iceted oa the tops of two deui bricks stiMd on ed^. A 
Uaxbip ftleobol-lanip b pUoH betwera tbe brk^ and midemeath the tc««^ which, being cot- 
end whb moClier pan, will preaerre unchanged the tempennm al its contents, lor larger 
upermtiooa, three or foor similarly prepared pana can be cmTenientlj arranged on a scfMtate 
Uble. 

Whenever a stoat adhesion or a pedicle is deligated and cut through^ 
it should be dropped bock into its natural position, where it should be 
inspected for a short while to see whether haemorrhage is thoroughly con- 
trolled by the ligature. Oozing points should be touched with the thermo- 
cauter}', but care must be taken not to go too near the ligature, for fear of 
burning it. 

Oozing points located on the gut should never be touched with the 
thermo-cautery. 

It is best not to tap at all dermoid cysts or tumors containing clearly 
septic fluid, as the integrity of the cyst-wall is the only guarantee of pre- 
venting contamination of the abdominal cavity by cystic fluids. Bather 
increase the external incision, and remove the tumor intact 

The relations of the bladder to the tumor should be carefully considered. 
Greig Smith advises not to tmpty the bladder before operation, and it is 
undeniable that a full bladder can not be well overlooked or injured. In- 
jury to an em[)ty and collapsed bladder, on the other hand, has re|>eatedly 
tK'curred in tlie presence of abnormal adhesions of the organ to the tumor. 
To further ascertain the extent of adhesions of the bladder, the introduc- 
tion and nianipu1:\tion of a :iolid male urethral sound will be found very 
useful. 

NoTS. — Cathetcri^m should be done, if possible, by a pervon not cmplovcd about the 
wound, or, if this be not feasible, c-aref ul eleanj^ing and disinfection of the hands should follow it. 

After the removal of the tumor, the toilet or cleansing of the abdominsd 
cavity has to be attended to. Sponges attached to long bandies are very 
convenient for this puriiose. With them first the lumbar, then the vesico- 
utf rint* recesses, Anally the utero-rectal or Douglas's iHJiieh, are to he thor- 
oughly cleiuiscd and dried. 

In the presence of lartre denmled surfaces lacking peritoneal investment, 
a glass or hnnl-rubber druinaije-tube is to Ix? inserted into the bottom of 
the small pelvi:?. It can be brought out through a connter-openiug made 
into the vagina from Douglas's pouch, or through the lower angle of the 
abdominal incit!:ion. 

In the former cju^e, the external t-nd of the tube projecting into the 
vagina or in the vulva must be wrapjied in a packing of iodoformized 
gauze, which ought to be changed whenever it gets saturated. When the 



^ 



SPECML APPLICATION OF THE ASEl^TIC METHOD. 



139 



tube is brought cnit throujxh the abdominal incision, its outt'r end must be 
80 dressed as to be wisily at'cvH^iblc. Every hour the serum cnllecling in 
it-8 bottom should be exhausted with a pud of ab:iorbent borated cotton fixed 
to a luuidle, or with u loug-nozKled syringe. In the intervals the tube should 
be covered with a moist pad of sublimated gauze. As the scrum diminishes. 
this process is gone through with at hjuger intervals. As soon as the tube 
remains dry for several hours, generally about the third day, it can be with- 
drawn. 

XoTK. — Mioulicz hait sureessfully ftubjitituled for the draii)aj;e-tubp a loose packlnp and fillet 
of iodoformiztd gauze, broug^ht out throijgh no aiit^le uf the woiiml. The exsiccatiuu of the scere- 
tioos liv ihirt arrangeiuent is certainly very effeetive, as wen in several cases reported by Dr. F. 
Lange. The fillet r<bould be removed on the third or fourth duy. 

ne closure of the abdominal wound Hhould be done as raptdlt/ as thor- 
ougbne.<8 will jiermit, jtimplicCfy and wlidift/ nf (he sulure being the main 
desiderata. 

A Peaslee's needle i« thrust on one side through the entire thickness of 
tlie abdominal wall, including the iieritonieum. and is brought out in a 
gimilar manner on the other. The points of eutnince and emergence should 
be at least two inches from the edges of the wound. A piece of well-tiisiu- 
fected silver wire or stout silk-worm gut, armed with a tpii^l, or u leailen 
button and shot, is threaded throutrh the eye of the needle. This is then 
withdrawn, briugiug out tlie end of the thread from one side nf the 




Fii». 115. — CmnpU-teil qiiHIi'J suture ni :r 

wound to the other, where it is temporarily sf^cured by an artery forceps. 
Three, four, or more retentive sutures of this kind are passed at intervals of 
about an inch, until the entire length of the wound is covered by them. 

JfoTK. — While the Htitchea are being passed, a 6at sponge should be kept npread over tlie 
int«-BtitieH to receive the blood MCaping froiti the stiteh-holcs. 

If the paticntV eondition be good, the pcritontpuni may he s«panitclj imitoil hy a row of 
cugut auturea phioe^i hetweeo the f\\vet or itilk-wonn gut tititchco. But tbin is uot etwenlial. 






I ul>>i-itiini 



tightened until the 
rdges of the incision 
^rc raised in tlje shaf>e 
of a. low ridge. Or, 
if lead but tone are to be 
ujied, one of tbese is 
slipped on the thread 
with u perforated shot,, 
the thread is tight- 
ened, and the shot is 
pinched. After this, 
!i suHieient number of 
exact "sutures of co- 
aptation," made of fine 
catgut, secure the edgei i 
t>f the incision. (Figs. 
II.") and 110). 

The ilrcssings con- 
sist of a few strips of iodofortn-gau/e, and un ample compress of fjublimnted 
gauze over it, all snugly faatcned by several .strips of adhesive plaster and a 
broad flannel or gauze bandage. 

On from the eighth to the tentli day the dressings are changed, and the 
retentive sutures are removed ; but the bandage must be worn for some 
time to serve as a support to the fresh cicatrix, 
(i) Special Observations : 

a. Ovarian Tumurs. — Probutory puncture of an abdominal tumor 
through the walls of the belly is not an indifferent mntter. If the iimior be 
cystic, and its wall very tense. Cf'eai^ of a limited quantity of cystic content* 
is unavoidable. Bhind and very thin contents may escape in large quantities 
without causing irritation. A large number of cases are on record in which 
jirobatory puncture of cysts of t!ie broad ligament waa followed by cure. 

Cask. — Mra. Fnuicisca N., liquor-dealer's wit'e, aged tbirty-fonr, was tapped, 
August 31, 187T, for n lartre nbdominal eyst. About a gallon of tluid, characteristic of 
a cyst of llif brond lifjjiim>nt, was removed, but a eonsider.'tblo qiiitntity was left bclunfl. 
In a ^^^ort time the Hubby, diu-tiiutinj; swelling disufifjcuroil fiilirdy, and the wuiuao 
reiHained free from any l'iirtbt<r trouble. 

Eseajie of minute portions <»f purulent cysit-fluid is apt to cause circum- 
scribed peritonitis, resulting in nutre or less extensive adhesions. Larger 
ijaantities of septic matter, that find their way into tlie peritoneal cavity, 
may produce fatal purulent jwritonitis. 

The [ircparations, with a view to the aseptic jwrformance of exploratory 
or evacuating puncture, must bo very thorough, as the use of an unclean 



SPECIAL APPLICATION OF THE ASEl^IC METHOD. 141 

needle or trocar nmij be tlic soiufie of peritonitis or .suppuration of tlio sac. 
The hollow needle or trocai' to \k- used must be sterilized cither by Ijoiliug 
for an hour in a tive-per-cent solution of carbolic acid, or by iucandeacence 
in the alcohol-tlanif. 

When nri exiwined cyst is to be tapped or emptied by incision, the patient 
should be liinied over on her side. An assistant should prevent the eHca^ie 
of gut ; anotber oue should Hurround tlie place of tjipjiing witli a eircle of 
tsjKinges to receive Ilnid that may escape alongside of the instrument. Tait's 
trocar is, on account of its simplicity, the best one of iiJl instniments devir^ed 
for evacnating cyet*i. 

As soon a.-^ the cyst begins to collapse, its folds should be taken up with 
large chimps. Tbe em|)ty cyst is then withdrawn to the pedicle, which is 
tied in one or moix> portions and cut off. 

Cask I. — Mrs. Dorothy Grunewald, fljted sixty-one, multipara. Unilocular cyst of 
tlje left ovary. iJecemher 19, 1S8?. — Ovjirii^tniny. Extenml im-isiou four itirhes lonp. 
Cyst prc»entiiip, patient wiia brought in lHt«-rftl position. Tdppitiff, evaruHtion, and 
extraction. Rather stoat pediclo transtisod with tliiiniL-fttrcepH, iiml tiwl in four por* 
tions, then cut ntf and dropped bark into tlje abdomen, L'ninterrupteiJ recovery. 
January 4» 1S8S. — Discharged cured. 

I Multilocular cysts can be t>cst em])t!cd by making u free incision tli rough 
■ their presenting part, through which the hand can l>e carried within the 

tumor to breiik up intervening si-fitn. .\11 this- should be done e.\tra-abdoni- 

inally if possible. 

»When a cyst is found extensively adherent, its contents should be eare- 
fnlly mopped out with a sponge, and the interior of the sac should be dis- 
infected while the patient is in the lateral posture. After this a hirgo sponge 
k thrnst into and left within tbe cavity until the cyst is dissected out. 

P Case IF. — Miss Lueretifi Bemwrd, aced seventy-two, virgin. Very large maltilooii- 

^r ovarian cyst of the right side, eaui-ing intense dy>tpnn-a. Atiffunt H, i^Si.— PiirR-t- 

•are and partial evacuation at Mount Siuai llnhpitul, resuhin^' in marked relief of ttie 

^lyspncea. Auguitt lOtfi. — Fever set in, witli sonic abdominal tendernesa, and Hupfmra- 

tion of tbe cyst was apprehended. An^naf JSth. — Ovariotomy, Incision twelve inches 

long. Broad, recent adhesion of the huc to the anterior abdominal wull severed by 

\>!ant preparation. Patient iieing brought into the sale position, tlie cywt was first 

tjipped, then incised, and its vohiioe was touch reduced by brciUiing down septa by the 

tiand. 8ome hajtuorrhage occurriag, a large sponge was thrust into the sac, and the 

patient was returned to tlie supine position. A nujuber of adhesions to tbe right side 

*>r the parietal peritomeutii and ascending colon were divided between severat double 

iiass ligatures of silk. Short (lediole was similarly secured. Tcdiet of peritonieuia; 

loAure of incision. Moderate elevations ttf the temperature. Uninterrupted healing 

of wound. Xorember ir>lh. — Abscess of right groiu was incised. Three silk ligatures 

were discharged. Avpugl 11, 1882. — Patient died of an intercurrent dif>oase not con- 

H.liected with ovariotomy. 

^ Case III.— Mrn, Lena Docbteniiflun, aged thirty-nine, multipara. Very largo 

malt'docnlar cyat of right ovary, (n-ncral condition very poor; chronic, bronchiul 

catarrh and chronic enteritis, witli tiiarrluea, ascites, and amisiirca. April 19, 1886. — 

Ovariotomy. Extensive adhesions of cyst to anterior and lateral parietes; to transverse 

20 



143 



RULE^ OF ASEPTIC AND ANTISEPTIC SURGERY. 



caloD, omentuui, and the bltiddcr. A large niirabcr of mass li^tures were made. 

IlfBinorrhage insitrniticjuit. Duration of ojterution two Iiourn ami a half. Patient dit^ 
iti collapse seven Lours after the ootiipletion of the t>ijeration, temperature remaining 
subnormal to the last. 

('jfstitof the broad ligamvni generally present great difiiculties on account 
of their situiitioii between the peritoneal faJds of the ligament. If they 
estond low* down into the small pelvis, their dissection is occasionallT im — 
pnicticable, and always very difficult. The utmost circumspection and care?? 
must be e.xerci.se(l not to provoke ha^niorrhaire by injuring large veins in tht 







bottom of the wound, and all adhesions, not yielding to gentle blunt dissec — ^s- 
tion with the fingers, tnust be fiushioned into suitable mas.ses, doubly tie C^a * A 
witJi Tbierscli's spindle-'^, and then divided. In cases bailing the skill or -«jT ' 
enterprise of the surgeon, the sac should be properly trimmed and 5titc)iec^»-=d I 
to the skin, so ag to convert it, if possible, into an e.\tru-peritoneal recaei<^^» s» ' 
Drainage of the sac is indispensable, , 

Case IV. — Mrs. Etliol D., agod twentv-one, nullipara. Rather immovable cyst <■ ^ of] 
the ripbt broad ligament of tlie size of a ohibPH heacl. April 6, 1887. — Ovariotoraj^^Z_J. , 
Incision five inclios long. The cvst bad tSissiected its way uut I'roui between the fold^E^ ' 
of tlie broHil lifraiueiit, and bad ]tusbed away the jjurivtal peritonasum of the anterior ^ 
abdoiiiinal wall on tin- rifjlit !*idu to .%ucb »a ystent as to reuiain entirely i ili i pt lilniK \~ ^ ' 
The sac was tapped and emptied, then it wna easily si-pnrated from ita attachnienta b_-^^y , 
btunt preparation. About uno fourtb t>f a square foot of peritonteiiin was detacbcdi^^ 
Finally, t!ie pedicle was reached, secured in tlireo ligature;* carried tbroa^nh by meai^^^** 
of Thlcraeh's apindk'H, tied, ami t!Ut off. The eavity was mopped out with eorronT( 

siibJimute lution, drained by two ordinary ru 
ber tiibt'H, and the external wound united .in 

dressed in the iiisiial manner. April 7th. — 

Nothing alarming liad occurred, tlie temperi^a*-' 
ture raof^ioff about 99 "' Fabr. A^/ril Sth.- — -"" 
TemjH'ratare 101 '5^ Fahr., with a good deal «:^^ 
tyin[ianites. and dyspncea. False of varying ii^ '~ 
tensity and rliythm, about 125 beat? per mimit L-^ » 
nnd nitluT weak. The oater bandaj:e liad to b^i*^ 
luoseiied, and energetic stiraulatton liy bourl^^" 
enemata, consisting of one oanee of brandy iumc^ 
two ounces of warm w.itcr, were admini.'^tereJ'^ 
till fc!ie [iidse became decidedly fuller and tiior*^ 
regnlar. April iOfh. — Some tbitus passe*] 9|>on 
taneoiisly, the ifietoorisin dinjtnisheil markedly -v 
and iJie teuipei'alure fdl to the normal standard 
April 11th. — Patient cousumeil a few oyster^ 
and a little champagne, her nourish meot bar" 
ing consisted until then of milk and lime-water- 
Oa the aunie date sligbt uterine and resic*! 
brotnorrh.'ige was noted. The former may hav* 
been dependent upon snbinvolatioa remaining bL'bind after a re<;oat miscarriage; the 
vOBiCid bfDniorrhage seems to have been due to detachment of the auperior and latert) 
vesictd wall during disacction. April 13fh. — A saline laxative was admiikii^tered, c«c»- 
ing some nnnsea and vomiting with a good denl of ^'rJiiing, but refliiltiiig in three copi- 



Fio. llir, — Diojrrorn of eyst of the broad 
ligament. (Ciwe IV.) 



^1 






SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



143 



oas stools. The same day the drainage-ttibes were shortened. The wound was found 
healed bj adhesion except where the tubes lay. Three of the plate and shot sutures 
were also removed, and two were left behind, ThL^ catgut sutures had been all ab- 
sorbed. April 18th, — Tlie tube** were entirely withdrawn and rerniiininp .sutures 
rvmoved. April 20th. — The (juticnt left the bed tfie tirst time. April 25th. — The 
wound was entirely heuletl. (Fig. 117). 

It seems that the extenaive detachment of the peritonBBum from its 
nntrient vessels led to a pravc disturbunce of itn cinuilution, ami jierhaps to 
partial {axeptic) necrosis. An adhesive peritonitis of the intestinal invest- 
ment apposed to the denuded parietal peritoneum was set up, causing 
paralysis of the museulnr layer of the ^it with mcteorisni. As !>;oon as the 
devitalized parts of the peritonaeum were enveloped by fresh exudutions, the 
irritation ceased. 

p. Supra- vat/ ina! hysierectamy for large myo-fibroma of the utern.9 may 
bo indicated either by profuse loss of blood at the men.strnal epoch, or by 
other causes rendering the patient's life unendurable. An operation should 
lie determined on only, after a faithful trial of less incisive remedies known 
to induce involution of uterine fibromata, has plainly failed u-t ^ive relief. 

The preparations for the operation are to be made with all possible care, 
directed to the avoidance of septic infection, iltemorrhagc is to be pre- 
rent<?d by the a[»pIication of single or double ma.S8 ligatures to the uterine 
adneicaon both sides 
of the uterus, and 
a Ktout elastic cord 
to the cervi.v. Tin- 
ker favorable condi- 
tions (that is, when 
the cervix forms a 
elenderjiedicte to the 
otherwise moiablc 
■womb), the applica- 
tion of double liga- 
tures can be obviated 
by ctitting off the 

blood-su]>]<ly of the organ from all sides by two continuous lines of mass 
ligfttures converging from the free margin of the adnexa toward the cervix. 
A suitable-sized mas.s is first formed at the margin of the broad ligament by 
means of Thierscb''s sjniidle, and is tied ofl with strong catgut or silk. \ 
second mass adjoining the first one is novv isolated, at:d the thread being 
carried around it and back through the aperture made for the applica- 
tion of the first ligature, is firmly knotted, A third mass is ieolatcd by 
Thiersch's spindle, and the thread is carried back through the hole made 
for tlie isolation of the adjacent mass, and the application of the preceding 
ligature. Thus the cervix will bo soon reached. While an assistant raises 
the tumor well above tlie pelvis, an elastic ligature is thrown around the 
elongated cervix; being tightened, it is secured by a stout pedicle-clamp. 




"Tt 



-y-, 



lis. — Diagram cltowitig tl>c jirrnnjicment of uinsii liJ^ttturc^ Ln 
akil>ra-vii)^ntil hystcrtictomy. 




i 



144 



RULES OF ASEPl'IC xVND ANTISEPTIC SURGERY. 






^ 



This step will have completud the isoktiou of the uterus, which can be now 
exs&cted without loss of blood, the line of section being carried just outside 
of the chuin of ligatures. (Fig. 118.) 

The uterine stump must not be cut off too short, as it is desirable to 
retain sufficient nuiterial for covering up its raw surface with ijcritoiia^uni. 
The cervical canal is to be burned out thoroughly with the thermo-caut-ery, 
to destroy any j?eptie materia! contained in it. After this, the cut surfjw^e 
of the uterine stump i?! hollowed out with the sc!il[>el in the shape of a cup, 
its center being located in the cervical canal. This is done until the edges 
of the cut can be folded upon each other, when they are united with a 
sufficient number of deep, intcrmodiate, and sutierficial catfjut sutures. 
The deep sutures are to bo a|tpliod with a large curved needle, that should dip 
down to the level of the elastic ligature. The intermediate sutures should 

reach to about one lialf of tlie depth of the stump ; 
the superficial stitclies are to hold together the 
peritouiPum. Thus exact coaptiitiou of the entire 
cut surface of the uterine stump is brought about, 
and it serves two good purposes : Fir-if, the elas- 
tic ligature can l>e removed witliout fear of ]iro- 
Fio. 119.— Suture' of uterine fusc haemorrhage. Anv oostiug between the stitches 
^;^;[Lc'.%.'"'l^hr3r> can be controlled by 'sponge pressure till a clot is 
formed within ihe wnuiul. The .vpf(>«f/ advantage 
is the exclusion of a!l communication between the vagina and cervix ou one 
side, and the peritoneal cavity ou the other. (Fig. 119). 

WheiT the pedicle is .short and vltv stout, sli])]ving of the clastic liga- 
ture must be prevented by crucial trausHxion of (lie cervix with a pair of 
large and well-disinfected shawl-pins. These can Iw removed, together 
with tlie rubber cord, after the completion of tlie suture of the stump. 

In the presence of adhesions, or a broad implantation of the myonuv into 
the deejTcr purt^i of the pelvis, the same rules uf dissection are to l>e hcediHi 
that have l>een elucidated in a former paragrajih relating to abdominal tumors. 
The author's only case of supra-vaginal hysterectomy ended fatally by 
seifticjcmia. The sources of infeetinn were presumably the sponges, nuui- 
aged by two raw members of the training-school for nurses at Mount Sinai 
Hospital. 

Case. — Mr;*. S. Levy, aged tliirtT-tlireiv ranltipara. Very large fibro-myomji of the 
corims uteri. Severe iriftrorrlwigia nt each riit'tistrimtion, with inorea.''inp luuomia nml 
urcat liuljileasut'ss troiu tlio size of ibu tiinior. Juiw 7. ISf^i. — Ilysterecfoniy nt Mixmt 
Sinai llostpital. Incision six inctic!< lunp. Ea-y tielipation <>f wlnexa in two rows of 
mnsa ligaturcfl ; cJaHtic ligature of cervix ^ at>l:ition uf tlie tniaiir and ttdncxa. SenrinR 
of the surface of tlio small fttiimp by thenini-cnutery. Tlie Htnallness of the stump 
iadnced the nutbor lo treiit it like tin ovarinu pt'tliele, and it wivs roplaoed in the abdomi- 
nal cavity after securinn ot tbe elastic lijraturc by a knot of »tronii <»ilk, Hunlly any 
blood was lost, and a sricmjIIj course of liealinK wnf* expeotod. Hut till ho|>e» wtro 
shattered by the development of noptje nyitiptDiiiH in the nijrht followin^j tlie operation. 
June 8th.— U'xgh fever, retching, and ftbarp abdominal poio were present, but no sij^na 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



145 



of peritonitis could be made out. Twenty-nlue lioiirs ufttT the operation the patient 
died in coma. Po.«t-mortem cxainiiiation pevcak'tl iin Hbsct^ts of the ubdominiil w all in 
the line of sntiire, and a gra.vi.«h dist'oluratimi nf tbu jieritonaMim near tUv olustic liga- 
tare. A faw droclmis of tarbid. bloudy seram were found in Dougloi^'s pouch. No 
sign of peritonitis 

Investigation showofl tliat during tlie opt'ration tiiu mjiniigonieiit of tlie 
sponges b}' the nurses liad been a cureloss one ; that a too large number of 
persons were intrnsteil with the care of tlie sponges, Tlie practical onl- 
come of this experience was the order, that Hie Lsponges should be attended 
to by one person only, :ind that this person should always be the most 
experienced and responsible one of the avaihible nomber. 

The preceding case shows that fatal septicjx?miii may be induced by inftc- 
tion of the peritonseum, and yet purulent peritonitis may be absent, Per- 
hapi? there was? not owougli time for the development of peritonitis. 

Mani/ rapidhj fnfal rases, dassfd it/ vtfrinns .v«/y/^-w«-"» vn«i*'r the heading 
of '^ shock," or *' exhaustion," would, «« closer inquirtf, tin'n ovf fo he cases 
of acute septicmmitt. 

y. yephrerttuny bif {tbdominal section is clearly justified in cases of de- 
generated movable kidney when the urine gives sufiRcient evidence of elironic 
pyonephrosis with or without stone. 

Casb. — Mrs. S. Weissen stein, ufii&d forty-six. Noticed fourteen vears apo a mova- 
ble painlesi* lump in her right hjpochontirinin. S:>inee about nine months very acute 
symptoms of rvstic troulde -^et iti. and tlie lump became lurper and painftil. Consttitit 
desire to urinate, oontinaous fever, with occasional ri^or!*, and liirge qiiatitilies i>f pus 
in tlie urine hrouKlit her to a very low stnte. A smooth, hard, kidnev-slmped mnvnhte 
tuuior of the size of a large man's fist could he fell in the right hypoclioudriuc region. 
Jantiary 11, 1887. — Examination onder cliloroform. The hft l-itlneif eouM not he 
made out dijitinetli/. The iiritie was scanty and acid, amouniinjr to aliout twenty onueca 
JK-T day, of the con^iHtenry of eroaiii, imd eontained very Iturtfc timintitles of pus. Janu- 
ary I'pth. — Abdominal ae[dtrect«»my at the (feruian IIiHpltal. Tlie ttniior hiinjr ex- 
posed, the hutid was clipped into the left liinjlmr jmrt of t!ie peritoneal eavity, when 
the Ifft kiditfif foitld he tlittittctly f'llt. Alter this the perilonipum :md its capsule were 
split along the whide anterior asjiect of the enlarged Ijidney, and the organ was easily 
peeled out. A pedicle wa.H. formed of the ureter and vessels, and was tieil off in two 
infWiiCii. After the retaoval of tlie tumor, the large retro-peritoneal cavity was carefully 
mopped out and lousely packed with strips of iodnforinod gauze. These were brought 
i»ut near the ufiper angle of the abdoniiaait wound. Tiie edges of the incision through 
the portferior hiiJiella of the pcrilouttMiui mid the reaal capsule were stitched to the 
peritoneal liniu;; of the anterior abdominal wjill. The outer wound was united in the 
uminl way. The patient lost very little blood, hut during the operation threatening 
lusart- weakness ne<'es.«?jtated tlie subcutaneous exhibition ofcflmjilmr and wliinky. She 
rallied pretty well, and [lansed some perfectly clear urine Hhortty iiltcr the operation. 
Jattunry IGth. — Teiiiperatiire, I'lfi^ Fahr. I'liticnt cheerfrd, and Htiffering very little 
pain. ITrine continues clear and very concentrated. In the night several fainting- 
gpelU. The night mirse did not pay sufficient attention to the patient, wlio died in a 
Bt of syncope early in the morning of January 17th. Post-mortem examination failed 
to show any morbid change aside front the aMoniinal wiamd, which wa» found dry, 
and Just a8 fresh ha at the time of the operatioti. With more untiring btimulalion, th« 





patient might huvo ^arrived. The enlarged rifcht kidney had ]oat its textural charsc- 
tw, Mid was con verted into an irr«,t,'u!ar siimtms bag, containing six uratic stones of 
various sizes, surruunded by n quantity of pus. 

r. Gastrostomy. — Impasmbh cicatricinl sfcnotfis of the mitopfuujus is a 
very stroiijj indication for the establishment of a giiBtric fistula. Threat- 
ening starvation will be thus averted, and an opportunity will at the same 
time be created for attempting retrograde cafhcferiym of the cesophagn^ 
which may succeed. 

Case, — lledwijr Meyer, aiifed twenty-four. Cicatrioisd itnpassable stricture of the 
resopliugiis twelve inches (mm Incisure, caused by swallowing pure curbotic and. 
Liquids only irould bi* swnllowt'tl, with Iroquent regurgitatiims, Extrcine einaciatioD. 
April 17, ISSft. — Gftj^trostouiy at the (ienimn llnspitsd. Itninediatdy below and jmr* 
ollel with the luiTfc costal iiroii, an incision of two and « hidf inches exposed the perito- 
naeum. After stanching the Blight hientorrhage, the ]teritonwuni was incised, and 
the edges of I he peritoneal incision were taken up by four artery forceyis. The left 
lobe of the liver was found presenting, Thi^ being {nis^hed aside, the anlerior wall of" 
the empty stomach came iu vioiv, and wa« withdrawn from the wound with a pair of" 
thunib-fnn-eps. The cardiac portion of the organ wa*^ drawn well into the wound, and 
was transfixed with a Poasloe's needle to prevent its slipping hack. The i>erit<»ncftl 
covering of the stomach was stitclied to the everted edges of the parietal ]>«ritonii!Uin 
Uy two tiers of interrupted silk !»iitnre9. The artery forceps were of very great servlw 
in Hecuring the apposition of broatl peritoneal surfaces. The external wound wm 
packed with iodofonrnzed gauze, and dressed nntise|itieally. No reaction ftdlowing, 
the packing was removed on April 2nth, and the I'ea«iloeV needle was withdr::wn. 
After this an incision one Iialf inch long was made into the stomach, and a shurt piece 
of fltwut drainage-tube snugly titling into tlie aperture wm placed in the stomach, and 
wa» secured frotn slipping in by a large safety-pin. Ita opening was closed by a cork 
stopper. Previous to this the lips of the mucous metid>rane were stitched to the outer 
ekin. From this date on daily attempts were made to pass the stricture with a sound, 
introduced into the osaophagus from below, through the gastric wound. Afnif 13th — 
Dr. Bachtniinii, the house-surgeon, sixccewled in pa.Hsing from below an olasiie catheter 
arnie<l with a mandrel through the striciure. Milk injected into the catheter made its 
appeaniuce in the fauces. Aftty l^th. — A .smiall-sized sovmd was posted from above. 
Alimentation was carried on both artificially through the draiuage-tubo placed in the 
stomach, and by the mouth. Grailually, as the ability to swallow solids returned, more 
and more food was taken by the mouth, and the drainage-tube was withdrawn from 
the htojiiacJi. The ga-strie fistula closed hpontuneously bv the end of June. Augutt 
aath, — Patient was discharged, with directions to continue the use of the oesophageal 
bougie. 

In canvx of cancer of the fPsopft(i(/n.s, gastrostomy does not yield favorable 
results. Of six casea, niosstly men past middle uge» and all presenting the 
picture of more or les-s e.xtrenic emaciation, five died in a few (all within 
twelve) hours after tlie operation. The slight depression of the heart's action 
by antesthesia was sufficient to induce fatal eollapse. The sixth case eiir- 
Tived the operation for thirty-two days, bnt was losing ground steadily m 
ppite of artificial feeditig by the tube |>lacod iu the stomach. A groat deal of 
ditficulty was exjiericnced in thii* case on account of the cimsiderablc leakage 
that was ttiking place alongside of the tube. Apparently the incision bad 



i 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 147 

been made too large, and gastric jnice was e:>caping in rarvicg qnantities 
into the dressings. The gradual emaciation and final dissolntion were in a 
great measure due to this constant loss of albuminoid substances. 

The outer dressings of a gastrostomy wound are arranged in the follow- 
ing manner : A split compress of iodofonnized gauze, similar to that used 
in tracheotomy dressings, is slipped in under the safety-pin holding the 
drainage-tube, and is arranged around the same. A piece of rubber tissue, 
or sheet rubber, somewhat larger than the gauze compress, is provided with 
a not too large slit in its middle, which then is also slipped on the end of 
the tube by being passed first over one, then over the other end of the pin. 
The rubber should fit snugly to the tube. Over this is laid a succession 
of two or more sublimate-gauze compresses of increasing size, each pro- 
vided with a slit for the passage of the corked-up end of the rubber tul>e. 
The safety-pin, which was underpadded by the iodoformed gauze and rul> 
ber sheet, is covered up by the subsequent compresses, which are snugly 
bandaged to the trunk. Over the outer bandage another apron of rubber 
tissae is pinned, the rubber tube projecting from a slit in its middle. The 
object of this is to protect the bandage from soiling by regurgitant food. 

Feeding is to be done at first in short intervals ; later on, larger r|uan- 
tities of food can be introduced m four daily doses. 

d. Colotomy. — Rectal obstruction, most commonly by syphilis or cancer, 
is au accepted indication for the establishment of an artificial anus, either in 
the groin or in the loin. Lumbar and inguinal colotomy each has siMJcial 
advantages and drawbacks, the consideration of which must determine the 
choice of the method preferable in a given case. While lumbar section is 
extra-peritoneal, nevertheless injury to the peritonaeum is very apt to occur; 
finding of the colon is not easy ; sometimes it is impossible without opening 
the peritonaeum, notably when there is a well-develojK'd mesocolon. Tlie 
shape of the artificial anus after the lumbar operation is mostly excellent on 
acconnt of the ample mass of tissues traversed by the fistula ; but the situa- 
tion of the aperture is unhandy, the patients generally recjuiring the aid of 
a second person for cleaning and dressing the artificial anus. 

Inguinal colotomy is a short and easy operation, and j)rovides for an 
opening located accessibly for the manipulations of the j>atient in cleaning 
and dressing the aperture. Its drawbacks are the necessity of incising the 
peritonaeum — a circumstance which has lost most of its terrors since the in- 
trodnction of the aseptic method — and the tendency to troublesome i)r()la]).se 
of the intestinal mucous membrane. The latter ditticulty can be overcome 
by a discreet proportioning of the external and intestinal openings. 

(a) Lumbar colotomy. — Finding of the posterior aspect of the colon i* 
very much facilitated by insufflation of the thick gut. This can be done 
either by a bellows attached to a soft catheter passed in beyond the stricture. 
or by the similar employment of a siphon bottle filled with niincral water 
charged with carbonic acid. The mouth of the siphon is connected Avitli 
the catheter by a piece of rubber tubing, then the siphon is inverted and 
the valve is opened. The carbonic-acid gas, collecting about the end of the 



us 



RULES OF ASEPTIC AND ANTISEPTIC SURGEKW 



glass tube reaching to the bottom of the bottlf, i'SfaiJ<3.s into the gut, au«l pro- 
iluct's a vis^ible btilgiwg of tho cohm. 

Wlimi the stricturt' is iiujwissable aud inflation not j)raoticable, recogui- 
tion «if the colou may offer great difficulty. The landmarks are the kidiiej' 
altove, and the reliexion of the pfritoniijum extcrually, but occo^sionally tbej' 
are of little practical use. 

Case L — Mrs. C. (*., mieii Hft.y-six. Very extensive fur-irone cjjiicer of the rectom 
with involvetnt-nt uf tlie uteriia. The strieturu wusverv lun;^ and nujmssable. Jum 2.\ 
1S8S. — Lnmltar colutoiny wiis atU'iiii*tvLl, Tljoiigh the kidney and the retiexiuii of Um 
peritonaMiiii were clearly discerneil, the iuetsian opened the j>eritnua3urn, »unl The pro- 
truding gut tiiriu'ti out t<j be siiitill intCHtiae. The poor condition of th« patient iu»Jc 
further prulungution of imtui^thesiii undesirable, tlierefuro tliu gut wus attached to the 
skin and imiised. The wnund heidod prornptJy, pivin^ much relief, Init the poUcnt 
died four weeks after the openition from emaoiation, due in jjart to insufficient niitri- 
tioQ caused by the hij|;h posiriou of tlie int«stinnl «[>erture. I'o!*t-inort<'iu exauiinatlon 
showeil thnt tlie iutt'stimd tiHtuhi wa^i midway between the mimiueh and eiecom. 

Ca!*k II. — Mrs. Mary Bnmnor, jiyvd forty -three. A uguxt 23, 1SS5, — Lumbar cololo- 
luy at Mount Sinai tloHpital nnder ether. Auffunt S^fh, S5th. — Acute lobar pneuinoiUA 
of the entire right Iting, to which tlte |fatietit sufcuinhed. Tlie colotomy wi>uni] hod 
clo«H;d by pritiiiiry adhesiuii. Presumably the pueuuioDiu was «^aiisetl by the entrance 
of fiiul ornl secretions into the right bronehvis during the operfltion. 

(b) Inguinal fohtomff. — A vertical incision is jireferable to one parallel 
with Poupart's ligament. With the former, the fibers of the oblique 
musek's will be cut across their cnur.sc and will retract, giving ample space 
for a clear iusight and free manipulation. Asepticisui has to be maintained 
as in all abdominal operations nuiiuly by scrupulous cleanliness. 

The periloTKeiim is sufficiently incised to grasp the presenting colou with 
the fingers for withdrawal, aud its edges are secured with four artery -forceps. 
The gut will be known by its taBuia' aud the epiploic appendices. A loop 
about two inclies in length is withdrawn, aud its mesial aud distal halves are 
stitched to each other in front and In the rear so us to cause the formation 
of a spur (a o, Fig. 120). The sutui-es are made with an ordinary straight 
sewiug-needle, the suturing nniterial being catgut No. 3. 
The stitclies should include only the peritoneal corering 
of the intestine. Tiie loop is then dropped back into the 
jK^ritoneal incision, and its a])ex is stitched to the pariefcsl 
peritonteiini all round with two tiers of catgut i?uture«. 
lit doing this the parietiil peritonieum can be well everted 
by the artery-forceps attached to it. and a broad surface 
of contact between it and the gut can be thus secured. 
Finally, the gut is incised and the intestinal mucous mem- 
brauo is sewed to the outer skiu. To prevent prolapse of 
the macotis membrune, or leakage, the incision should not be made too 
large. The formation of tlie sjuir as suggested by Verneuil has this advan- 
tage, that fecal matter will not find its way into the lowest part of tho 
rectum situated below the artificial anus, atid thus painful and otherwis- 
disagreeable regurgitation of fieces will be avoided. At the same time, seen 



: 




F«». 120. — Fonnu- 
tion ol spur in in- 
l^inal colotomy. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



149 



tions forming In the distal section of the rectum will not be retuineil, but 
ran escape ihrougli the fistula. 

The [in>position of conijiletely dividing the loop of extracted colon, .sew- 
ing the upper end into the wound, and elosin^jf Ijy .suture and droivping buck 
the distill en(J, i.-*. feasible, but m met by u serious objecti(m. The stricture 
may lend to eoni]>lelf occlusion, and the secretion.s of an ulcerated cancer 
may »o distend the closed gut tks to lead lo rupture of the sutured part and 
to fatal peritonitis. 

Ca3e I. — Mary SU'iger, nperl fiffj-niiie. Extetinive rectal caneor witli fi nutuber »f 
periprortitU" iibsoesses can.sinj; proluse puriili'nt disrhari^e ihroajjti tlie imii*. tliiiaciat- 
ing hec'tk" fever md(1 flistressinf.' feral rott-ntmii. AixjuKt ],% lfiH5. — hi^jina] rolotuiuy 
at tlie Gwrtuuu Hospital. The tbick jriit was witJidrawn. loirl was clust'd with two 
ligatures of ptnut silk carrieil tbrougb ibu mesocolon by the point of a thuaib-forceps. 
The peritone.'il incision was covered with two Hut f«ponffe,<} and the put was cut througli 
bi'twc'fu the htjaturi-i*. A liltle fiM^al iiiatttT I'scapod and was «'aiif;ht by tin- Hpoiigf-H, 
wliL-rtMipnu thi'v weri' chaii^jjed. 'Yhv •jjucn liiun-n of the j^ut wm* mopped init rleaidy, 
and WfU irrijrated witli TtiiersebM sulutiou. After tbfs the distal viid of ihu friil wus 
closed by two tiers of Lt-mbert sntares made with oalpit, and wim returned to the 
abdoruinal cavity. The peritoneal layer of tbo mesial end was stitclicd to the pai'ietal 
peritontBOin and the miu-ous xutmbrane to the outer Kkin. The patient rallied well 
from the ojieratioti, but the higli fevt-r and profii»i' disehurpu from the jmtiis coutiuuL-d. 
Auyuat ISfh, — Tbe patient 4lifd imder septic syiuptonis. On aiUopsy, the wound was 
foaud healed by the first intention, likewise t!ie sutured di.-4tal end of the iini. The 
peritoDiOum was normal, but a very larijfe retro-peritoaael abiseeaa, oommunicatiufj with 
the rectal pouch above the cancer, extended high up along the front of the wtcniia, and 
contained a large qKantity of extremely letid jius. 

Case 11.— John Baruett, clerk, aijed filty. Inoperable cAncer of lower end of 
rectum. Xottmber 15^ 1SS6. — In^uhial eolottmiy with fui'maiiini of ^piir iit Mount Sin.d 
Hospital, yrnfemher iifJitl. — Slit<'lies tluit were r*<it Hb^(>rbed, removed. Fonnel-sbjified 
artificial onus, no pndnjise of gut. Auijutt 10, 1887, — Wears, with comfort, a (nmdl 
hollow rubher ball over the hftula. 

Cask III. — Stephen Y., government oflScial, a^red sixty -one. Far-gone rectal cancur, 
with involvement of the prostatw and tdd strictures of the |H>ndtilous part «if the 
urethra. Sorcmher 15^ /*'?<>.— Inguinal coluttimy with formation of J<|nir at Mount 
Sinai llospitjil under ether. Xoranher 10th. — Lubular ]»neumoni)», probaldy caused by 
aspiration of mucus during the anajsthesia. Hy Noveniher 2.'jth, tlio acute febrile 
ayujptoms had subsided, but profuse purulent .'^puta were coatinuidly eX]»ectorated. 
The bladder altjo eauK-d luueh trouble, although the tight strictures hud been well 
dilated. The urine contained much pus, later on hloo<l, c«>uung from the ulcerated 
portion of the cancer uccupying the neck of tiici Madder. The colotomy wound ht-.nled 
kindly, und a satisfactory artiticinl amis had l^ecn secured. The chronic bronrliial 
catarrh, feti^l cystitis, Mud hiler pyclo-nepliritis, bowever. luistcned the death id" the 
pati^t, which iKiourriil on tlireiubcr 23il. 



Zn. HTSROCELE, VARIOOOELS, AND CASTRATION. 

I. Hydrops of thr. tunira vwjinnliK of the tetflin i.s either an es.sential 
disorder prr sr, or t.s .symptomatic of .some acute or chronic affection of the 
testicle. If it Iw produced by acute e})ididyinitis and orchitis, it is transient ; 
21 





RULES OF ASEPTIC AND ANTISEPTIC 8URGERY 



but if it'* cause ia tuberculosis, or caocer, or syphilis of the testicle, it 
assumes the charucter of u chronic complaint. For the sake of a correct 
prot^osis the recognition of secondary liydroccle is important, as it is im- 
probable that, brought on by tliese affections of tlie testicie, hydrocele cau 
be cured by either tapping and injection or the radical ojieration. 

If t!ie hydrocele is very tense, preliminary tapping is advisable, in order 
to afford an opportunity for cstimatiug the condition of the testicle. 
Should this be found rugged, swollen, and bard, it is very doubtful thai 
measures directed to the cure of the effusion wilt be successful, unless ibe 
condition of the testicle be improved by approjiriiite treatment. Gnnimy 
swellings will usually disappear under antisyphilitic medication, and wiih 
them tlie hydrocele. Tuberculosis and cancer, on the other band, will 
require castration. 

The cure of aim pie hydroreh by tn^tpimj and .subsequpfif j'//;Vr/io/i with 
tincture of iodine or pure carbolic acid is safe, and ia generally followed bv 
cure. The only caution to be taken is a proper disinfection of the trocar or 
cannula to bo used, by either boilin«r in carbolixcd lotion (five per cent), or 
by beating the instrument in an alcohol-flume. Care must also be exercised 
not to leave behind in the sac too large a quantity of the tincture of iodine, 
as there is on record a case of acute iodine-poisoning brought on by that 
circumstance. 

VolkmaH}i\<< radical operation is also safe, and offers the best chances 
of a permanent cure ; but it necessitiites longer confinenent of the patient 
than the preceding method , The author has performed this operation suc- 
cessfully thirty-two times on thirty-one patients, and net serious disturbanc-e 
was ever oh>*erved dnriufr the course of healing. In each 
case cure was eompk'te in from two to three weeks, and 
was permanent. I^'ttely the ojieration was done with 
the aid of local anaesthesia by cocaini'. 

The procedure is as follows: The penis and scrotum 
are shaved, scrubbed otT, and disinfected. A rubber band 
or drainage-tube is tied about the root of the penis and 
scrotum, and about twenty minims of a five-per-cent 
solution of cocaine are injected along the prospective 
line of incision. The skin and dartos are incised for 
about two inches, and the exposed tunica is opened. A 
grooved director is slipjied into the sac, wliich is then 
slit oiien, this incision being somewhat shorter than tlie 
cutaneous one. The sac is mop^jed out with a s^HtngQ 
dipped in a five-per-cent solution of carbolic acid. After this the tunica is 
stitched to the skin by a continuous suture of fine catgut. .\ small drain- 
age-tube ia inserted and secured from slipping in by transfixion with a 
safety-pin. The constricting rubber band is removed, and the siTotam is 
held compressed between two sponges for a few minutes to stanch any jx);*- 
sible hiEmorrhage. .\ small t^trivi of <lisinfected rubber tissue is laid on the 
wound, which is enveloped, together with theriilire scrotum, in a dry dress- 




'rum 



Fit). I--;:. - l»i 
tlluj.tmtiD.|ijE V'olk- 
njann's openitimi 
fnr Jinlrowlf. 




SPECIAL AFPUCATION OF THE ASEPTIC MEfHOD. 151 

ing, beld down by ft roller bandage applied in the manner described in the 
paragraph on herniotomy. (Fig. 181.) 

The dressings are changed on the tenth day after the operation. On 
the second day the movement of the bowels is attended to by enema or laxa- 
tive. On changing the dressings the patient can be permitted to get np and 
to exercise moderately. The wonnd is dressed with a strip of iodoformed 
ganxe until it is healed. 

2. Varicocele of a moderate degree is best treated according to Keyes's 
' plan, which comdsts of subcutaneous ligature of the distended veins with 
catgut. The scrotnm being cocainised, the cord is separated from the vari- 
cose veins, and is held in the grasp of the thumb and index of the left hand, 
the patient standing during the procedure. A straight Peaslee's needle, 
armed with a loop of silk, is thrust through the scrotum from in front until 
its eye appears behind the scrotum. The left hand releasing its grasp is 
used for placing the ends of a medium-sized thread of catgut into the loop 
of silk, whicb is then pulled through forward and out of the anterior punct- 
ure-hole, and the catgut is released from the silken loop. Now the left 
hand grasps again the scrotum, and the needle is reinserted exactly iDto the 
anterior puncture-hole, and carried around the varices externally to them, 
and close to the scrotal integument backward, until it emerges exactly from 
the posterior puncture. The other end of the catgut thread is then taken 
Qp by the loop of silk, and is brought out through the anterior aperture by 
iritbdrawing the needle. Both ends of the ligature are now seen emerging 
from the anterior puncture-hole. They are tightly knotted, cut off short, 
and disappear in the scrotum as soon as released. A slight amount of hard 

Swelling will appear around the place of ligature the next day, but will not 

oause sufficient discomfort to prevent the patient from attending to his avo- 

Oation. 

The author has employed this method with the best success in four 
^^ases. 

Extensive, varicocele can be cured only by free exposure, double ligature, 

^ud excision of the dilated veins. Under aseptic precautions this measure 

'is free from danger. 

Cask. — ^Emil Lnhidng, baker, aged twenty-one. Large varicocele of the left side, 
extending down to the middle of the inner aspect of the thigli. April 25, ISSJi. — At 
the German Hotpitol the scrotal yarices were exposed by inci^^ion, and a largo plexus 
was separated and tied above and below. The intervening veins were exscoted. 
Another incinon of eight inches in length exposed the varicose veins extending down 
the thigh, and they were also exsectcd after being secured by double ligature. A 
rather wide strip of attenaated skin had to be removed along with the veins, prevent- 
ing entire olosare of the femoral wound by suture. Uninterrupted euro of the sirrotal 
wound by primary union of the femoral one by granulation. June S2d. — Patient was 
discharged onred. 

Four more somewhat less extensive cases were treated in a similar man- 
ner, and all healed by the first intention. 

Care must be taken not to remove nil the veins of the pampiniform 



152 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



plexus. In tlic Authors sixth case necrosis of tiie testicle was caused by t^o 

extensive excision of the dilated veins. 

Ca»e. — .Joseph Stern, b.'ikiT, iij^ed twenty-two. Extetisive varicocele of the left 
side. March 17, ISM. — Kspisjon of varices at the fierniiui Hospital. March i^th.— 
Necrtwis of tetttiiile was anted. A few of the stitches hiid given way, and tiie yellow- 
ish, dist^olored testis was distinctly visilde. April Sffi. — The testicle came away with 
very moderate wero-purtilent secretion. April 26th. — Patient was dist'hiirg^od eured. 

3. Vastratimi is indicated by neoplasms, tuberculosis, or pypbilis of the 
testicle, in the hitter case, however, only when the disease is not jinienable 
to systemic treatment, and is a source of much suffcriug. 

The author's procedure for fa.sfrafion is ns follows : The patient*-* geni- 
tal region is shaved, scrubbed with soap and hot wat-er, and dit^infected with 
corrosive -sublimate lotion, or, if any open ulcer or tistula be present, these 
are Hnally syringed or touched up with an eij*ht-per-oeut solution of chloride 
of zinc. Fir.Kfy ihf seminal cord is exposotf well above t!ie diseased testicle, 
and, boincf scparuted, is taken up by the index of the left hand. The ves- 
sels eonijiosiiif; it mv successively g^rusped by separate artery-foreejis, while 
the vas deferens remains intjict. As soon a.s all the vessels are thus secured, 
they are nipped o(T one after the other with the scissors in front of the 
arlery-forceps, and are at oace tied. The vas deferens is cut through. 
Hefore being released, the mesial end of the severed cord is somewhat relaxed 
Mild carefully inspected, to see whether nil bleeding be stanched or not. 

iiy making the division of the cord the tirst step of the operation, the 
subsequent parts of the procedure are made decidedly less bloody. Dissec- 
liuii of the testicle pro|ter is nuich easier and more rapid than if the reverse 
onler is observed, and the stump of the cord serving as a convenient handle, 
oonlaot of the surgeon's fingers with ulcerating surfaces or fistulas can 
»lt<»ijether be avoided. A few more ligatures will be generally needed along 
the hiitlom of the scrotum, 

\ drainage-tube la inserted, extending from the ingtiinal ring down to 
\\w lower angle of the cutaneous incision, and then the wound is united by 
intorruplt'd catgut sutures, the edges of the cut being held innehed u]) by 
the liugi'fs in passing the stitches. A dressing similar to that used after 
tw»n»iolji«ny is applied and left on generally for eight or teu days. The tube 
k* irnioMMl with the tirst dres^sing. 

Txm(! i*f <he cortl in mass saves a little time in operating, but the stump 
|{v4tH^h' nocrosos. and cure is very much delayed by the slow process of its 

K^tf^rHtioi) WM i^rfnrnied by the author twenty times : in fift<'en cases 
llNI ^^iW^nHtKiiiB. One of these cases died of erou2>ous pneumonia, probably 
'MftfrJI ^v f4hcr iintBsthesia. 

.«% - ^yK^*«* IJ-. merchant, agwl sixty. Jannart/ 24-, W<'?7 — C'flHtratii»n for tnber- 
^ ^,^ .: ^>At iv«4Mcnt Mnunt Sinai Hu^pitul mtder ether. The operatiou did not pre- 
^llj^^y, '.*ttn^ Mid the patient did well after it imtil two o'clock on the after- 

k», '^^'. when suddenly high fever with dyspnrea appeared, and developed 

I,. t fc»» hour*. .\l (5 f. M. the tliernioinuter indicated lOtV'** Fahr. in 



; 



J 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



153 



the rectum; at 9"55 i\ m. the patient iMfd. huHness at the ba»e uf tlie right lung, 
iiiiide ont a few hours before deatli^ t-orre^ipondef] to an art-a of frttili lobar pneitmnnia 
luujid at the autopsy. The wouud, jjtritoneiJ cavity^ and kidneys were normal. 

Fourteen cases castrated fur tnl>erculosis all recovered. 

In oi»e case castration was done for -^lyphilitif {^unim:i of the left testicle 
of tive years* standing, which had remaiued uniuilueneed by various kinda 
of constitutional treatment. 

Case. — Jitlin W. (J., brewer, aped tbirty-ei^jlit. Ijirge liydroeele cnnse4 by chronic 
specific disen.se of tlie testicle. March 4, l^ST. — The liydrocole wjia incised, and the 
testicle was found very much enlttrj^ed ; the ragged iind hard epididymia waa occupied 
by a solid fibrous moss cxtentUnfr well into the gluuduliir tisi^iie of the teHticle. Cas- 
tration was Ht once done. Man'h l')fh. — Patient discharged nearly ciire<l, the place of 
exit for Che drainage-Eube [^renenting u dtnnll Mpot of granulation:*. 

Ill hvo cases ablution of the tt-sticle Irad to be done for malignant ueo- 
^lIai^^l. They recovered. 

Case I. — .Jacob Praeger, t-silor, aged soventy-two. Very large giant-cell sarcoma 
of right tt>**tis. Dte«mbfr .J, 1879. — Castration. Preparation of the howels by laxativea 
was insufficient, and on the third day atYer the operaliitn viok-iit colic <Ievelo]ied, xvhieh 
could not be controlled by optuted. In ihe ni;;ht ii large «tool escaped into tlie lied, 
the dressings and the wound were soiled, and in a few hours fever !*et in. The wound 
was injected with an eiglit-fner-cent solution of chloride of zinc, which checked the 
fever. Much ^loughi[lg tissue came away, but patient recoveretl, and was disiihnrged 
cure*! about five weeks after the oj>erati«m. 

The author's exiwrience in this ease taught hitn the valuable lesson of 
ru'vcf ti'uxting thi' pftiicniii' staleintnt rftjartlin;i the ariion of their boipcja^ 
mid iit'ver leaving the numner of pre])aratiou of tlu> intestine fo their judg- 
ment. Ill this ease the patient a.ssured the author that eitrate of magnesia 
acted ou him like a eharm. Citrute of magtie.-iia was taken, with the ivsult 
reported alH)vt'. Had a good do-^^e of oil or cnlomt'l raked out the ilaecid 
and co|irostatic gut of the old man before tlie operation, his life would not 
have been endangered by snbsefjuent fecul infection of the wound. 

Oabk II. — Siegmimd Hertz, clerk, aged thirty-two. Angttst 5^, /^A^.— Castration 
of right testicle for niyxosurcornn nt Mount Sinai IIoHpital. Primary union. Srj»tem- 
her I6th. — Patient disclinrged cured. 

Twice cantratrm mi ft thnc fur Hprnitaneous ganf/retie of (hi- frsfich. 
Bt»tli cases recovered. The record of one was lost ; that of the other is as 
followa : 

Cask. — (ieorgo <)ttr>, Imtrher. /vged thirty-nine, admitted, February 2, 1«8(>, to 
Geriuiin llnspilal vvitli tin enormous enipJiysenuitoua sweSling of tlie left testicle. The 
organ had nearly the size of a tuan'« lii.'ad, was du.sky red and hot. 9howe<l crepitus, 
and gave tympjinitic percnHsjon-wJund. The patient, a powerfully built man, showed 
•ymptomn of tm^M, fu-ute septic intoxication. He stated, on being shaken out of his 
atopor, that the swelling had cmie on ttirec days ago suddenly with much pain after 
n probatory pundnre. Irnuiediate ablation <if tlie organ was done. The skin was pre- 
served, and the very large wound cavity was filled with a packing of carlmlized gauze. 
An almost itnrnHliate iroprovement of the patient's general condition followed. The 





l.U 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



wound Lealed mtbor rapidly by (!:rauulatioo. Febrttan/ i?6/A. — Patient was disirharge 
loured. Exuiumiition ot the speoimeii showful hlondv iiifari-timi of the testis and epi- 
didyuiis, witli far-gime disinte^jralioii uiid softening of tlie lid^uea. The tunica aad 
subcutaneous coDnective tiBstie were in a state of emphysematous gangroue. 



r, 




Liitcrul view i.l'i.utiitit in Hi«»iiu.tj 



ZUL ASHPTIO OPBRATIONS ON THE RECTUM. 

1. General Observations. — The aseptic iierformuiicf of rectal ojiorationif 
done for hnemorrhoiflul or othoi* tumors^ re(|iure.s a. cureful preparation ol 
tlie gut. It consists, first, of ttie 
admiuistratioii of a catlmrtic like 
cftrit.(ir-oil or calomel several dayj^, 
in elderly subjects a 
week before tbe op- 
orution, followed up 
by Hit' daily exhibi- 
tion of i\ i^aliue laxa- 
tive, to be rfiven on an 
empty stomucdi. Four 
hours before the time of the 
operation a ljirf;e enema of 
soap-Wiiter is tidminisitered, 
and, as soon as it has neteil, 

a full dose of opium is given by mouth, or is introduced into the rectum 
in the shape of a suppository. 

When the ana^sthetiaed patient is laid on the operatintj-table, a gixnl- 
sized sponge attached to a stout silken thread is 
thrust well up the rectum, and, the sphincter 
beinnr thoroughly stretched by manual force, the, 
aiiU8 and rectal pouch are fVnslied with a ijtrcaiiii 
of corrosive-sublimate lotion (I : l.Oixi) throra 
from an irrigator. 

IKiring the jirogrcssof the operation irrigation 
has to be kept up con- 
stantly at short inter- 
vals. When the jicrito 
iia'um iij approuched, , 
or has to be iuva<led by 
r he aurgeon/rhierseh's 
solution is sukstitutet] 
for the mercuric lotion 
as an irrigating fluid. 
'I. Haemorrhoids.— 
A varicose condition 
of the ba*morrhoidal 
veins of recent origin, 
tcrior vi.,w of i-i(Ui;!)t in H'-ziiihinrt i-.-iii-ii. euused by sonic dia- 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



155 



* 



turbauce of the portal circulutiuu, is often ameuable to ^eueral treatment 
by fultilling the causal iudicatioii. Kemoviiitr a fecal reteution, or regu- 
lating the portal circulation with a dose of calomel, followed up by a course 
of Carlsbad salts, will often do away with the hsemorrhoids caused by these 
conditions. Or regulation of the heart's action by digitalis in valvular 
lesions will be followed by marked improvement. When the h:eniorrhuidal 
nodes are iu a state of acute phlebitis, marked by painful hot swelling and 
fever, topical applications of cold in the shape of enemata of ice-water or 
iced compressors will give much relief. 

Aggravated cases, however, especially when there is a state of prolapse 
of the mucous membrane of the anus, can be cured only by operative meas- 
ures 

Of all ojyerations for the cure of haemorrhoids, tliat by ligature com- 
mends itself as tlie simplest and safest. This statement is based on an 
experience gathered from sevend hundred ctises operated by the anthor 
according to various methods. 

The manner of procedure is as follows : The ansestlietizcd patient is 
brought either in the lithotomy ]H>sitiou, with a liard cushion under his 
buttocks, or he is arranged in Hozemauls manner far the uperittiuu uf vesico- 
vaginal fistula (Figs. 122 and 123). , This latter position is uspueially use- 
ful where the assistance needed for holding the patient iu the lithotomy 
position can not be procured. In both cases the feet and legs of the patient 
should be iirotccted fnmi exposure by a wrapping of rubber sheets. Tliese 
fhould be covered over with clean towels wrung out f>f mercuric lotion for 
the protection of the assistants' hands from contamination. 

Selecting the lithotomy jiosition, the patient'sji palms sliould be brought 
in contact with his soles, and this relation sliould be ^iecured by tight band- 
aging. The operator, well protected by a rubber apron, takes a seat in front 
of the patient, and proceeds to vigorously stretch the sphincter aui muscle 
with his thumbs inserted iu the anus. As soon as the sjihineter is paralyzed 
by stretching, the hsemorrhoidal nodes, external and intermU, will spontane- 
ously protrude, A s|K>nge secured with a thread of silk is thrust into the 
rectum, and the field of operation is eleauped by irrigation. The lowest 
node is grasped with an artery forcef)9, and, Iteing well drawn out, is cir- 
cumscribed by a shallow incision made witli a pair of curved* scissors, A 
curved needle is taken, armed with udctubh* thread (►f stout disinfected silk, 
and with it the ba-e of \hv tumor is transfi\eil from without inward. The 
eilk la cut near the needle, and. the threads being .separated, the base of the 
node is tied in two portions. The node is cut off below the ligatures, and 
then the renuiining no<les are attended to in a similar manner. When Ihe 
o()erati(jn is linished, some iodoform powder is rnbtM*! into the nodal slumps, 
and, after a final irrigation, the sponge is witlidrawu from the rectum, 
which is mop|>ed out dry with another s^ionge attached to a long stick or 
sponge-holder. (Fig. 124, a and r. ) 

A hollow tampon is next prepared by vvrai)ping a few layers of iodoform- 
ir.o<l gttuze around a piece of stout rubber tubing three inches long. This 






end is tmnslixed with a large-sized safety-pin, (Fig. 125.) 

The object of thit? tampon is twofold, Its^ main object is to faclliiau* 

the escape of llatus. a ciroumstjince liigblv 
appreciated by elderly tlatuleut individniib:. 
Another purpose is the prevention of oozinj 
from the stiteh-holes. 

The anal region is thickly anointed with 
vtujeline, and, the 
saftHy-pin bi'inguo- 
der-pud<led with a 
few strips of i«ido- 
fonnizetl gaiue, a 
large \)ad of com»- 
ive-.siiblimate ganze 
k lield down to the 
anus by a T-band- 
age. (Fig. 12G.) 

Forty-eight hour* 
after the oj>oration 
foil r on ncea of hWirt 
oil are injected into 
the reetum through 
e rubber tnJ>e, which 
can be withdrawn a 
short vvhile after with 
very little pain to the 
pMlient. A large ene- 
ma of !!onp-wat«r ii at 
once administered, and 
geiicrally is fedloweil by nn evaeuation of the 
linwt'Is. After the stool another small enema 
k given to cleanse the hiiemorrhoidal stumps 
of adherent fa»ce.«. The anus is dresse<l with 
a strip of iodoform ized gauze and a pad jw 
before. 
na*iNijig u (UiHQ of salts i.< given, and, stool following, the rec- 
tum is again washed citjt afterward. This ])ractice may liuvt- to lie repeated 
onee or twiee within the next few days. 

T\w patient may be (termitted to get up about ten day-; after tlie 
opiM-ation, but mnst remain at home til! after the detaehment of tin- 
ligatnre^, 

(Jnuierizaiwn withfttmimj nitric avid was formerly also much employed 
by the author ; but in one case almost fatal hremorrliage occuiTed from a 
small artery just within the s[>hiiicter on the detachment of the eschar. 
Since then the author has abandoned this practice. 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



15T 



Fig. 125.— TwDpuiJ-tuhe. 



Cabe. — Mr. M. I'., gihler, iiged tbirtj-one. Frbru- 
ary ;?4, /5/?:i.'.— Cauterijcutiou of extenml Jia<l intertittl 
lufimorrboids with riitric! acid, Mareh 10th. — At *2 a. m. 
the author was hastily summoned tu the bed siile of 
the jvatieat, and found hiin in ti co]lap!>ed cunditiun. 
He reportt'd tbat shortly after supper Le felt a desire 
to fftwA, and had a oin>iuus cvtiouatioir. Evai-untioris 
followed sinoo thcfi about every Iiniir, but, the r-lciset 
being dark, ho could not nay whctlier the stools were 
bloody. At 1 a, m., on coniinj!; back to bed from the 
water-closet, the patient fainted, HeiDg brought to 
bed, another siool followed, onnsitittng of a larjjje clot 
Aod some Iii|tiid blood. TIte putient was at unce juia^s- 
thctizcd, and, a speeiihuii beiiip inserted, ii rather hirge- 
sized artery was seen spurtini? from whero an e^rhar 
had been detaihed just inside of the sphincter. The 
vessel wa<3 seized and tied, and the putiout made a good 
recovery. 

Langenbeck's clamp and actual canteri/ meth- 
od is very good and safe, its only drawback be- 
in^'' llie necessity for a Ciuitfry u|>])anitus. Cjire 
mu.st be taken not to grasp witlr the clatni) the 
nodes too near their hiise. a.s the resulting e.schar i.s apt to be very large, 
and anal strirtiire may follow. Th(^ hnltow himpon is very nsefwl in this 

method al-^o, and its 
iitie ciiu be warmly 
recommended (Fig. 
lv*4, u). 

3. Rectal Tu- 
mors. — Since the 
imblication of Volk- 
mann's remarkable 
results achieved by 
extirpation of tlie 
nt-tuni (or cancer, 
the oj>eration, for- 
merly condemned, 
has met with fre- 
(|uent imitation. 
The author's mel- 
anchnly record of 
six deaths out of 
eight ojwrations has 
lid, however, that most 
i'orable conditions. All 
nvolvement of the gut, 
three inches — in one caee> 

T 








RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

uiiiL' inches — of intestine. Almost all of tbeni were performed during t ^^ 
first yc'ura of tlie author's imlependent surgical uctivitv, when his in;L«to 
of the ditlicult tectmiijUL', huth of the aj^eptice atid hemostiisis of the regJL 
in question, was imperfect. Much unnecessary hjemorrhuge was incnrrec:::^^^^* 
and several of the most important enutelai! against infection remained imcn 
jtloyed. Accordingly, two patietits died shortly after the operation of oji 
lapse, due to aculte nntemia; two died of purulent peritonitis, caused b; 
infection of the incised peritonfeum ; one died of septicaemia, indncwl b^ 
the presence of a largo retroperitoneal abscess, extending far up in f ront o^ 
the vertebral column. One patient, a very fat, flabby woman, died of loba* 
pneumonia at a time when the wound was nearly healed. 

Two eases of very extensive removal of the rectum made a remarkable" 
short and easy recovery. 

Cahe I.— Ed. Tm-tiiT, tiiwluinitv aged twtmty-nuie. Extensive soft adenoid canwr^ 
of tlie rt'trtiini, nf nipitl giovvtii. Tiie iiivolvod part of the fjiit was fWely mo^-ahlt!, 
altlioii^lb its uiifter limit omdd not bo ruQcliLHl by the ti[i of ttie iudex-finger, Smtm- 
htr 1<% JA"<V^. — E.xlirfiution of tli** rectum ut Muiml Sinai llospital. As the g:rowlli 
did not extend downvvjird tu within un ineh of the sphim-ter, this niusrie was pre- 
servod. The coecvs \vi\s exposed by a posterior niediun iiit-isiou, und was expected. 
Thy rnu(!<His meiribratu! of tlie lower unci of tin; gut wnB diftiectud up in the hliafte uf a 
cyhiider, mid wns cfhi-sed by n ligature to prevent ttio c's<'«pe of rettal contents during 
tilt' o[ierHtiL>n. Every vesi-^el vvu» immediuteiy yeeured and tied, eitlivr at being <-Ht <>r 
before divisiun, if it could be previously reeogmzed. The levator ani niu^k-le wa» 
detru-lied by dissection from the intestine. All rv.HiHtinf^ l^ands of' tissue, tiiostly oun- 
tjiininj; vessels, were secured iiy double masa ligatures ifefnre being divided. Motit diffi- 
eiilty waa met with in freeing tlie gut from its attacliuieutA to tbe deep pelvic fusoia, 
but by dint of muss ligntures tliis wa.s also overconie. A.s soon «» the pelvic fascia was 
parsed, the intestine reskdily yielded to traction, and was witlidrawn until the upin-r 
hiuit of the tumor was dislinetly felt through the walls of the gut. The peritoDxeam 
was detached anteriorly by blant separation, but it had to be incised on the posterior 
aspect of the rectum In permit complete removal of the growth. The gut was grasped 
with a large elamp-force[is about an inch above Ihe tuntor, and was severed. Tbe^ 
patent orifice of the rectum was carefully cleansed and disinfected, and, the clamp 
being removed, a nnniber of vessels of the reetal wall were secured and tied. Dnrinfr 
the whole i>peration the wound was almo-t constantly irrigated with corrusive-sabli- 
mate lotion (1 : 2,500), Tbe peritoneal incision being closed by catgut satofe. tb«*- 
wouml was* !oo*ely packed with iodoformized gauze after the insertion of two drain- 
age-tubeH into its bottom, and the gnt was attached to the skin by two silk siitarei'. 
The ends of the drainage-tubes were left projecting from the dre>*fings :ind the wonnil. 
was tltisliod through them at regular intervals of an hour. The reiuperatnre reni.iiueA 
normal except on the sixth day, when it rose to 103^ Fahr. The ]mtient compluini-fJ 
of colicky pains, and a saline purge waa administered. A stool following, the fever" 
disappeared. The wound was carefully cleansed by irrigation after ea<'h stool, and 
honied in spite of its great extent in six weeks. The removed portion of the gut meas- 
ured, when laid upon the taNe, just five inches. 

The resulting incontinence of the widely patent gut was reme<Ued by a procto- 
plasty porfornicd February 28, 1885, at the German Flofipital. The divided ends of 
the preserved sphinetur mus<'le were dissected out, and were united by a row of catgut 
stitches |>laced in the median line. In April, 1887, the pntient was free from relapse. 



■ Ca8B II. — Eu^roiie UaflFner, waiter, age<l twenty-four. Kelapainf? cancer of rectam 

aafti-r t'Xtir[iiitiiin done by Dr. F. Lanjie. February 24, JSS7, — Extirpation of tuldi- 
tioiiiil two inches of tho gut at tlie Geriimn Ilospitnl. reritona'urii wils found descorided 

I*" witiiin half an indi frotu thesikiD. It Iiud to be freely incised, aud wfH subsunnotitly 
closed by five catgut sutures. Uoiuterrupted recovery. April 'M. — Patient was di»- 
cliarged cured. 




The main soiirco nf infection is tlie interior of the giit. To exclude this 
<'ariger, the lower end af the rectum must be closed by a ctreular ligature. 
IKhen the gut is divided abore, care must be taken to prevent soiling of 
^he wound by escaping intestinal contents. 



XIV. ASEPTICS OF THE BLADDER, 

1. Catlieterism, — Infectious processes rarely orifjinate in the bladder 
itself. Their must common way of entrunco ik by the urethra from with- 
out ; next to this como the modes of infection from within — that is, by 
*lci}cent from the kidneys or by extension of contignous septic processes 
^i-om the orjorans located in the vieinii^y of the bladder, as for instance from 
X^»eritoneal or retro-peritoneal suppurations. 

As before indicated, the most common source of infection of the Madder 

is nn unclean catheter, Thf nnlimtri/ nn'/finf/s af rhunnuKj niffaiUc cathcfcru 

^y flushing with hot or cold wate}\ and stihsrqutnt rubhin;! off with a ch-an 

^owel, are aUogether inadequate. In order to secure their absolute clean li- 

:ness, the same processes of sterilization must be employed that were rccom- 

niendied for cleansing other hoJlow tubes — notably, as]>irating needles utnJ 

trocari*. Boiling for an hour in water, or passing the instrument through 

an alcohol flame until all organic matter contained in its lumen is volatilized 

by burning, is meant thereby. Only after smoke and steam have ceased to 

H escape from the catheter can it bo declared to be surgically clean. 

■ Before use, the cleansed catheter should be placed in a tray or flat pan 

filled with tepid salt water (6 : 1,000, or one heaped teaspoonful to a quart 

of boiled water) ; the surgeon's hands should be previously well washed with 

I soap and hot water, and the instrument should l>c anointed with ioduform- 
ized vaseline of the strength of 1 : 50 (fifteen grains to two ounces). 
Note.— The ordinary solutions of conro.'^ive aublimale or carbolic acid corrode the niitcoua 
membrane of the urethra and bladder, often causiag iatoti^c pain and reflex EiyuiptomB. The 
resulting denudations of the epithelial layer all may serve as poi-tuls of subsequent infection, 
manifeating itself in the form of urethral fever, urethritis, cystitis, and, in extreriie ciisca, 
meta.«tatic proces*8*.'9. None of these very active geriuicides should be iutrodiiwd into the 
healthy urfthm or bladder: first, hecaurte they are unneeessary; and, Becotidly, because they 
may do hann. Simple imiucriiion of a filthy catheter into the^e genntcidal tutiona nilt not dis. 
infect it sufficivntiy, and, if some of the strong solution he carried iuto the urinary pueeagefl 
along with a filthy catheter, the duktiecs of infection wiU only be tncreai>ed by the combination. 
Catheters that were immersed in strong disinfcetant Bolutions should be freed from thciu before 
being aeed. 

In passing the instrument into the bladder for exploration or evacuation, 
the utmost gentleness should be exercised, not only for the sake of the 





160 RULES OF ASEPTIC AND ANTISEPTIC 




i 

lile 
31 al^^ 



patient's comfort, bnt also because it is of impartiiDice not to injure t 
urethral mucous membrane. Certain parts of the normiil male urethra wiT 
oftcu raise obstacles to the pa'>sagc of the instrumeuL^ wliieh should netcr 
be overcome by force, but only by patient and gentle manipulation. 

The first obstacle is usually met at the suspensory or triant^i'ar ligament. 
Holding the shank of the catheter parallel with the abdominal wall while 
gently extending the penis upward in the same direction, thus pulling the 
latter over the former like a glove-tinger over a finger, will easily guide the 
beuk of the catiu^tcr around the promontory formed by the inferior margin 
of the symphysis pubis. 

The second obstacle will be occasionally found in the sinus of t 
bulbon.s portion. This pitfall must be avoided by exerting digital pre-ssui 
upon the perina?um, and indirectly upon Ihe beak of the catheter while 
gently depressing its handle. In sensitive urethra% the compressor ureth 
or ** cut-off" muscle, will offer by reflex contraction considerable re«ii 
ance to the progress of the operation, especially if an instrument of smal 
caliber be emtdoyed. It ia injudicious to f<)rce this obstacle. A better 
plan is to abide the moment when the muscle will relax, the instrumeili^| 
being held against the resisting band by gentle pressure. As soon as relaxa- 
tion begins, the point of the catheter will be felt slipping through the 
contracted part of the urethra. 

The enlarged prostate is the last and most difficult, becanse deepest, 
impediment that may retard the operator. A long-beaked iustrument will 
penetrate to the bladder easier than any other one. The liandle of tl 
catheter must be deeply depressed between the thighs of the patient, and, 
this be insutficient, tlu» tip of tiie left index introduced in the rectum mui 
aid the entrance of the beak by gentle upward pressure. 

Proper Itf perfort/u'fl calhetfrium of a healthy urethra and bladder should 
not be followed by hwrnorrhttje, 

iSoft catheter .s made of gum elastic or welibing impregnated wi 
resinous matter are never safe unless their history is known to the operatoi 
They should be new, or, at least, such should never be employed that had 
been previously used on a septic case, or were not carefully cleansed, disiu- 
fectcd, and preserved in a proper manner after use. ^^ 

Soft gum-elastic or l*Jelaton cathct<M'3 are very cheap, and need not 14^| 
preeervcd after having been used in a septic case. Before employing a soff^ 
catheter, it must be soaked for ten minutes in hot soap-water and flushed 
out with it ; then it ia disinfected with a strong germicide lotion, preferably 
corrosive sublimate, from which it must be freed again by another flusbin 
with salt water before it is anointed with iodfjforniixed vjiseliue for in 
duction. 

After use, the catheter should be again Hushed out thoroughly with 
bolic or mercurial lotion, dried, and put away in a tight bos or wid 
mouthed bottle. If needed frequently, the catheter should be ke]>t i 
mersed in a two-per-ccnt carboJic lotion. Before use, hoAvever, the adhere 
carbolic lotion must be always removed by washing in salt water. Tl 



rdl 

1 



I 




I 

I 



I 



APPLICATION OF THE ASEPTIC METHOD. If^l 

anthor saw a considerable number of eiises in which catheterism had to be 
done for gome time after rectal operations, and in which troublesome 
urethritis developed on account of the corrosion cansed by frequent contact 
of the urethral mucous membrane with the carbolic acid adherent to the 
elastic catheter. 

Searching a non-dilated bladiler for stone, tumors, or foreign bodies 
would lead to superficiid injury of the mucous membrane; therefore, dilata- 
tion, by injecting three or four ounces of salt water, should precede every 
exploration. After completion of the search, clots should be removed by 
irrigation with the saline solution. 

These remarks refer to bladders only that discharge normal urine. 

Whenever examination of the urine gives evidence of a catarrhal or 
septic condition, every intravesical manipulation must be preceded by disin- 
fection of the bladder by Thiersch's solution, or a lotion con.-^isting of one 
part of [>ermanganate of potash to five tliousand parts of tei>id water. Tiic 
operation should be completed by another disinfecting irrigation of the 
organ. 

2. Litholapaxy. — The rapid and complete evacuation of the bladder in 
one session, of all fragments produced by crii.shitig concrements with a 
lithotrite, forms a most valuable improvement of tlie tpchnique of lithotripsy. 
Bigelow*s evucuator eniibles the surgeon to free the fdadder at once of all 
sharp-edged fragments of stone. This circumstance justices the prolonga- 
tion of the operation to an extent formerly considered unsafe, as subse- 
quent irritation cansed by the presence of sharp fi'agments is thus done 
away with. 

Before introducing the lithotrite, strictures ought to be cut or divulsed, 
and the bladder onght to be thoroughly washed out with tepid |>ermanganate- 
«f-potash or boro-salicylic solution. After this the bladder is filled with 
from three to four ounces of tepid boro-salicylic lotion, and the lithotrite is 
introduced well anointed with todofortnizod vaseline. The penis is tightly 
doligated with a piece of rubber tubing, and the stone, being gi-asped, is 
crushed first into a number of larger, and subsequently into as many small 
fragments as possible. The crushing instrument is removed and is replaced 
by the evacuating catheter, which is connected with the ev;icuating bnlh, 
that was previously dlted with bnro-salieylic lotion. All small fragments 
are next sucked out of the bladder by the apparatus. Should a jTeeiiliar 
click indicate the fact that one or more fragments, too large lo pass the 
catheter, are still remaining, the lithotrite must be introduced anew to com- 
plete their reduction to a propur si/.t'. after which complete evacuation will 
meet no ditliculty. 

The bladder is washed out again until the irrigating fluid returns free 
from blood, and the patient i-< brought to bed. 

Small atones, es|iecially of the softer varieties, are eminently suited for 
tbie treatment, which has the great advantage of a short convalescence; 
but its disadvantage of a |H>ssible relapse from failure to remove all frag- 
ments can not be denied. 



LAKE imm. STWFORO UHlVtRSITY 




1R2 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Case I. — Moritz Witzkal, peddler, aged fifty. April 5, I884. — Litholapaxy «t th* 
German llosf«itul. Uratic stono with [iliortjiluitic shell wcipliing lour drachtu* liftr- 
five griiiiiH, Diiriition of operation, thirty-live minntos. Discharged April 28th. In 
June, patient was readinitted for Btone, which was removed hj I>r. Adler by mediitD 
litliotorny. 

Cask II.— Mr. E. B,, clerk, aged twenty-one, renal colic followed by symptoms i>l 
stone in flie blaii<Ier, whicli was diagnosticated by sounding. In March., 1887, litliot- 
rity au<i eviicuiition. The bludiler symptoms contiuucd until June, when Dr. 8ched«r- 
of Hamburg, removed aniither small calculas. 

The author performed litholapaxy in fonr more oasei. 

Oasb III, — Edward Mink, biiker, aged twenty-one, January Sfi, 18S1. — Ra| 
lithotrity for a phosphatic calculun weighing two hundred ami fifty grains. J^i 
5th. — Patient discharged cured. 

Case IV.— ^Ilunry Bowitz, agent, aged forty. April 2J^ 188^, — LitholApazy 
uratic calculas, weighing three draebniB and ten grains, at Mount Sinai Hospital...-^ 
May 10th. — Patient discharged cured. 

Cask V. — Francis Johnson, draggist, aged forty-seven. Pliosphatic calciiliu,^^^« 
amiiHmiacal urine. Oetoher 6\ 1S83. — Rapid lithotrity at Mount Sinai Hospital — — 
Weight of atnne, furty .seven grains. Duration, litty-five ininute.n. Discharged cured,. 
October 27th. 

Oabe VI. — Philip Prinz, shoeinaker, aged fifty-nine. Eapid lithotrity for r 
nratic calcalu?, done January 25, 1887, at German Hospital. On the day foliowi 
the fiperation all the symptoms of stone disappeared, but llie patient sostaincd n 
of the leg^ rciiuiring surgical treatment. This delayed his diseluirge until March 1" 

Intense forma of cystitis caused by the presence of calculi require aftei- 
lithotrity cotitinuod trefitmcnt of the bladder by irrigation. 

3. Cystotoiny. — In ])erineal as well as in suprapubic cystotomy, the con— 
dition of the urine should serve as a guide in determining whether aaepticr 
or anti.sGptic measurt^s hiive to be observed during the operation. When th 
normal condition i)[ the urine indicates that the vesical mucous mcmbran 
is in a healthy state, strong disitifeeting solutions should not be used within 

the bladder, and the surgeon's chief attention sliould be ilireett'd to the care • 

ful cleansing of his instruments, in order to avoid the introduction of filth— — ^ 

into the bladder. For purposes of filling and cleansing, a saline 01 ' 

Thiersch's solution will be all sufficient. j 

In cases characterized by pyuria, with or without ammoniacal odor, or*" 
with outright fetidity of the urine, disinfection of the bladder must precede 
and follow each operation. 

The rules of asopticism referring to the treatment of the external wonnA 
must also be scrupulously observed. During the after-treatment, drainages 
of the bladder may be required^ especially in cases where a septic condition* 
of the organ would render retention of fetid urine undesirable or risky. J^ 
rather stout rubber drainage-tube inserted in tfie bhuider will answer every 
practical purpose, 

(a) Perineal Section : 

Care I. — Fred. Kurtz, tiged fifty-five. Fhosphatic stone, ammoniacal urine. Feb- 
ruary i, 1881. — Lateral Uthotoiuy at the German lIuBpital. Weight of stone, tbr«« 




icr 



SPECIAL APPUCATION OF THE ASEPTIC METHOD. 



163 



drachms and fortv grains No reaction or fever. Continued waabings of bladder with 
aalicjrlic-ucid soltitions. April 10th. — Discharged cured. 

Case 1L — IIu;ro Liedtke, aged three and n half. Small aratic stone. March 19, 
1S81. — Lateral litbotoiny with the assistance of the family uttendant, Dr. Haasloob. 
Weisrht of ^toae, eiphleen grains. April ir>th. — r>i*«hHrtre<l cured. 



Fio. 127. — Arraii;^<'iijvtit "I I'lifiiui tVir I'orifjL'iil <-v.-tuti.'iji>. Feet wrBjif»t'd up in Jisink-t-tivl towcK 

{b) SrPRAprBlc Sectiok. — Tumors, a ver^- large prostate, encysted or 
very large stones, oxalic concrements, or rebellious cystic hseinorrhage from 
dilated veins of the neck of the bladder, indicate the .seleetiim of the hi<rh 
oiK'ratiou. Petersen and (^arson's jirojiositiou to distend Ijoth bliidder and 
rectum before cutting, marks a most valuable improvement of the method, 
as injury to the anterior reflection of the peritonieum can be thus avoided. 
A soft rublKM- lutir, «>r " col [>eurynter," similar to Barnes's dilator, is intro- 
duced into the rectum, and is filled with from fifteen to eighteen ounces of 
water. Escajie of the water is prevented by attaching an artery forceps to 
the end of the tube. 

Seven or eipht ounces of tepid salt wnter or boro-salicylic lotion are 
injected into the bladder, and the penis is tied with a piece of rubber tub- 
ing. The patient's shaved sujirapubic region is carefully di.siufected, and 
a median incision is made, corameuciug about three inches above, and ex- 
tending to the symphysis. The recti muscles are separated, and the j)re- 
vesical fat is incised. Care mvxt be taken not to injure the reflexion of the 
peritoncBum. which maij be loolnl for in the upper angle of thr woiintl. In 
many cases the peritonaeum will not come in view at all. Should distention 
of the rectum and bladder not suGBce to push up and out of the way the 
jieritoneal fold, this must he separated from the bladder by blunt dissection, 
to be done preferably by the tips of the fingers. Vessels crossing the pa*- 
vesical space should be divided between double ligatures. 

The bladder is transtixed on each side of the median line with curved 
needles, carrying fillets of silk. The vesicid incision is made between these 





RULES OF ASEFnc AND ANTISEPTIC StJRGERY, 






164 



hold-fusts with a sharp-poiuted bistoury. In cases of doubt, the preiienti 
organ mny be first piuicturcd with h hypodermic needle. While the silke; 
threads keep the vesical wound patulous, the surgeou's finger explores th 
interior of the bladder. Stonea are then extracted with forceps, or th 
scoop, or even with the finj^ers, tumors are inspected and excised under th 
guidance of the eye, and bleeding varice;* of the neck of the bladder 
grasped and tied off or touched with tbe thermo-cautery. 

After thorough irrigation, a T-shaped draiiuige-tube (Fig. 128) U in,*ertec3^1 
in the bladder, and the external wound is loosely packed with iodoforniizetl^B 

f^auze. A split compress of the siinie material is ar- 

ranged about the projecting end of the tube, and i- ^-^ 
covered with a number of compresses consisting o^c^ ~ 
corrosive-sublimate gauze. The skin all around tlie^^ 

wound is profusely anointed with iodoformixed va*- 

line, and the dressings are held down by a few tuni^^ ^~^ ' 
of a roller-bandage. The patient is brought to bcd_ . 
and is laid on his side upon a circular air-cushion—— 
his back being supported by a number of cushion^=^^ 
beld up by the bucks of several chair!-, or by board -^^ 

stuck into the side of the bed. As the lateral po^i ■ 

tion has to be maintained for three days at lesit-( 
sides should lie changed every two or three hour> 
The drainage-tube projecting from the dressings i 
connected with a longer tube, that is led into a urina 
placed alongside the patient in or out of bed. A 
soon as the urine ceases to be bloody, and its reactioi" 
becomes acid, the patient may be allowed to assumi 
the supine posture. The drainage-tube can be 
moved on the fifth day, when the wound will be usu — ^ 
ally found in a state of healthy granulation. The packing of iodofurmiztH - -^ 
gauze has to be continued as long as urine e.sca[ies through the wound. A^ji" "^ 
soon us urination per vian naturaks is re-established, the woun<l should b«^^^^ 
dressed as any other auperficial wound. 

Oahk J. — Martin Gyr, laborer, H;?eil fifty. Large oxalic calculi of ten yc8rs' stand- — ■ 

my:., with nndilatable hhuldLM'. Wit'tchcil (general condition. April J^, ISHO. — Supm " 

jiubic lithotomy tU tho tiernian IIuHpihil under i;hl<n"ofoni), which was preferred V -^^ 
^>lher on nccoimt of tbn priisunci'' of ntsts rit the urine. Two immovable !»tones wrr^^ 
foand occupying the contracted bhuldiT. They were grfleptHi. freed l>y rotation. iio«^ 
extracted one afttT tbe other. They allowed on extraction two freshly broken *iip— ' 
faces, corres])ondJng to as many pedicle-like projections, bninciiing into two divert! — ■ 
cles, each containing a separate cidcultis. One of tbeae calcnU was extracted, the other" 
•ind smaller one waa left beliind, as thu patient's poor condition verging on coUap«»2' 
did not jnstify contiuuati«m uf the operation. The patient did not rally from tbe col- 
lapse, and died three hours jdter the completion of the lilhotoniy. 



J 



Fio. 123.— T-ahapoJ druiu- 
D^re-tubc for mitj'iipul'ir 
oyBlotomy. (Tixude- 
lenbur^.) 




The suprapubic incision gave free aece>\s to the bladder, and enabled the 
atithor to conduct the search and extraction of the calculi under the guid- 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



1B5 



ance of the eye. Tlemoval or even the Hndinit of the encysted calculi would 
have been utterly impossible from a perineal wound. Weight of ctileuli, one 
ouncej five drachms, and twenty grains. 

Cask II. — Mr. Adolph W., [duiubcr, aged fifty-siix. Vesical trouble of tliree years' 
^•tanding. Urine ^ligLtly acid, turbid, coutaininir mucit pus, but no casts. March SO, 
1S87, — Exploration of the very irritable bladder with the stone-searcher yielded no 
positive result. April IS^ 1SS7. — On exploration in ether auasstbesia, stone was found. 
A Thonipsou lithotritc beiug rutroduced, a larf^e ^torie was grasped, and on rotation 
was felt to grind af^'uinsl annther calfulus. Suprapubic Utbotoroy. Extraction of three 
•tones, each weighing; about forty-three prarnraes, their uggrepate weight being four 
ounces and tliree grains Troy weight. April 20tk. — Temperature, 100"5° Falir. ; urine 
clear, acid, containing no blood ; iti* daily quantity eighty ounces. April 2Sd. — Pittient 
was allowed to owupy the supine position. April !^5th. — The drainsige-tube was with- 
drawn and the packing removed. A soft catheter Wiu intro<Jiiced by the urethra, and 
the bladder was irrigated through it. The catheter was left in the bladder: the ex- 
ternal wound was refnicked. Temperature, y8'5" Falir. Matf M. — Thrombosis of 
right furaoral vein, apparently due to defective circulation caused by confinement. 
The right lower extremity enormously increased in size. Treatment: Elevated post- 
ure; later on, moist [lacking, and elastic c»mipre8»iuii by Martin's bandage. May 2;tth. 
— Lithotomy wound nenrly (."luHti] ; puiwed i*ome wati-r tbroii^Ii nretbni. Jmu- 'ith.^ 
Lithotomy wound closed; urination normal. Patient up and about most of the time; 
<Bdeiiia of thigh fast diirnnishinp. June 20th. — Swelling of tliigh almost gone ; patient 
discharged cured. Jniy 25th. — tleneral condition excellent. Patient entirely recov- 
ered. 

I'asb III. — Mr. Meyer IL, liveryman, aged thirty-nine. Symptoms of very ai-nt© 
cy«tic caUirrh of four inontlis' duration, causing the ]i>s.s of tifty pounds of flesh. 
Almost constant desire of and very ]ia)uful luicttirition, the acid urine containing 
blood, pus, some mucus, uric acid, and oxalate-of-lime crystals. The prostate was 
rery paiafiil on toach, but not ap]ireciably enlarged. The patient had become niorphi- 
ophagoas, and wsib thoroughly demnralized. Stone was searched for nnsut'cessfully 
by a surgeon. Jntie 17, 188G. — Suprapubic cystotomy at Mount Sinui Hospital. No 
stone wad found, but the mucmiH membrane of the bliulder presented & most marked 
itate of bypera?min and thickening, profusely blee<Ung ut the slightest touch. The 
ioHiunmation was mo!<t pronounced about, the trigonum and the neck of the bladder, 
where the retldening and tendency to htpmorrhuge were most intense. Trendelen- 
borg^s T-sbaped drainage-tube was inserted, und the ease was treated in the lateral 
position. The cystic irritation ceased at once, the Wood and pus in the urine dimin- 
ished, and morphine was discontinued, Jufi/ 17th. — The patient was removed to his 
home, where be maJe u rapid and perfect recovery. In Mnrch, 1887, a sliglit degree 
of catarrh of the neck of the bladder was cured by irrigation with permangunate-of- 
potaah lotion. The patient remained well ever since tlien. 



88 



leS RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Cajse I. — Moritz Witzkal, peddler, aged fifty. April 5, 1884.—L\tho\Hpiaj at the 
German tlo8|ntaL I'ratic stone with phoaphatic shell weiglnng fonr dracbuw fifrj. 
f5ve grains. Duration ol' operution, tLlrty-iive itiinutes. Discharged April 28Ui. lo 
June, patient was readmitted for atone, which was removed liy Dr, Adler by median 
lithotomy. 

tl.vsE 11. — Mr. E. B., clerk, aged twenty-one, renal colic followed by symptomtuf 
stone in llie bhuMcr, wlii<-li was ilingnosticated by soundinp. fn March, 1887. litlmt- 
rity and evacuation. Tho liladder symiitonis cantiaued until Juuu, when Dr. Scbeile, 
of Hamburg, removed ouother stuall calculus. 

The author perforraod litholapaxy in four more cases. 

O.iSE III. — Edward Mink, Uiiker, aged twenty-one. January S6, J8fil.—¥ia\>\i\ 
lithotrity for a [dioaphatic calculus weighing two hundred and fifty grains. Marth 
5th. — Patient discharjjfd cured. 

Cask IV. — Uenry Bowitz, ageut, aged forty. April 2J^ 188J^—'iA\X\o\xpvs:j 
nratic calculus, weighing three drachma and ten grains, at Mount Sinai Uoapii 
May lOih. — Patient di.-4rharged cured. 

Case V. — Francis Johnson, druggist, aged forty-seven. Phosphatic calculi 
ammoniacal urine. October 6^ IfiSS. — Rapid lithotrity at Mount Sinai Ilotpital 
Weight of atone, forty seven grains. Duration, firtv-tive minutes. Discharged core*!, 
October 27th. 

Oase VI. — Philip Prinz, shoemaker, aged fifty-nine. Rapid lithotrity for small 
nratit! ealculnsi, done January 25, 1MH7, at German Hospital. On the day following' 
tho nporntton all the symptoms of ^tone disappeared, but the patient sustained n burn 
of the leg^ requiring surgical treatment. This delayed his discharge until March ITUi. 

Intense forms of cystitis caused by the presence of calculi require aftor 

lithotrity continiiod troiitnii'iit of tho bliiddor by irrigation. 

3. Cystotomy. — In perineul as well iis in suprapubie cystotomy, the con- 
dition of the urine should serve as a guide in determining whether aseptic 
or antiseptic measures have to be observed dnring the operation. When the 
norma! condition ttf the uriac indicates that the vesical mucous membrane 
is in a healthy .stjite, strong disinfecting solutions should not be used within 
the bladder, and the surgeon's chief attention should be directed to the care- 
ful ch-ansitig of his iiistrnnients, in order to avoid tho introduction of filth 
into the bladder. For purposes of filling and cleansing, a saline or 
Thiersch's solution will be all sufficient. 

In cases characterized by pyuria, with or without ammoniacal odor, or 
with outriirht fetidity of the urine, disinfection of the bladder must precede 
and follow each operation. 

The rules of asepticism referring to the treatment of the external wound 
must also be scru])nlously observed. During the after-treatment, drainage 
of the bladder may be required, especially in cases where a septic condition 
of the organ would render retention of fetid urine undesirable or risky, A 
rather stout rubber drainage-tube inserted in the bladder will answer every 
practical purpose. 

(rt) Peri. VEAL Section : 

Case I. — Fred. Kurtz, aged fifty-five. Phosphatic stone, ammoniHoal urine. 
tuary 1, 1881. — Lateral lithotomy at the German Hospital. Weight of stone. 




PART n. 



ANTISEPSIS. 





RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

nine inches — of intestine. Almost all of them were performed during the 
first years of the authors independent surgical activity, when his masterr 
of the difficult tcchuique, Iwth of tlic aseptics and homostjwis of the region 
in fjuestion, was impci'fect. Much uuneeeseary liaemorrhnge was iucarred, 
and sevemi of the most iniportunt eaut-ela? atjainst infeetion remained unem- 
ployetl. Accordingly, two patients died shortly after the operation of col- 
lapse, due to acute anjeniia ; two died of purulent j>eritonitis, caused bv 
infection of the incised jieritonasuni ; one flied of septicapniia, induced by 
the presence of a large retrojwritoneal ahsccss, extend in<:r f«r uji in front of 
tlio vertebnd column. One patient, a very fat, flabby woman, died of lobar 
pneumonia at a time when the wound was nearly healed. 

Two cases of very extt*n>*ive removal of the rectum made a remarkably 
short and ea.sy recovery. 

(Jask I. — Efl, Turner, mc<>lianic, nged twenty-nine. Extensive Boft fulenoiJ cwiper 
of the rectum, of rapid griiwtli. The involved part of the ^ut was Irt-oly niov&ble, 
olthotiixh its upper limit could not bu reached by the tip of tlio index-finger. Notem- 
her IS, ISS^. — ExtirpiUion of ttu- rtn'tiira nt Mount kSitmi llospitnl. -\a the provtk 
did tiot extend d(nvnwiir<l to within iin in<.-h uf tho Hpliini-ter, ttn'i^ luus^'le waft pre- 
served. The coccyx vvns esfxjst^d by a pojittTior mudiun iD«ii^ioii, and was exsected. 
Thy tmieuus nieinbrajnj of tliu lower end of tlie gut was dtsseeied up in the shape of A 
cylinder, and vvjw closed hy ii ligature lo prevent the escaj>e of revtal cunt-ents daring 
the operation. Every vesssel wus ininiediately feeuretl and tied, either at Ix-iDg cut or 
before division, if it could ho previously recognized. The levator ani luudele wjtf 
det;nhed by di»t*eetioii from the intestine. All resisting bands of* tissue, moetly pon- 
tiiining vessels, were secured by double moss ligatures before being divided. Most ditfi- 
nilty was met witli in freeing the got from its attaohnients to tho deep pelvic fascia, ^^M 
but by dint of nniHi!* ligntoros tins* was also ov«.*rconie. Ah soon as the pelvic fascia wa* ^^^ 
parsed, the intestine renilily yielded to traction, and was withdrawn onlil the npper 
limit of the tumor wus diminetly felt through the walla of the gut. The peritonicani 
was detached anteriorly by blunt separation, but it bad to be inciseti on the posterior 
jiHpect of the re<'ttim to permit complete removal of the growth. The gut was grasped 
with a larue elamif-fon'e|»s about uu ineiv above the tumor, and was severe<l. The 
patent oritire of the rectum was carefully cleansed and diwnfected, and. tlio rl&iiip 
being removed, a number of vessels of the rectal wall were secured juid tit,*d. Dnring 
the whole operstion the wound was alniost constantly irrigated with corrostve-sabH- 
tnate lotion (1 : 2,500), The peritoneal incision being closed by catgut suture, the 
wound was loosely packed with iodofonaizeil gauze after the insertion of two drain- 
age-tubes into its boltora, and the gut was attached to the skiu by two silk sutare*. 
The ends of the drainage-tubes were left i>rojertiug from the dressings, and the wound 
was Hushed through them at regular intervals of an hour. The temperature renunned 
normal except on the sixth day, when it rose to 103'' Fahr. The jiatient coniplained 
of colicky pains, and a saline purge waa administered. A stool following, tike fev^r 
disappeared. The wound was carefully cleansed by irrigation after each stool, nnd 
henled in spite of its great extent in ais weeks. The removed porthm of the gat uiea»* 
ured, when Inid upon the table, jn>t live inches. 

The resulting iDcontinence of tho widely patent gut was rerae«iied by a procto- 
plasty performed February 28, 1885, at the (ierman Hospital. The divided end* of 
the ]ireserved sphincter muscle were dissected <«ut, and were united by a row of cat^t 
stitches placed in the median Hue. In April, 18h7, the patient was fn-e from relapM> 




Case II. — Eu^reno Ilaffner, waiter, agm\ twenty-four. Relapsing cancer of ret'tmn 
»ft*r extir|»atinn dont) bv Dr. F. Laii(fe. Ftbruary S4, 1S87. — Extirpation of fidfli- 
tiuual two inches of the gut at the Germftn Hospital. Ptsritnnroum wa.s found ilescemU'd 
U> within half an inch from the skin. It lnul to be freely incise<]t siiul wus siibseijui'Dlly 
closed by five cutgut sutures. Uuiuterrunted recovery. April xtd. — Patient was dis- 
ch urged cured. 

I The main source of infection is the interior of tho gut. To exclude this 
danger, the lower einl of the rectum must be closed by a circular liguture, 
Wlien the gut is divided above, care muat be taken to prevent soiling of 
the wound by escaping intestiual contents. 

XIV. ASEPTICS OF THE BLABBER. 

1. GathBterism, — Infectious processes rarely originate in the bladder 
itself. Tlieir most common way of entrance is by the urethra from witli- 
out : next to this come the modes of infection from within — that is, by 
descent from the kidneys or by extension of contiguous septic processes 
from the organs located in the vicinity of tho bladder, as for instance from 
|)eritoneal or retro-peritoneal suppurations. 

As before indicated, the most common t?ourceof infection of the bladder 
is an unclean catheter. 77ie ordimiry meihodx of dtansing meiallic cathdt'r.< 
by fluskintj with hoi or cold water, find fnihseqiienf ruhhitifi off with a cJitut 
toicfl, are idUKjiihcr inadfqttfftc. In order to secure their absolute clean li- 
ne.".'*, the !5ame processes of sterilisation must be employed that were recom- 
mended for cleansing other hollow tubes^ — ^notably, aspirating needleti and 
trocars. Boiling for an hour iu water, or pa-ssing the instrument througli 
an alcohol flame until all organic mutter contained in its lumen is volatilized 
by burning, ia meant thereby. Only after smoke and steam have ceased to 
escape from the cathctt«r can it be declared to be surgically clean. 

Before use, the cleansed catheter should be placed in a tray or flat pan 

filled with tepid salt water ((J : 1,UUU, or one heaped teaspoonful to a tjuart 

Bf boiled water) ; the surgeon's bands should be previously well washed with 

soap and hot water, and the instrument should bo anointed with iodoform- 

iised vaseline of tlie strength of 1 : U) (Jifteen grains to two ounces). 

P Note. — The ordinary solutions of corrosiye sublimnte or carbolic acid corrode the mnoous 
membrane of the urethra and bladder, often cutisiog inknse pain and icfles fiymptotna. The 
rt'>«ultmg denudatioDd of the epitfaclial layer all miiy serve a.t portals of .Hubseqnent infeetion, 
manifesting it-self m the form of urethral fevt^T, mretbritif, cy^titiSj and, in estrciuc eiifiCS, 
metastatic prwessi-s. None of (hi'Sf very uelive geriiiicidcfl should be iatroduiied into the 
healthy urethra or bladder : first, because they are unncce»t;ary ; and, necondly, because they 
may do barm. Simple immerdian of a Olthy catheter into (hcic gerniieidal lotions will not di!<. 
infect it BuflScicutly, and, if some of the strong nohidon he earried into the urinary passai^ea 
along with a filthy catheter, the chane^s of infection will only be increa.«e<l l\v the combinalion. 
Catheters thai were imnier.ocd In Btr(>ng difeiiifcctant solution.* should be freed from them before 
eing need. 

In passing the instrument into the bladder for exploration or evacuation, 
the utmost gentleness should be exercised, not only for the stike of the 





li-yu RULES OF ASEPTIC AND ANTISEPTIC SURaEKV. j 

piilicnt's comfort, but also because it is of itu]iortarice nut to injure t\» ^ 
urethral nnicous membrane. Certain parts of the normal male urethra vi ^' i 
often raise obstacles to the passage of the instruments which should ner^^^ 
be overeouie by force, but only by patient and gentle manipulation. 

The lirst obstacle is usually met at the su8|>eiisory or triangular ligamen^K' V 
Holding the shank of the catheter parallel with the abdominal wall whil^t^ Jf 
gently extending the penis ujnvard in the «ime direction, thus pulling th 
latter over the former like a glave-hnger over a finger, will easily guide th 
beak of the catheter around the promontory formed by the inferior margiKi S| 
of the symphysis pubis. 

The second obstacle vvill bo occasionally found in the sinus of th" ^*l 
bulbous portion. This pitfall must be avoided by exerting digital pressun*''""^ 
upon the perina^um, and indirectly njwn the beak of the catheter whili^ < 
gently depressing its handle. In sensitive urethra;, the compressor uret hi 
or " cut-oflf " muscle, will ofEer by reflex contraction considerable resist 
ance to the progress of the ojieration, especially if an instrument of smaL. 
caliber be employed. It is injudicious to force this obstacle. A bettei 
plan is to abide the moment when the mu.-^cle will relax, the instrumen' 
being held agaijist the resisting band by gentle pressure. As soon as relaxa.-^ 
tion begins, the point of the catheter will be felt clipping through the 
contracted jiart of the urethra. 

The enlarged prostate is the last and most ditlicult, because deepest, 
imi>edimeut that may retard the operator. A long-beaked instrument will 1 
penetrate to the bladder easier than any other one. The handle of the 
catheter must be deepiy depressed between the thighs of the patient, and. if 
this be insutficient, the tip of the left index introduced in the rectum mu6t 
aid tlie entrance of the beak by gentle upward pressure. 

Properly pcrfnrmrd vu/ftrfm'.sm nj'tt fnvlfhi/: urvthra and bladder should 
not be JhUowi-d by httniorrhwjt. 

tSoJ'i cfdhi'trrs m:\\\v ttf gum ehistie or webbing impregnated with 
resinous matter an m ■. i r sife unless their history is known to the oj>erator. 
They should he new, or, at least, such should never be employed that had 
been prcviously used on a septic case, or were not carefully cleansed, disi«j- 
fected, and preserved in a jtroper manner after use. 

tSoft gum-elastic or Nelaton catheters are very cheap, and need not hv: 
preserved after having been used in a sejttic ease. Before employing a soft 
catheter, it must be soaked for ten minutes in hot soap-water and flushed] 
out with it ; then it is disinfected with a strong germicide lotion, prefcrahli 
corrosive sublimate, from which it must be freed again by another flushing 
with salt water before it is anointed with iodoformizod vaseline for inti 
dnction. 

After use, the catheter should be again flushed out thoroughly with cai 
bolic or mercurial lotion, dried, and put away in a tight box or widj 
mouthed bottle. If needed frequently, the catheter should \>e kept \i 
mersed in a two-per-cent carbolic lotion. Before use, however, the adhenj 
carbolic lotion must be always removed by washing in salt water. 



PART II. 



ANTISEPSIS. 



162 RULES OF ASKPFIC AND ANTISEPTIC SURGERY 

Cabe I. — Moritz Witzkal, pMJtldler, aged fifty. April 5, I884. — Litbolapaxr at the 
German tlo8[>it!i]. I'nitic skme witL [)bo.sphatic i»liell weighing four drachau fiftj- 
five grains. Duration of o[>eriitioii, tliirtj-tive minut^js. Dii»charged April S8tiu In 
June, patient wuh readmittecj for stun*?, which was removed by Dr. Adler by mn'i'um 
littmtomy. 

Ca»b II, — Mr. E. B., clerk, iifred twenty-one, renal colic followed by Bympftoouof 
Htonvi ill the bhidrk^ri whit-li waa L|iti|,'ut)9tjeated by soundinjr. In March, 1887, litixA- 
rity and t'Vii<"iiation. Tht} bladtJer sytnptonia coDtinued until June, when Dr. Sch«dr, 
of Hamburg, remoTed another Kniall caloulus. 

The autbor perfiirmed litholaiuixy in foar more cases. 

Cabe III. — Edward Mink, bnkcr, afjcd twcnty-unc. Jannanf 20, iA9/.— lUpli 
Hthotrity for a phuxphulif cab-uliis weigbinij; two hundred and fifty grains. Ma 
5th. — Patient di«obar(rt."d enircd. 

Cask IV. — Henry Bowitz, agent, aged forty. April ^4. JSS4. — Litholapaxy 1 
nratic calculus, weighing three drachma and ten grains, at Moant Sinai Flospit 
Ma^ lOi/i. — Patient discUurgeil cured. 

Cahk V. — Francis Jolm.son, druggist, aged forty-seven. Phoephatic calcaliUk 
amnntnincal urine. Ockihcr 6', ISg-'jl. — Rapid lithotrity at Mount Sinai Ho»|HtAL 
Wi<iglit of Btnne, furty Mevun grains. Duration, dfty-five minates. Discharged cured, 
October 27tli. 

Case VI. — Philip I'rinz, shdeinaker, aged fifty-nine. Kapid Hthotrity for small 
nratie cQleulii?, dono January 2'i, 18K7, at German Hospital. On the day following 
the operution all the syni|)toin»4 of t^tont) disappeared, but the patient s^ustained a bora 
of thi-^ legs retpjiring surgical treaiiaent. This delayed his discharge until March ITth. 

Intense forms of cy.stitis caused bj the presence of calculi require after 
litliotrit}' contimiod treatment of the bladder by irrigation. 

3, Cystotomy. — In ])eriucul as well as in suprapubic cystotomy, the con- 
dition of the urine should serve as a guide in determining whether aseptic 
or antiseptic measures luivo to bo observed during the operation. When the 
norrnitl eotiditiori tif the uritie iiidieatcs tbat the vesical mucous membrane 
is in n healthy state, strong disinfecting solutions should not be used within 
the bhtdder, and the surgeon's cliicf attention should l>e directed to the care- 
ful cleansing of liis inslrumcnts, in order to sivoid the introduction of filth 
into the bluddrr. For purpo.Hes of filling and cleansing, a saline or 
Thiersch's sohition will be all sufUcient. 

In casew chiiraeterized by pyuria, with or without ammoniacal odor, or 
with outrij^ht fetidity of the urine, disinfection of the bladder must precede 
and foHow ouch operation. 

The rules of aseptieism referring to the treatment of the eitemal wound 
muMt also he scrupulously observed. During the after-treatment, drainage 
of the hfadiler in:iy be required, especially in cases where a septic condition 
of the organ would render retention of fetid urine undesirable or risky. A 
rather stout rubber ilraitiage-tuhe inserted in the bladder will answer everr 
practical purj)ose. 

(rt) Pkrineal Section : 

Cask I. — Fred. Kurtz, aged fifty-five. Phosphatic stone, ammoDiacal urine. F(^ 
ruary i, 1881. — Lateral lithotomy at the German Uoapital. Weight of stone, threw 



^ 




drachma and forty ^rmoa. No reaction or fever. Continued wustilngs of bladder with 
salicvlic-acid aolutiotis. April tvt/t. — Disichartied cured. 

Case II. — Hugo Liedtke, aged tiireo and a half. Small uratic stone. Jfarrh 19^ 
1881. — Lateral lithotomj with the assistance of the famil; iittendant, Dr. Uassluuh. 
Weight of stone, eipliteen a:rains. April 15th, — Discharjreil cured. 




JF 



i"iu. i;;^. — ArrftngciiKUt >>j inaivw lor i*rineal uystotomj- Feii ,ii.>j.| .4 uj. m .lihinii.. ivl t.nuL-. 



(b) Suprapubic Section. — Tumors, a \-ery large prostjite, eiicy!5ted or 
Tory large atones, oxalic concromcuts, ur rebellious cystic haemorrliago from 
diluted veins of the nock of the bladder, indicate tbe selection of the high 
o|)oratiou. Petersen and (iarsou*s pro|tosiLiou to disteud both bladder and 
rectum before cutting, marks a most valuable imjtrovemeut of the method, 
as injury to the anterior reflection of the peritoiueum can be thus avoided. 
A goft rulitier bag, or '•ocdijeuryuter," similar to Barnes's dilator, is intro- 
duced into the rectum, and is filled with from fifteen to eighteen ounces of 
water. Escajie of the water is prevented by attaching an artery forceps to 
the end of the tube. 
■ Seven or eight ounces of tepid salt water or boro-salicylic lotion are 
injected into the bladder, and the penis is tied with a piece of rubber tub- 
ing. The patient's shaved suprapubic region is carofutly disinfected, and 
a median incision is made, commencing about three inches above, and ex- 
tending to the symphysis. The recti muscles are separated, and the ]ire- 
vesical fat is incised. Care mud be fakfti not (o injure the rtjk'xion of (he 
perifonwum, which may he looked for in the upper anfjle of the louuntL In 
many cases the peritonaeum will not come in view at all. Should distention 
of the rectum and bladder not suflSce to push up and out of the way the 
peritoneal fold, this must be separated from the bladder by blunt dissection, 
to be done preferably by tbe tips of the fingers. Vessels crossing the pre- 
Tesical space should be divided between double ligatures. 

The bladder is transfixed on each side of the median line with curved 
needles, carrying fillets of ailk. The vesical incision is made between these 





m&f mA, m Ub^ intent 

Am • mtitn of (art, tiwy do wefl at iiirt, and 
MM af Cliafli. But if« a* *Aiea faaiipeiu, tke 
and fnCMt&Mi hy aootact irith iam\ nuUer follows, thp 



Ae palieBi takes 

if Rujaxady 

is ja|>- 



Mia, fiiitaiMilwy Iwiwi •< Um Ate mv fkvifd 
iMH ttMtf ifTodaaal mv ofl« <b* puruU of tebcUoa. 

2, lofeetioB ibroDi^b Leeiom of tbe MneooB Membraaea. — Less nnmerMu 
thufi tiK' litfiont of th«? hWiu. }('t prodtictire of fre^jnent mischief, &np tbe 
(riiiirnatic uiid itifliimmflUiry litition>« of the mncoas membnnes. Slight 
inJiiri<M \4i tlio li|Mi, tongue, buccal and fsucial maoooa meznbmie an* renr 
coniruon. In mo«t c(imw u pntfuM* flow of salira is instantly prodaced bjr 
tt IKiinfii) injurj^, und, if hAfmorrhaj^e U* abM preaent, infection rarely takes 
\t\m'Ai, lle»llhy oral cavitiin* und their adneica are eepecially exempt from 
infaotioun proci<<wk'ji following injuries. Even gunshot wounds of these parta 
<;an heal without mippiinition under favorable circumstances : 

CUnr.— K. L., anwl eliihU'i'fi, adiiiitt^Kl t<i Mount Sinai Itoepira), December 7, 1884, 
witli MoicWlal frmih pliitol-«li(>t wound of the tonRUo, oxti-mltug from the tip backward 
t4r thtf Inft ulilc of till* tidflis <livkilin({ tin' or|{iin in two iiiii'ijua) jiurtn. (iun!»bi>t pcrfura- 





tto. 1^7- — Arrau^L-Uitnl vi jiuLtciit iuv imnueul L'Antuloui_> . i wX « iiij)|,>i,-ii uii in ilittilil'L-vk-il Unvel.-t. 

(b) Suprapubic Section. — Tumors, a very large proRtute, cixn^tctl or 
•ery large stones, oxalic conerements, or rc-bolliouf; cystic Uffimorrluige from 
lilated veins of the neck of tlie bladder, indicut© tlie selection of tiic lii<:li 
•pcration. Potorsen and Garsoirs projio.sition to distend both bhidder and 
'ectum before cuttin*;, marks a most valinible improvement of the method, 
18 injury to the anterior reflection of the peritonanim can be thns avoided. 
4. soft rubber ba.tr, or *' colpenrynter," similar to Banies'e dilator, is intro- 
luced into the rectum, and is filled with from tifteeu to eighteen ounces of 
irater. Escape of the water is prevented by attaching au artery forceps to 
the end of the tube. 

Seven or eight ounces of tepid suit water or boro-aalicylic lotion are 
injected into the bladder, and the penis is tied with a piece of rubl)er tub- 
ing. The patient's shaved suprapubic region is carefully disinfected, and 
a median iDcision is made, commencing about three inches above, and ex- 
tending to the symphysis. Tlie recti muscles are separated, and the pre- 
vesical fat is incised. Care must he taki'ii not to injure the rejfcxiim of the 
prritimoBum^ ickirJi may be looked for in the upper angle of the wound. In 
many cases the peritonfcum will not come in view at all. Should distention 
of the rectum and bladder not suffice to push up and out of the way the 
peritoneal fold, this must be separated from tlie bladder by blunt dissection, 
to be done iireferably by the tips of the fingers. Vessels crossing the pre- 
Tesical space should be divided between double ligatures. 

The bladder is transfixed on each side of tlie median line with curved 
needles, cai'rying fillets of silk. The vesical incision is made between these 




U'A 



RULES OF ASEPTIU AND ANTISEPTIC SURGERY. 





hold-fasta with a sharp-pointed bistoury. In cases of doubt, the preaenting- 
organ may bo first punctured with a hypodermic needle. While tJie silken _ 
threads keep the vesical wound ]>atulouii, the surgeon's linger explores tbe ^jz 
interior of the bladder. Stones are then extracted with forceps, or the 
scoop, or even with tho fingers, tumors are insspectcd and excised under the 
jE^idancc of the eye, and bleeding varices of the neek of the bladder 
grasped and tied off or touched with the thermo-cautery. 

After thorough irrigation, a T-shaped drainage-tube (Fig. Vii^) i* insertoi 
in the bladder, and the external wound is loosely packed with iodoformi 

gauze. A sjilit compress of the same Diuteriul is ar— "skJ 
ranged about the projecting end of the tube, and i^« i j 
covered with a number of compresses couaistiug ofc^ud 
corrosive-sublimate gauze. The gkiu all around th^ ^:J4 
wound is profusely anointed with iodoforniized va!*e--^*<l| 
line, and the dressings are held down by a few turntr 
of a roller-bandage. The patient is brought to bed 
and i.-i laid on his side upon a circular air-cushion 
his back being .supported by a number of cofhion ^crs/il. 
held up by the backs of several chairs, or by board iP~l$) 
stnek into tho side of the bed. As the lateral jx«ii «i-l 
tion has to be maintained for three days at leasti*" 4,^ 
sides should be changed every two or three honri^^*"^ i 
Tlie drainage-tube projecting from the dressings imi w' 
connected with a loTiger tube, that is led into aann«»^ J' 
placed alongside the patient in fir out of bed. A-^^^ 
soon as the urine ceases to be bloody, and its reactioc -^CDib 
becomes acid, the patient may be allowed to afisum ^C3«4| 
the gnpine posture. The drainage-tube can Ix- w^a^"^' 
moved on the fifth day, Avhen the wound will be usi».-^** 
ally found in a state of healthy granulation. The packing of iodofurmirt-*-*'^^' 
gauze has to be continued as long as urine escapes through the wound. i\_-^^^ 
soon as urination per vitf.'^ ntifvmh's is re-established, the wound should b ^"""^ 
dressed as any other superficial wound. 

Cask I. — Martin Gyr, Lthoror, iv^M fifty. Large oxalic CJilcnli often yenrs' stAOt: 
iag, with umliliituble blaJtltT. \VrL<teliod >;eiieral eomlitiuth April IS, 18S6. — Supm 
pubic lithiftomy iit tho German ILiMpital onUer chlnrofonu, which wa» preferre*! t« 
ether on aci-otint of tbe presence i>f cnsts in the urine. Two imiaovable tstonos w« 
found ocmipyinj; tlu' contracted bladilfr. They were grnsf^'d, freed by rotation, vu^^ 

extracted one after the uthor. They sliuwed on cxtrftctinu two freshly broken smi ' 

faces, corresponding to as many pcdiclc-iike projections, branching into two direrti — 
cles, each containing n separate ctdculus. (.)no of \\\\tm calcnh was extracted, I he othc-r 
and eniuller one was left beliiod, ns the patieut** poor condition verp'injr on coUap*«-* 
did not justify continuation of the operatiftn. Tlio patient did not rally from the col- 
lapse, and died three hoars ufter the completion of tlie lithototny. 

The sujtrapubie incision gave free access to the bladder, and enabled the 
author to conduct the search and extraction of the calculi under the guid- 



Fio. li?.— T-flhttpcd drain - 
ii4^>-ti)bc For rtupirapuhk- 
cyntirtdmy. (Tn^iule- 
Icnbur);. > 



HISTORY 01 



Tthic suppuration. 1^ 



tion of the |»illar» of the fauces of the left siJe ; gunshot wi>nn<l of tlio posterior [iliaryn- 
geal wall, the poiur of entrance situated jnst back of the faucia] |iillai*s of the left side, 
jihont an int;h ami a qnarter from the oietiian line, ail of these injuries being produced 
by a bullet of 22 mm. caliber. A second non-penetrating lyrunsbot wound on the fore- 
hejul withorit a point of exit. Free hanjorrhage from the tongue, and also a stream 
of arterial bloixl from the pharyngeal wound. The latter being in clo.se viciuity to the 
left internal carotid artery, the left common carotid was tie<l at once iuh a preventive 
measure, mainly with a view to tlie possibility of subsequent suppuration and second- 
ary lia?fnorrbage. The perfect condition of the teetli and oral niucons membrane was 
note<l. Tlie lingual w^ound was lightly rubbe^l over with a small sponge dipped in 
iodoforni-powder ; the phunjngeal trnuful ipcu nof j/roficd, and lioiirly irrigation »if the 
oral cavity with weak salt water vfAs prm'ticed. Profusw sweating, perhaps due to 
reflex vrwomotor disturbance, set in, and persii^tcd for about forty- eight hours. The 
febrile movement wjis very slight, and both the operation wound and tlie gunshot 
wound on the forehea*!, being redressed on December loth, were found healed and 
dry under tbeir itMloIoritJ dressings. The lesion ^ti' the tongue wa.-* found granidating 
and contracting, the perforation of the pillars of the fauces nearly closed, (he pninl of 
entrance in the posterior pharyngeal wall firmly occluded by a fresh-looking blood- 
dot. Hreath odorless. December 2ht. — The flatteneil ball removed by small incision 
from the top of the head, where it could be felt beneath the skin. Tlie entire track 
of this projectile had literally healed without suppuration. The jdiarynpeal wound 
found also cicatrized over, the ball being imbedded near and below the left transverse 
proce^'S of the athus, iii <l(>se [troxiniity to the vertebral an<1 internal carotid arteries. 
The head was lield inclined to the right side, erection of tlie spine and its flesioji to 
the left being impossible on account of the intense ]>ain caused by the attempt. This 
functional disturbance diminished to such uu e.xteut within a few months that the con- 
templated extraction of the small projectile was ahaodoued. 

Had tbo pat ient'.s oral cavity been foul from juitrid processes accotnpati}'- 
iti(r au acute or chronic urul catarrh, due to dental caries or other causes, 
suppuration of the pliarynp;eal wound would have been very probable. The 
danjrer would have been very niucli jrraver on aeeouut of the possibility of 
exten.'«ion of the suppuration and the likelihood of uncontrollable secondary 
ha?tnorrhaf;^e. A prttbimj of :<innlar wounds without a clear and nvcrssart/ 
olf/ert in view is alwayx a dnnf/fron.s and invnriabhf usdess stepy and should 
he rf'fraifttd from under ahnosi all cirrumytanicx. We may use a clean 
probe, iuid the probe may not U- the carrier of infection ; but its introduc- 
tion will break down the lilood-ehit, (!»e natural barrier provided by the 
or;!ani.siu itself a«;ainsi infeetiun. and tlie \\\\\hv will h-ave behind an oj>en 
channel f«»r the entrance of possibty fetid oral mucus into the narrow wound. 

Next in frequency to the inihinimations in and ulxtut the oral cavity 
and its adnexa are tlio.se due to injuries and other lesions about the anal 
and nro-genital orifices. 

ni- ENTRANCE, PROGRESS, AND LOCAUZATIOM OF THE 

INFECTION. 

As long as the integrity of the epidermis is preserved, no infection frotn 
ithout will take place. The integrity of the epithelial covering of the 
mucous membranes does not seem to liave the .eamo protective power us the 
24 




174 



RULES OF ASEPTIC AND ANTISEPTIC StJRGERY. 



75^ 



y. 



epidermis. This may be exjilaiDed Ijy the tact thut slight injuries of the 
nuieous lining aie iirudticed much more ca:*iiy thiiii those of the skiu, and 
are not readily ascertaiued on account of the normally moirit touditiou of 
the parts. 

Aa formerly j^tuted, the i^Hghtest dcTiudjition, not deep enough to canso 
hamiorrbage, and just prnduetive of a slight exndatiou of serum, offers a 
favorable point of entrauee to the virus in the patulous orifices of the 
lymphatic vessels or lymjili-spaee.-!^ thus exposed by the injury. 

In lacerations or punctured wounds the infective agents are very 
often deeply inoculated with tlie point of the injuring article — that 
is, they are at once deposited in clo.^e vicinity to dceji-seated lymph- 
vessels. 

In the more superficial forms of injury, the implantation of the virus 
occure only in the neighborhood of more superficial lymphatics, and its 
transmission to the deeper lymph-vessels is accomplished 
by forces which govern the How of lymph from the pe- 
riphery to the center. Aside from the uormal current set- 
ting t^jward the thoracic 
duet, externa! forces and 
the play of the volun- 
tary muscles have an im- 
portant part in hasten- 
ing the Oow of lymph. 
So, far instance, the 
[pressure exerted upon 
the lymphatics of the 
palm by the frequent 
and vigorous graf^piog 
of a tool wielded for a 
long time with great 
force, will undoubtedly 
help to projM?! the con- 
tent?; <»f the peripheral Jymphatics toward the larger, more deeply situated 
lymphatic trunks. Or the vigorous contractions of the muscles during 
mastication will undoubtedly empty the adjacent lymphatics centerward, 
their action being aptly comparable to that of a force-pump. 

Wiiat was formerly denoted a.H exiernul mechanical irritation is nothing 
but this forciny of pu»-generaiing subsfancr.s into the open lymphaticii hy 
friction or other preasuro due to exercise. 

The direction and extent of the spread of the infection by the lymphatics 
are prescribed by the anatomical arrangement of the lymph-vessels of tho 
region concerned. Thus, on the palmar aspect of a finger, the poisoning 
will rapidly extend to the periosteum, as tlie lymphutics ail tend tliat way. 
In tho vicinity of lyniph-giands, the infection will [irumptly exr^^nd tothcra, 
an intervening lymphangitic streak often clearly duimting the route by 
which it traveh'd. 









«ii;*iiiiarx). (Kooli.) 




SPECIAL APPLICATION OF THK ASEPTIC METHOD. 159 

Cahe II. — EiiiLTcnc' Ilaffner, wjiiter, njj;e<l tweiity-four. Kelapsing cancer of rectum 
aft«r ejitir|>»aion donci by Dr. F. Laujje. February S^ 18S7. — Extirpation of adJi- 
tiunul two inches uf the gut at the German Iloapiial. Peritonseum was found dt-MCfiiiled 
t<» within half an inch from the slcin. It liad to be freely incited, and wns 8tihi*('i|m."tUly 
rl«>sed by five catgut sutures. Uuioterrupted recovery. April 2d. — Patient wiia dis- 
charged cured. 

The main source of infection is the interior of the gut. To exclude this 
dau*:cr, the lower end of the rectum mu;5t bo olascd by u circular ligaturc. 
"Wbeu the gut is divided above^ care must be taken to prevent soiling of 
the wound by oscitping intestinal contents. 

XIV. ASEPTICS or THU BLADDER. 

1. Catheterism. infectious processes rarely uriginato in the bladder 
itself. Their most cammon way of entrance is bj' the urethra from with- 
aut : next to this come the modes of infection from within — that ie> by 
descent from the kidneys or by extension of contiguous .scptie processes 
from the organs located in the vicinity of the bladder, as for instance from 
peritoneal or retro-|>eritoneiil suppurations. 

As t)eforc indicated, the most common source of infection of the bladder 
is an unclean catheter. The ordiuarif mcfJiodn of cleansing metallic catketvrx 
by flnahinfi with hot or cold water, and fnib.wffm'nt ruhhituf off imth a clnni 
taweif art' aJfot/efht'r inadfi/uaft'. In order to i^ecure tlieir absolute cleanli- 
ness, the same processes of sterilization must be employed that were recom- 
mended for cleansing other hollow tubes — notably, aspirating needles ami 
trocars. Boiling for an hour in water, or passing the instrument through 
an alcohol flame until ail organic matter contained in its lumen is volatilized 
by burning, is meant thereby. Only after smoke and steam have ceased to 
escape fn>m the cathettn* can it be declared to be surgically clean. 

Before u?e, the cleansed catheter should be [ilaced in a tray or flat pan 
filled with tepid salt water (tJ : 1,U(X>, or one heaped teaspoonful to a cjuart 
of boiled water) ; the surgeon's hands should be previously well wa.slied with 
soap and hot water, and the instrument should be anointed with iodoforni- 
ized vjiscline of the atrength of 1 :50 (liftcen grains to two ounces). 

NoTB. — The ordinary solutiona of corrosive sublimate or carbolic acid corrode the mucous 
menibraQc of tlic urethra and bladder, often eau»iag intent* pain and rcHex gymptomH. The 
resnlting dentidatiotid of the epithcbiil layer atl imty serve a.'^ portul^t tif t^ubsaiiieiit infciition, 
manifeflting itHelf in tlie form of urethral fever, urcthrUii?, cyslilis, and, id extreme ca^ea, 
mctaHtatic procei<se!). None of thcg« very active gcnuieides should be introduced ioto the 
healthy urethra or bladder: first, because they are unoecessary ; and, aeconclly, bccauae they 

■ rnay do barm. Simple lnjiner*icm uf a filthy catheter into these gepttiieiflal lotions will not rlis. 

H infect it sufficiently, and, if some of the strong !<o!iition lie carried into the urinary paa.*ages 
along with a fillhy catheter, the chnnces of infection will only he increas^ed hy the coiubinution. 
t'athetors that were immersed in strong diHinfcctant polulioiiii .should be freed from thcui before 
being need. 

^ In passing the instrument into the blatider for exploration or evacuation, 
H the utmost gentleness should be exercised, not only for the sake of the 

■i^ 



I 



NATURAL HISTORY OF IPIOPATHIC SUPPURATION. 17.' 



* 



The Tarying intensity of the infoftton, depenclent on liithcrto unknown 
and varying fermentative qualities of different; cultures of micro-organisms, 
will also greatly iufluenco the rapidity and Ainilence of the inflaminiatory 
process*. So much is well established that the intensity of the iufeetion 
de[>end.s,_;?r.v^ on the virulence of the invading eultiire of bacteria ; .scmndhf, 
ou the (juantity of fungi nhs<irhed ; and* /kirdlt/, on the [)ower of resist- 
ance — that is, the state of liealth of the invaded organism. 

Mechanical Irritation. — Mtrkmn't-Kf im'fafwfi by forfiijn .yubf</anrejt 
imbedded in tissues, such iu^ bullet:-, splinters of glass, or a bniken-oll point 
of a knife-blade, is also a myth in the old meaning of the phrase. Thetf 
jicvrr muse .^nppvrnthnt ntili'ys hifh-fioti-s sith.^^ftmrfff — flnrf /.«. f/nrrfiljial 
fifth — hv (iilhi't'ent iu thcni at the time of tlieir being deposited in the H;*- 
snes. They may cause pain by jiressure u])on nerves, or may intirfire 
witli the ]ihiy of a joint or a muscle, but, as a rule, never will cause \\\- 
ilummation or suppuration. Weil-disinfected steel nails, driven l»y mallet 
through femur and tibia after exsectiou of the knee-joint, are unhegitat- 
iugly left imbedded for thirty or more days, never causing any irritation 
(see Exsectian of Knee-Joint, page 287.) 

Oasr. — In 1882 II young blackBinitii pn'setited himsflf in the HurgioAl dirision of 
the Gcnnun Dinpfiimry. A(i anjjiilur foivi^ Imdy could be iltHtinptly felt undor tli« 
skid on tl)*.^ palmar aspei-t «if thy ri':itt t'orfurm, niiilvvu)' latwL^eii ellitiw and m risl, 
orttising pain hy ivapingin^. Tho bixly had jippeured only liiure a ffvv weeks. Near 
tliL' carpus a transvcrstt ciratris was lo be seen, aud the piitiont tixpluiued that lie was 
rut- there during a drunken hrawl two yejira jigo, and tiial a 8nrg«)ii luid tied an artery 
and sewed up the wmind, wliich had liwiled withont snppurntion. Ever since tlien he 
had worked ut ids trade witlKmt any ineonveutetue until wittun a few days. Frutu 
the incision nuute over the projecting hudy, a bkukeued knii'e-bhide, four inches long 
and tJve eighths id" an inch wide, was oxtractcd, tu ihu greatiest aatonislKnoDt of the 
patient. Tho small wound clo8e<J jiroruptly. 

Here we saw a massive, sharp-edged foreign body lie imliedded for two 
years between the muscles of the forearm witlnnit any inconvenience to the 
patient, until the angular base of the blade had worked out under the skin. 
Why did it not cause sup[)uratton ? Apparently the tihute must have been 
newly ground, oral any rate very clean, when it broke off in the arm of 
our blacksmith. Had a considerable annnint of infection l>een carried along 
with it at the time of the injury, its presence would not have been over- 
looked so long. 

Dead orfjanic suhfttanceftf as, for instance, blood, or cubes of animal tis- 
sues, such as muscle, tendon, or portions of liver or bone, were taken from 
a freshly killed animal, and introduced into the abdominal cavity of a num- 
ber of other rabbits under strict antiseptic precautioris. In a very hirgo 
proportion of cases no reaction whatever fa!h>wed. The aninuds being 
killed, it was found that Vdood was absorbed outright ; thnt muscle, liver, 
tendon, and bone were encapsulated ; and that their structure was gradually 
invaded by granulation tissue — disintegration and final absorption follow- 
ing after a while, proportionate to the density of the implanted bodies. In 



ITO 



RULES OF x^SEPTIC AND ANTISEPTIC SURGERY. 



cases where the ordinary useptio measures had been omitted, septic jmruleiit 
peritonitis fuUowed as a rule. 

NoTK. — The roost retnarkahlc nf Dr. JI. Ttlliniinri's ciperiiuents (Virchow's " Archiv," Bd. 
IxxvHi, ls79) is ibiil coticfrniiifr a nibbit, in the iihilouicn of whifh an otitire rabbilV kidney was 
depoaitL'i! withont causing onj harm whatever. The amuial bcinf; kill<Hl forly-POT»'ti <lay* aft<»r 
tl)C 0|>LT>ilir>n, the iniplnnteil kidiicy was sought for in ratn, as it hail ili»^ap]K-art'd by ub^torption, 
the nuly vi^stige of its formiT preamicc bcin}^ ii s|nit nf tough cicatricial tissue, denotiDg the 
Uiciility where thf foreign body wii^i attached by fsudations. 

This experimental observation is fully borne out by the ejqierience gained 
in nnmberlcss ovitriotoinies. wliere muasive jtedieles, deitd tlirougli stoppage 
of their circulation by ligature, are dropjjed back harmlessly iu the perito- 
njBura, to be finally absorbed — that is, they will do no harm if a culture 
nf bacteria is not deposited on J hem by the o{>erator. 

Chemical and Caloric Irritation. — The common experience that certain 
ncntely irritating substance!^, u^, for instance, croton-oil, oil of cantharides, 
tur])entine. concentrated solutions of corrosive sublimate, and others, 
brought in contact with living; tissues, always woidd j>roduce suppuration, 
represented a serious gap in the theory of the microbial ori^u of suppunt- 
tion. If invariably proved, it would be more than a defect, a;? it would 
positively contradict the thesis that supjmration is exchisively and ahctt^H 
the i-esnlt of the development of micro-organisms. The exiJcrimeuts of 
{'nuncilman,* who introduced under the ^ktn of animals small glass globes 
liiU'd wttli .sutidry irritating suhstancc-s and then crusJied thcni, all led to 
suppuration. Schenerlcn f and Klemperer,]; however, in going over Coun- 
cilman'.s experiments, showed that his procedure was faulty, inasmuch as 
8utFicient precatitions had not been taken to exclude the introdnction of 
microbes along with the croton-od, etc. They moreover positively denion- 
gtrated by a very large number of successful experiments that, whenever 
thorough aseptic cautelte were observed, suppuration never followed the in- 
troduction of even very considerable (juautitiesof the mentioned substances. 
Small quantities caused some exudation of plasm, and tlieu were absorbed 
outi*ight. Afterward the fragments of the glass receptacle were found im- 
bedded in a film of new-formed connective tissue. Larger fpnnitities of 
crotou-oil, for instance, caused a coaguhition necrosis of a limited mas.s of 
tissue, which was found dense, bloodless, and of a yellow color. These 
nodes of necrosed tissue were gi'admilly aljsorbed, .^Hpjtut'ufion ntpft follow- 
iiuf ffif (xpcn'oHiit. This fact is in full acct*rtl with other incontestable 
facts of the same chiiracter, as. for instance, the absorption of necrosed 
ovarian stumps in the abdominal cavity if there be no niiicrdbial infection 
present. 

Caloric irritation, or even an outright destruction of tissues by exces- 
sive beat, presents a similar state of things. As long as microbial infection 
is successfully kept away from the exudations in burns of a milder charac- 

• yir«bi>W« "Arcbiv," 18S8, vol. xcU, p. 217. 

f "Archiv fiir klin. Ctiirur^c," vol. xixil, p. 500. 

\ Prize essay, Berlin I'nivcrsity, "Zeilschr. fikr klia. McJ.," 1886, vol, s, p. 188. 



NATURAL HISTORY OF IDIOPATHIC SUPPURATION- 177 

Ut. uml from the fs^cliur aiicl exudations in severer farms, no riiipjmration 
will fallow. The raadorn use of the thermo-caittery in tlie peritoueal cavity, 
in jaiiils. and, us ii matter of fact, in wounds of Hie mortt various eharrtcter 
uiid of all saiutamieal regions, is followed by uninterrupted unioji in all 
cases where, at t!ie same time, adequate aseptic measures are emjiloyed. 
An eschar or a iTia!«s of dead tisHue, whether produced by lip:ature, or eheini- 
cal corrosion, or red heat, will never assume the irritating character of ti 
"foreigii body," in the meaning of the term as presented by llie tenets of 
an older pathology, if the decomposing action of the presence of micro- 
organisms is excluded by proper meai^nres. 

The behavior of Mupcrpciat buruM of the skin is fully in accord with the 
facts just presented. 

If 11 bleb be raised, and ii* left unbroken and dry. it* eontenU will be 
ab-orbed, and the ejnderniis will settle back into its nnrmul relatinn to the 
cutis. It will turn into u dry scale, and will peel off within ten to twelve 
days, exposing the tender new epidermis. 

How different is the course of a burn if tlie epidermis is torn otT bv acci- 
detit or intentionally, and the exudations are thus ex])osed to the inva>*ion 
of raicrocoeci ! If the surgeon do not employ timely disinfection and the 
application of a protective dressing, suppuration of the exposed cutis, with 
all its accomjianiinent of jiain, long-con tinned granulation, and a very tjirdy 
healing, will follow. 



IV. DEVELOPMENT OF FHI.EGMON. 

From the inomeiU that a sufficient *iuantity of active fungi have estab- 
lished themselves within the living tisvsues, remarkable local and general 
phenoTneiui develop, known under the name of injlanimafion ftjuj sfpftr 
frver. 

Our object is not re!?earch iuto, but rather a lucid explanation of, the 
essence of Jntlantmation, n» understood and accepted by contem|»orary au- 
thorities. Hence a brief sketch of the leading features of the process is 
deemed suttirient. 

Micrococci iind a nu>s>t favorable pabuttim in dead or devitalized organic 
substances. The living tissues otfer a decided resistance to the ravages of 
the micro-organism. The sjiantancouii liinilation and occasionid unaided 
cure of some forms of suppurative iutlanimution ]>rovc this assertiou. 

Bacteria can not thrive on the products of <lecompositiou : they need 
for their snstenance dead but nndccont posed nlI>UMiinoid substances. As 
MMHi as the supply of dead animal tissue is exhausied, the micro-organisms 
st4irve and perish. Their xporm or seeds are left behind dormant, but will 
becomo active if fresh pabultun is offeretl under favorable circumstances- 

This explains the fact that frf-sft rtnhtvers or utiiiiial xuhstamrH in Ihr 
recent tttoffcti of putresrencv are much more, infecliou-s fftan those that artf in 
a prorfresfted /(tale of ileeompoxition. The varying intensity of different eases 
of infection sc^enis t«) de]>end in a great measure np<»n the varying degrees 



1H4 



RULES OF ASEFnC AND ANTISEPTIC SURGERY. 




hold-fasta with a sharji- pointed bistoury. lu ciuies of doubt, the proHentioi 
organ may be first punctured with a hypo dorm ie needle. While the eilkei 
threads keep the vesical wound patulous, the surgeon's finger explores tbi 
interior of the bladder. StoBea are then estnicted with forceps, or thi 
Bcoop, or even witli the fingers, tumors are inspected and excified under th^ m^i 
guidance of the eye, and bleeding varices of the neck of the bladder & ]» > .mJ i 
grasjied and tied off or touched with the ther mo-cautery. 1 

After tliorongh irrigation, a T-sliaped drainage-tube (Fig. 128) is inscrteo -LJ <^ 
in the bladder, and the external wound is loosely packed with iodoform izeL»-^3Bd 
gauze. A split compress of the same material isarTK:..«M)j 
ranged about the projecting end of the tube, and i 
covered with a number of compresses consisting o 
corrosive-sublimate gauze. The skiu all around th ^r^Mtd 
wound is jjrofusely anointed with iodofomiized vasci^^-se- 
line, and the dressings are held down by a few tum«r::«m8j 
of a roller-bandage. The patient is brought to be<fc:^, | 
and is laid on liis side njion a circular air-cnshion — ^n, \ 
his lutek being supported by a number of cnj>hiotr^ '^is 
lie Id up by the backs of several chairs, or by boanEI^arig , 
stuck into the side of the bed. As the lateral pos -^^i- 
tion has to be maintained for three days at leasr ^U 
sides should be changed every two or three hour;- «• ] 
The drainage-tube projecting from the dressings w ; 

connected with a longer tube, tliat is led into a urins- -•*' I 
placed alongside the patient in or out of bed. .^^=»As 
aoon as the urine ceases to be bloody, and it^ reacticz:z:^n 
becomes acid, the patient may he allowed to assun^K^^j* 
the supine posture. The drain age- tube can be 
moved on the tifth day, when the wound will be u 
ally found in a state of healthy granulation. The packing of iodoformizi 
ganze has to be continued a.t long as urine escapes through the wound. 
soon a^ urination per eiffs nfffurnlcs is re-established, the wound should T 
dressed as any other superficial wound. 

C.\f*K !.— Ifnrthi (iyr, hiborer, iified fifty. Large oxalic calculi often jours' sUi 
ing, with undiliitjiblo bladder. Wreu-hed jjoncrul condition. April 12, ISSft. — Supa 
pubic lithotomy at the German riospita] nnder chlorofonu, which wan preferred 
ether on aofoimt of the presence of easts in the nrine. Two immovable stones ««'^ 
found occupy in;; the contracted bladder. Tbey were graHfiLHl, freed by rotation, a. 
extracted one alter the other. Tfiey showeil on extraetinn two freshly broken >■ 
faces, corres|)oiidiii(i to as rimuy pedicle-like projection.% brunehiujr into two direr 
elcB, cfich containing a neparate cidonhis. One of these calculi wsis extracted, the otL^K ~"^ 
and smaller one was left behind, ns the patient's poor etmdition verging on collaC — '/•*" 
did not justify contiauation of the operation. The jaitieiit did not rally from the is — ^' 
Inpae, and died three hours nfter the completion of tiie lithotomy. 

The suprapubic incision gjive free aeee-s to the bladder, and enabled K^ ^f 
author to ciMuliu-t the searcli anti extntctiou uf the calculi under thegu-'</- 



FiG. 1*2^. — T-shnpcd ilniiii- 
u^*-tiibe I'or f-iipr;ipiiliH 
eyBtot!)iny. iTrtiude- 
lenburit' • '' 




NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 



179 



uevor abgfiit. we Imvu completed the clussiesil inulii oi tlic* four curdiiml 
Bymptoms of in Summation — " rubor, color, turgor, dulor." 

NoTK — The cau^p:* of lociil priiii luiiy be several. The Initial pain U very likely due lo a 
direct iiifluenfe of rlie piotiiuini-s niwii I he sensory filanteiUs. I>in>t't pn/S'^utT oiiiikkI hj t\w 
densi" fufiUiatioii insiy jil:-n luive syiiif itifluetiw; but tin.- most ucmte puiii !» miiloiibtcdiy iircctoil 
by the actual do^truction uf the nerve-lit'sue during the udvanC't'd sta;:;<\'* of riujipnriitluri. 

Stagnation and dfiif^o iiililLrutioti tiually produee a very high degree of 
tension, leadin<if to compression of largor afferent vessels. The infiltrated 
portions, devitalized hy giijjprt'ssion of the normal circulation, readily suc- 
cumb to the inroads of the millions of micro-organisms, and uctnal necrosis 
rapidly follows. The last stage of textural destruction is the liiml rH|uefac- 
tion of the tissues and infiltrating leucocytes, aided by the exudatiun of 
large quantities of lymph-scrum from the adjacent unobstructed blood-ves- 
sels, and thus the formitfion uf an abscess or a cavity 111 led \vith lymph- 
eerum, myriads of dead white blood -corpuscles (pus-cells), and (juanlities of 
shreds of necrosed tissues, is accomplished. 

The veins also participate in the disturhanee, C"onpulati<jn (pf their con- 
tents— thrum bosis — takes jilace, and existing .stagnation is materially aug- 
mented. 

The deleterious part played by thrombi in tlie causation of metastases 
will he later mentioned. 

When aseptic inflaaimalion of sufficient extent and intensity has been 
well advanced, the great tension of the parts will necessarily cause an over- 
flow of the most dilTusible contents of the focus into the surrounding effer- 
ent vessels — the veins and lymphatics. The ptonniines, thus entering the 
general circulation, will at onee produce systemic intoxication, manifested 
by a very marked rise of the body-heat, rigors, sickness, lieadache, delirium, 
and general dejection — in short, a deep-going altA^ration of the nervous 
system, known as xepiic fever. 



V. SPREAD OP StJPPtJRATlON. 

The way of the extension of septic (extiu'al destruction is twofold. It 
tikes place» jfrs/. by a direct infiltration of the tissue-interstices by columns 
and hosts uf iFie immensely prodigious micrococei — that is. by an immedi- 
ate growtii and extension of the microhial colony ; and. scconfUt/, on the 
way of the lymphatics, openly communicating with the focus of su[>pura- 
fcion. lnt<> these, bacterial mjusses, or pus charged with micrococci, are 
forced by the hydrostatic pressure exerted by the tension within the nbscess. 

If the parts affected are composed of loose tissues, the spread will be 
rapid and extensive ; if the parts are dense, the inflamniation will remain 
localised as long lu? the density of the tissues {fiiseia?. for instance) will resist 
the pressure of the secretions. But, as above mentioned, (his very pressure, 
or tension, involves another great danger. The afferent blood-vessels become 
thereby occluded, and the resulting stagnation generally leads to extensive 
necrosis. 



PART II. 



ANTISEPSIS. 



RULES OF ASEPTIC AND ANTISEPTIC^ SURGERY. 



a repetition of the metiu^tatic process and tti? febrile accompaniment, until 
a numher of joints, lyniph-glaiuls, the liver, iji fact, almost all the organs, 
l)eefjm<3 the seut of secondary abscesses. 

This is the classical type of well-developed p^mnia, formerly so common 
in all surgical hospital wards, hut now became a rare' phenomenon wherever 
the k'tiven of the Lister ian spirit has jiermeated surgical i)ractice. 

This form of microbial colonization of the entire human body baffles 
every plan of treatment, and almost invariably leads to the destruction of 
the or;i:ani8m. It is ;i,s good as incurable, irnf if rnn he prevented ; hence it 
is the moral duty of every physician to do everything in his power to avert 
this form of mischief. 

NoTK. — Recoverii of n c<ue of iwfl-det<eiopfd ptftemia is so nirc that recording the following 
catti* sci'tiif* pcmii-Sfiililc, The notes wi^re UiniJly fiirnisheJ hy Dr. A. (.'aill(4, with whom the 
Hiithor saw tbi" patient in consultation tit hi* home in Williaraslitirg: 

" Hf iiry lluliii, aa ffderly man. Enortnou.i earbuiu'le iivit left scapula; nevnwis of fascite 
Hiid siibcntaneonH ciitniective tisane from chiviele to seventh rjh [WSlLiiorly, the result of thre«? 
weeks' neglect ( poult ii-itif^). 

" Energetic treatment {by Dr. f'ailU') with knife itnci irrigation (earbolic). Well-marked 
H>mptan)!i of {)yteniiit ; geiveral furuneiilosiii of trunk. 

"Angutt 10, JSSO. — Consultation with Dr. Get^ter, who advi«<>d tonic treatment and ilaily 
f'ufl bath* in trrak hirltloriiie-ff-mrreufif motuiion, together with fretjucnl inigaiiona with ram- 
phontted water. Teiiipenitiire!* at this lime cin an average I(l2' Fahr. Pulcc, 1-t* to I40. Dy^p- 
iKi-n, ehillrt, und sweats. Ini|>rovenient luitteonhle, hut slow. In Si>i>(eml>er, siipjmnition of 
nhiioitt all the lyinf)ligluiKU tcKjk iituee within one week, without reilnei<A or t<aidernes.a, ui that 
h( one time a tenotomy knife ititrodiieed almoKt anywhere would dntw pus, RubficHjuently eslen- 
hive ttiid pstiuful periostitirt and nb.sei'ss at iijiper Ihinl of ri;;ht libia developetl. About this time 
rjamhtation uf urine revealed a large )iereentage of sugar. The paticot's diet was properly 
rtignlnltHl, and hit^ urine wsi^ fret> from .«ugar fire monthi! later. Mr II. has since been, and is 
lo-clny < December 2:\, 1886), it« excolknt health." 

Il will Iw noticed that a methodical use of a mercuric lotion was itdvi^'cd by the author sev- 
er«l yenrn before Kuemmers ami Schede'w ex|>erinu>nts brought corrosive Hublinmie so proroi* 
Mcully to the notice of the medical w<irld im an cKcxdlent dij^iiifecrant. The rccoinmendatioii 
wiiH buKfd iit»on t!ie long-known good influence that corrosive sublimate has upon acne pnstn- 
to«u of the face. It;* npplieuliou in the shape of a full hath Hugge.-^led itself by the extension of 
Ihu affectloft to nltiKMt tlie entire akin, und by ihe etiortnoUB difliculty in clean.*iijg and dressing 
Ilii< Inumiiernble soren of the patieot. Since Ihat time the author has employed the fffuMnnil 
httlh lit Houther Minrlar casCj to the great relief of the pntient aiul his attendant'^. Twice daily 
lUti haili wan clmrped with corrosho sublimate (I : 5,(MJct) for nil hour, after which the solution 
»«• drawn off, and substituted with a weak salicylic lotion. The remarkable relief brought 
«huiil by the Imnu'ritioo of the entire bmly was due to the cironmstame ihitit^ firgt, the frequent 
aud extremely painful change of dressintrs w>idd he ilis'pen.-ed with ; ami, ntr<iudl;i, that, aeeord- 
lM4 lt» J»yilrtn«tntic law, thr huoi/atirt/ of the immfTMil Ifnhi TfUn-fft lo a rrri/ tfrrat nfrut ii» 
IWtatMi* U^Mtt Ihe rotieh fpreail in (hr bottom of Ihf hath-hih. The s^piead of the bed-<ore« 
vvmiikI Hefine Id* attnck. the patient had been in very wi-ak health. After three nr four seiz- 
wv* ^v Kvll.»p««', relieved hy iucreiufe of the tcmiH-mtuiv of the hath to llo" Fahr., he suc- 
cuukbiHt W \w*\\ failure. 

Tbt* tHiutenls of the preceding pages have in a rough way illustrated the 
(MMMit.H> ikf tHdliilar phlegmon, or the /mppuralion of connrctive iiMsue, inele- 
jmii ted in text-books as "* velluHtis.^' 

i . .1 ,iou.-< reitsona Ipnplmfic ninmh very often become the seat of 
luicu^iul |»ixUifi'ration. Their direct communication with a numerous set 




NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 183 



of lymphatics and their filter-like structure naturally lead to ready absorp- 
tion and detention of noxious .substances. In this churacteristtc is to be 
sought a by no means insignificiint i>rotcctivc (juality of the lymphatic 
glands u;?ainHt general inviisiun of the liody by microbial musses. 

The difference exhibited by lymph-gland absceases in comparison with 
the ordinary forms of phlegmon is due to their anatomical structure and 
eitnation, Tlieir strong capsule will resist destruction for a comjianitively 
Itujg time, thus preventing for a whik' invjision of the vicinal tissues. But 
the Jnterual tensiun of a glaiulular abscess s<M>n becomes very great, and will 
lead to extensive mortiltcation by compression of vessels. 

The anatnmieiil siluatif>n of many lymplr-gland ;tbscesses. their deep seat 
and dnse vicinity to large vessels, the [ileuni, the fauces, and larynx, invest 
them witli additional importance, both as regards the danger |>eculuir (o 
their locality, and the ti-ehnical difficulty of their treatment. 

7'hi' .skt'h'fon is fori unatcly i» comparatively rare seat of bacterial infec- 
tion. The fearfully dangerous and destructive character of mute infcetions 
osfromtffh'fi'i, OT "bono phlegmon," is due to the rigidity and unyielding 
Tiamre of the periosteum and bone tissue, which lead to rajiid (tcclusion of 
the blood-vessels, and extensive, of len widely disseminated necrosis. The deep 
situation of the bones renders tlio sympttuns of this form of suppuration ex- 
tremely violent and daugerous, and increases the diiliculties uf treatment. 

NoTK I. — Ttic «M."all<.'d bjibituatinn of butchcrt*, cattkmeci, and anatouibta lo infection wcms 
to bt' bn^oil rattier on structural ("1i!ii»f,'i'S of tlie skin of tlicJr lionds frctjuentlv expO!«cd to coti- 
tAniinttlion, Hiati to a real tiuljitimtion^ sucli usi i*^, for instatjcc, broii<;ht about by vaccination 
ftiiainiit the I'malt-ftox. Tli:«t ilie system of llii's<» pcrsotiH docs not bectuiic liiinltued or nccu.s- 
tiiincd to the lipptic virus js [tniveil tiy the (»i't, thai plilc<;irioii<)iiri jirwcsscw will ii'inlily c!>tablisli 
tliofijsclves, aud dcvctoi} in the ordinary way, if thr infrelinn itrrur rUrtrhtir than on Ottir hnttds. 
A mon- plaui'ible explanation of ilits miparcnt immunity will lie found in ttic r'tate of the lym. 
pliatios of llic iiitrpiiment. Iliuiuf; been tlic seal of rrc<|iiont more or less intense uttacUs nt 
tnflnmtniiiiim, they become ol>litci!itcd and <listnrfwl, as it were, by cicatriciwl ctianges in ami 
nniiind tliern. Tliut recent or old clnuriciul forniaitons do not possess liirjte-slzeil lyuipli-vesscU 
is well known, hence absorpiitAi tbrouf;li llieni of corpuscular elements int« tlic deeper lymphatics 
will l>e dtfBeutt and seimty. In short, the chronically inflamed state of the skin covering the 
hands of theae persons offers in its in6ltrate<l ctrndition an effeetiTe protection agiuiisi the deejt- 
going or iuiu«iTe implantation of micru-organisms through superticial Icsiuus, 

Parallel with this slate of things scorns to be the well-known fact that children subjwl to 
frequent attacks of septic ttmsiilitis or di|>htherio rarely smcutjib to the discu-e. Penetration 
by bacterial elements of thi* dense cicatricial tissue left Iwhiml by many preeedinf; attacks Is 
didieidt, and absorption of the i»tomaines lhr«Uf;li the scanty lymphatics Is very limited, Ilence 
the prfK-css soon becomes exhausted tlirouph lock of ]>abnlum lo tlie micmbial sjrowlh. A cer- 
tain quantity of viable spores remain iniljeddcd in a follicle, to ajrain develop their activitj ns- 
aOOD oa a oimple catarrhal inflammation of the phnrynx will havr prepared the soil for theil 
reaewed growth. 

IHphth«ria in children who never had been subject to tnc disease \? a much niore 0criuu» 
matter. Unchanged tiasues irith open IjTnphaiic* arc attacked here. The conditions for local 
ndcrnbiul proliferalioa and invasion of the tissues, and for absorption mid systemic iiitoxicaiinn, 
•n? much more favorable then, and, as is well known, often lead to minvertable death. 

The comparative safety of all operations perf«in»cd within the linnts of a precitling but 
tcrtniiuted iuflaininaiion — that is, within recent or older cicatricial tissur' — is very well known 
to all ■urgcouH. Ri-aniputatiunii, many joint ext>ecliond, almost nil necnMondeii, rarely give any 



I 



17t) 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



hM^i 






'\<'r>- 



"5''V^ 



1 



KM 



'-% 



^Z'^. 



This coccus is foiirifl in almost all forms of acute auppnrattun — in 
plilegmon, glandular abscesses, and in acute, infectiouB osteotnyelitia. fif 
certain methods nf manipulation, a piii*e or unmixed culture of tit' 
can he ruisofl upon glass ])late:* covered with a lilui eonsisling of .1 

of peptonized mwil-jelh 
and af^ar a^r. a TcsfcU* 
hlc form of gelatin. Tbu 
mold resembles in stmrt- 
ure tlie common form of 
mold dreaded by hmue- 
kee]>ei'8, only it luu » 
deep orange color. It 
lia.s the ixjculiarity iif 
thriving upon the living 
human tissnes, c^ilUBilig 
their inSammation tnd 
ultimate death. (Plat« I, 
Fig. 1.) 

Another fonu otgn^ 
coccus, not so coiniDon 
a^ the preceding one^aad 
appearing either alone or 
ussoeiatcd with the goW- 
en grape-coccus, is Kosen- 
bach's ** Stvphylococrvi 
p)/OffPH('A albus.^' It run not be distinguished from the yellow coccus uinh^r 
the microscope, but the mold produced by pure culture is easily recogDia'<l 
by iti> (R'arly white color. (Plate I, Fig. ti.) 

Both forms of grape-eoecui* have the clinical ]jcculiarity of causing vieW 
localized foci of phlegmon. All tissues \v'ithin a certain area beoonif uai- 
formly permeated by the grajje-coccus. They coagulate, then emuUify,iia<i 
the result is a dij^tinct abscess. 

Another form of micro-organism — RoiJenhjieh's *^ Strfptococcun pyogmnC 
or pun-ffent'rntittff ckaiti-rncrus — is so called on account of the arr«ngeini*tit 
of the .-ingle globular cocci in more or less elongated ehain*. (Fig. 130.) lu 
peculiarity is to rapidly extend along the lymph-spaces and lymphatic Yt^ 
sels. Its enntlsifying property is not as pronounced as that of the gnp^' 
coccus, but it may become very destructive to the tissues by nipid infiltri' 
tion along the lymplnities, causing progressive gangrene. The peculiarilj 
of extending along the courso of the lymph- vessels, as well as its micro- 
sco}»ical appearance, testify to its close morphological relation with tltf 
M/ri'ptoaiccu.s, or cfiain-corrun of frf/fuppfas, discovered by Fehleisen. (Plaic 
I, Fig. 3, and Plate II. Fig. i: then Fig. VU.) 

Pure cultures of the pus-generattng streptococcus and the coccus ol 
sipelas ditTer very distinctly in several iniiiortant points (see Plate II, Figa 
4 and 5), but microscopically they can not be distinguished. 



[liwilli 01 piitrcliiotintt nnd ilivorHe forms of coed 
in ['(itrid lilomt. i Koi-ti. > 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



185 



organs may be very extensive. The coincidence of matnrity and perforatirm 
is abo rare. In itsabsenc^e fhe ]ierforntinn will nut lead to complete evaen:t- 
tion, and the septic process will perBtsteiitly extend iu one or another diiTC- 
tiou. not relieved by such incomplete drainage. Lastly, natural drainao:e by 
perfomtion will often be located in the nKX-^t unfavoruble place, and will not 
be ample enough for the escape of large nias-ses of pus and of sloughing tissue. 

The most direct indications for the cure of phlegmon are offered by a 
clear understanding of the natural history of its causation and development, 
as pret^entcd in the foregoing pages. 

One or more proptrly madr ifirisions./olhn'ed hy effective drainaye^ will 
at once empty the focus of most of its infectious contents, relieving at the 
same time the dangerous amount of ten.«ion. 

Infected tissuej* not yet Itipietied, and still adherent to the walls of the 
abscess, must be di.sinfeeted by more or less frequent or permiment irriga- 
tion with a germicidal lotion. Finally, all conditions tending to impede 
free arterial and venous circulation mast, be eliminated by proper position 
— that is. elevation of limbs, removal of constricting dressings or clothing. 

The necessity of rest — that is, the avoidance of all mechanical injury — 
is a matter of course. 

{a) Superficial Suppuration, or Septic Ulcer.— Inspissation of the dis- 
chargea of an infected snperticial lesion will, by the formation of a crust, 
often prevent proper drainage, causing a more or less complete tjeclusion 
or retention. The gentlest way of detaching these is by the a])pUcation of 
a warm dressing of gauze moistened with a two-per-cent fiolntion of carbolic 
acid, pvaponition of which should be guarded against by an external luyer 
of rubber tissue nr oiled silk. After due softening under this wiirni, moist 
dressing, the overlapping eiudermidat masse^', hiding small recei?ses, .should 
he laid open hy cantiou!*ly clip])ing away their undermined edges with curved 
scissors. Thifi ran be done wUhintf eansuttj (he h-ast pain. Thorough dis- 
infectiun by the lotitm contained in the dressings will thus be possible, and 
the diJTusible ^uuHties of carbolic acid will nut fail to exert their beneticjul 
disinfecting influence upon the germs scattered through the vicinity of the 
nicer.' Its yellow coating, consisting of a superficial layer of niurtilied tis- 
sues, will he cast off, the angry look ()f the neighboring skin will disappear, 
and the remaining healthy granulations will soon he cicatrized over. 

StreakKofhjmphanijitix evtetiding tovs-urd the pertinent lymphutie ghimls 
ehould l>e well «jlYe<l with niercnrinl uinlinent. But, if their cause — thu 
septic state of the ulcer — be removed, they will disappear without special 
treatnjent. 

(7.) Cutaneous and Subcutaneous Phlegmon. — Tbi-* graver form of sup- 
puration ia marked by violent local and general symptoms. High fever, 
with rigors, the general sense of .«iiekness, headiiehe, and a foul tongue and 
hrenlli are present. The skin over tiie fuens of infeetiim becomes deeply 
inflamed, oeiletnutous, and shows dense inliltratinn, nmt)ifesk'<i In' hardness 
and pitting. The constant gnawing pain puts sleep out of the (juestion, 
and the sju'eading of the afitection over new areas of tissue is evident. 



I 



DIAGNOSIS AJ^D TREATMENT OF PHLEGMON. 



187 



dr^sMtuf, held in plrtce by loose turns of baudage, vvill fomplete the work. 
An immediate fall of the temperature, with marked local and general relief, 
will reward Iwth patient and surgeon. Daily, later on, a i-arer chancre of 
dressings will lead to a rapid cure. 

If the patient decHucs an operation, topical applications are in order. 
ToW, in the shape of iced compresses, or the ice-bag, will ht' prnjK?r where 
the affection is superficial and acconijiaMied by lyniphangitit'. On the whole, 
it may be said that cold is beneficial in the initial .stages of moat phlegmon- 
ens affections, and is often very well home and effieaeious in the milder 
forms. To many it beconie-s nnbeanible from the time that suppuration 
ii3 well established, and often indncen a severe chill, the real cause of which, 
however, is always to bo .sought in the pnesence r)f pus*. 

Note. — Cold is badly borne by elderlj or ruu-di>W() subjects, »v iliose prone to 
rhvuiuatiBin. 

Drij nr mnint heal is very soothing to many patients, and is a power- 
ful stimulant to the local circulation. Occusionally it nndunbk'dly averts 
threatening suppuration, and may lijjtly be employed as a tentative or initi- 
atory measure. However, if the local and general symptoms continue to 
increase, it should not beguile the surgeon into jn'ocrustiiuttiotj. Especially 
if a gathering become soma-ssivo as to cause/ Mr/ (/«//«//, incision t^hould lujt 
be further delayed. 

NoTK. — The main effect of the curirju.>* ami often incomprehensible combinations of siit»- 
Btances entering, at the rcronimciulatiou of layiiu^n and some pbysiciiins, into the compusition of 
piMibicet, seein« to be upon Ihi? fiiith and inuiginaiion of ihc piuiciit. JIwsl kmi is their active 
proiK'rty, and, the simpler nnd ch-aniT its einpioyinont, tho better it will l>e. The nauscuuti prat- 
tici' of smcarinj; the tikiti, or, Ktil! vor»e, n wound, with hot linseed dough, is^ not yet extinct. 
Even a well-inelosed p«nilticc U not a proper covering to u u-tnind, unless a clean chfth and clean 
mush be tuken for i-utfh H|ip1ieutiou, rcrtaiuiy a mixture nf !»miivd linseed with ichor ami pus, 
ineloi^ed in n faiil rag, i* the worst (if ail alKJiiiiuation:) that a deenyin^; era of Hurgery liuj* left 
I>eli5nd n« il.i legacy. A r/rnn chth dippeij iu imd irrunff out of hot wafer, covered over with a 
|)i<-ee of oiled silk. U the best, the eheap'St, uiid the WnM unapjielisrinp of all catftfiUsuj«. The 
e«t)ipl(isni sbiiiilij never Im> plueed in iietual contnei with a wound. The interposition uf » ibin, 
nKMst drejuHiug will peuti-et the wfiuiid from uieehaiiicnl iiiMiuIts nnavoidiibly eoniiei-liHl with the 
change uf poultice, aitd the poulliee itself will thus rentain untwiled by the xeeretions of the 
wound. 

For special treatment of carbuncle, see page 210. 

Snbrutatirniift pkkt/mtjfi, left to itself, or treated by too long poul- 
ticing, will assume very large proportions. The form of the abscess cavity 
is nii'cly globular, but mostly irregular and siuuoui*» This is partly due to 
eonfluence of several smaller absi-i'sses, [nirtly to irregular extension, catjsed 
by the varying tleusity of Ihe subentaueoua connective tissues. Fluctiinhun 
noon appears, and without delay one or more incisions should be (dacetl so 
aa to dniin every ncess in \\w most direct manner. VolknuiUTrs jninetmi- 
tion of the periphericiil infiltration of the skin, a thorough irrigation of tho 
cavity, and a moist dressing, constitute the treatment of these cases. The 
first incision is made where fluctuation is most marked : the Index-finger of 
the left band »< then cautiatisly inserted, and carefully explores tho iuterit>r 



172 



RULES OV ASKPTIU AND ANTISEPTIC SURGERY. 



hsBniorrhage is very aj>t to dislodge and carry off particles of filth (iei>osited 
in the wound from without at the time of the injury ; and, further, itag- 
nifies an abundant Wood sujiply, good nutrition, hence promjjt union. An- 
other point of importauce is. thuh wounds that bleed profusely gpneralU 
come under the c^re of a physician, and will receive at once proper atten- 
tion and protection from further injury. 

Small abrasions, lacerations, or punctured wounds that bleed very littl 
or not at all, have deservedly a bad reputation. If the injuring instrument 
or object does not inoculate the wound with HlHi, and subsequent inf(?ction 
is prevented by pru[ier measures, healiug will proceed without iuterrnptiou. 

But, as a rule, these wounds are neglected from the outset, because there 
is scanty or no hemorrhage. The sharp-edged tool of the mechanic, or 
the pointed object handled in the daily voeatJou of the laboring man. 
very rarely clean. In certain occuj>ations, an that of the butcher, anat 
mist, or cook, the hands are frequently injured while in contact with foul 
organic substanceH, and tiie injuring force will at the same time inocalftl 
filth. No hft^'morrhage following, and the pain being insignificunl. lb* 
matter is lightly passed over, and work proceeds without interruption. Th« 
cleansing effected by hemorrhage is absent, the small orifice of the skin >• 
soon filled by lyni])li and obliterated, ami we have to deal with a hermetic- 
ally sealed focus coutaining filth, leavened by a certain number of micro- 
organisms, that at once must and do begin to develop and multiply, cuusin? 
a destructive purulent inflammation. 

Not all of these small injuries are infected from the beginning. Thej 
may and, as tlieir fi-equent spontaneous healing proves, are often enoi 
aseptic. 

As a matter of fact, they do well at first, and as long as the patient tal 
care of them. But if, as often [lappens, the protecting scab is reinjuretJ. 
and infection by contact with foul matter follows, the consequence is sujf^ 
puratiou. m 

Note. — Inflammatory Icfiiona of the ekin mv rruitful sources of infection, •mong Umsu 
tMExeum the foretuost. Tlic inteiiac itchtug tends uTtsititiblj to Ewratching, and the aniaU esecriir 
ttona thus produced nre oftea the portals of )nfe«(ioii. 

2. Infection through Lesions of the Mncous Membranes. — Less numc 
than the lesions of the skin, yet productive of fre<|uent mischief, an? 
traumatic and inJlammatory lesions of the mucous membranes. Slill 
injuries to the lips, tongue, buccal and faueial mucous membrane are 
common. In most cases a profuse flow of saliva is instantly j^rodnced 
a painful injury, and. if hapmorrliage be also present, infection rarely 
place. Healthy oral cavities and thoir aduexa are especially exempt 
infectious processes following injuries. Even gunshot wounds of these pe 
can heal without suppuration under favorable circumstances : 

Oabb. — E. L., flgef! erjihteen, adinitted to Mount Sinai Oospital, December 7, U 

with st]ie5(]ftl fresh pistol-uliot woimtl of tlie tongue, cxtcndiiiiaf from the tip backt 
to the left Hide- of the base, dividing tho urKan in two nne.i«ul purts. (iitnNhot iK-rfa 









•^ultare of cbain-ooccits fwra a caso of acuto progrossive gang^ne. Transmitted 

light. « 

-C'hain-cocous of erysipelas (Fohlcisen). Trananiitted light 
•Cbain-coocus of erysipelas by reflected light. (From Roeenbach.) 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



191 



Fir.. Ui'i. — Bui.-iHi uf tiiiilijfuiitvt r>^leiiiu or iiodti- pr»)rrw*»ive 
pliU'ifUK'H tT'Xi tJiiiiiietor^i. (Kik'Ii.) 



(ianyrrutitci phh'tjm'tH- (rii'ogoff'i^ acute ininileiit oedema) rt-prosoijU one 
of the highe-it degrees i>f microbial [MiiscKiiug, where ihc iiitilti[ilicali(ui af 
the micrn.oriraiii.sms i;- 
no rajii*! iiiul pervad- 
ing that the establish- 
nieut of itHiuiuorablL" 
foci throughout all of 
the ttjisue?* e<>mj)osing a 
whole limb leads to e.\- 
t<.'nsivc general intiltra- 
tion. Bfiard-like hitr<l- 
iiet»8, a dusky hue of tlic 
integument, bleba and 
eceliytno.ses, and finally, 
thrombosis of veins and arterie.", will end in necro.sis of the entire enor- 
mougly swollen and cold limb. Incisions do not yield pus, bat oul}' give 
vent to scanty qnantities of turbid ichorous serum. In these cases tbo 

]U'ognosis is very bud, and 
r '"\ i^^P^^^^^BI^^^^^^B ^'^^' "^^'^^ heroic incisions 

^-i>. *■ r^.^^m^S3iM^^^^^BX ^r%^^MS^^ the nieiuber. If to(> jortg 

delayed, even a high an»- 
putation may fail to save 
the ])atient'> life. (Figs. 
U5 !jud 14n.) 

/Jiiipfipsnndfuus fJan- 
i/rnif. — The inoculation 
of the human nrgniiism 
with a specific baclerium 
(Fig. 134) is generally followed by the (Unelojnneni: nf a dusky, rajadly 
>*prp.'»ding infiltration, exhibiting (ui palpation the jfecnWar crackling, and 
on percussion, the tyni])anitic sound of subculaneous eniphy.seina. The 
process is accompttnied by profound septic intoxication, with delirium, high 
teni|K?mt tires, chilli, and dejection, and ti'rniinates in gangrene of the 
affected pai'ts. Rcsnlute nteasnres — th.it i.-i, timely amputation 2K'rfi>rmed 
through heultliy part-j — may succeed in fireventinga fatal issue, 

{fl) Acute Infectious Osteomyelitis. — Suppuration of the ntednllary ntib- 
stance of jmrts of tiu^ skeletioi represents rme of the most djinjrerons luul 
destnictive forms of jihlegmon. Its cause is the establishment of cult- 
ures of the ijohl - ndnrfil tp'ttpt-roccuK in the caijiilaries or arterioles of the 
marrow. The manner in which this infection occni-s is still matter of 
controversy. iSn much, however, is known that it is most common during 
adolescence, and that a ]ireceding suppuration, followed by ex|Mjsnn' tu 
weather, or certain traumatisms, are common provocative causes. 

The invasion is marked by a severe chill, followed by a deeji altenilion 
uf the general well-being. Very liigh tempeiatuivs, with chills, somnolency, 



Kt... U'i, — Bacilli of malii/naiit (rUouiu in iIk- kidney 
(700 dinmcUTfO. <Kui!li.^ 




174 



RULKS OF ASEPnC AND ANTISEPTIC SURGERY. 



epidermis. This may be ei])Iained by the tact that slight injurie* of 
roucoas lining arc produced much more easily than thoeo of the skin, 
are not readily ascertained on acconnt of the normally moi^ condition 
the purt«. 

As formerly stated, the slightest denudation, not deep enough to cm 
haemorrhage, and just productive of a slight erudatiou of eernm» offen 
favorable point of entrance to the virus in the patulous oritices of 
lymphatic vessels or lymph-spaces, thus ex|>osed by the injury. 

In lacerations or punctured wounds the infective agents arc w 
often deeply inoculated with the point of the injuring article — ^tht 
is, they are at once depotdted in close vicinity to dee]>-seated lympt 
vessels. 

In tlie more superficial forms of injury, the implantation of the vii 
occurs only in the neighborhood of more sujierfieiul lymphalir 

transmission to the deei)er lyraph-ves.«els is ace - , 

W~* by forces which govern the flow of lymph from the 

riphery to the center. Aside from the normal en- 

tiug to ward th' 



V*- 



1^6. 



(7W diumetere). (Kooh.^ 



duct, external forenssi 
the play of the voluB 
tary muscles have an iiB 
portant part in liasti'i 
ing the flow of lyiniilia 
So, for instimce, 
pressure exerted uj 
the lymphatics of tJ 
jiulm by the frequt 
and vigorous gnvjrpinj • 
of a tool wielded for i 
long time with grrat 
force, will undoubtedly 
help to projwl the con- 
tents of thu }>eripheral lymphatics toward the larger, more deeply situated 
lymi)hiitie trunks. Or the vigorous contractions of the muscles during 
nuwti(!itii)n will undoubtedly empty the adjacent lymphatics centerward, 
their action being aptly comparable to that of a force-pump. 

What was formerly danoted as external mechanical irritation is nothi 
but this forriiif/ of pua-fft'na'aiinfj !<ubstanci:>< into the (ypen lymptiaticjt 
friction or otlier pressure due to exercise. 

The direction and extent of the spread uf the infection by the lymphatics 
are prescribed by the anatomical arnuigement of the lymph -vessels of the 
region coneorncd. ThuK, on i\w jutlmar jispect of a Hnger, The poisuMiiti 
will rapidly exteiul to the periosteum, a.s the lymphatics all tend that way. 
In the vicinity of lymph-glands, the infection will promptly extend to them, 
an iutervoning lymphangitic streak often clearly denoting the route 
wiiii'h it Irnvelc'iL 



ics I 
he 




7. — Mixed culturD of golden and lomon coloivd and of white grapfrOoocua from ft 

case of einpyiynjiii. RcfleeUnl light. 
8, — Common organism of putrescence. Racilhis sttpnj^nca. Reflected light. 
W. 9, — Bacillus saprogenes fn>n» h fticus of snplic tompound fracture, Sopticvt^mio. 
Refle«tl«l liglif. (Fmiu ffn«>nh*wh.) 




(if iht; liicalioo <>f 
ii«it«'omyt'litii- near 
(lu»kii(eai)(l,slu>ul- 
tler joints. Tht 
iifitrirttt luxxftK of 
I fie /nil ur a ml iibia 
tiivrrife from ihr 
kiin' -Jituil ; t/tdMr 
i>f the hujitrrun ami 
tli( !>o)Hn of tfu 
forearm <x»tvfrgt 
tnifiiril the etfmtP* 
Tlie tUiLHTt iinil 
ntHindatit bliMHj .•■u]iij«ly itf \.\\v iiialli'uli niid llie c^^xal cad of tlio femur si'v'Cus to cau^o mi 
varUer conetiinniutioti of tht* Ofitpogeiictic prociVH at ihest* tocalitieSj and alsio ninkeri tht-iit 
liable* to n fonn of mfi;elioii jkhhiIiih to llic infantile |tcrii«i uf tifc — inirinly, lulHn'iiUtsls. 
TiitH'i'cular alfiH^liniis of the ankle- uud liiji-jajitts [ire iiHin- f<jiiuiir>it '\i\ I'hilijM'ii lliaa MJiitv Hweli- 
ing «if the knet'. During adolesoence, when the jili} j*iolopeAl tliixiun (oward tin- knri'-joiiit fire- 
p<jo«l<.'mtei* over that toward the ankle and tip, liift ttndfncv to ut^teomyoliliri mar and tubcrcu- 
loniii near and in the l(aui--juint tK>tM>me» niurc piutiouucori. ^>;ilni!ar rulatiuus aeem tu pix-rail iu 
rvferenw to the ujijkt citremity. During infancy wlijtc ttwcliing of tin- eUiow is more cotnmot) 
iliaii lliat «f the tihonlder aod wriMt-joint?; in «do!i'Kcenct> tlie npiuM- end of th<* huiiioru^ is thi- 
conuiiun s.>-at of U4.-utc> ustfKiiDyeliti^ ; in udults tin- .shoulder itnd wri.^t are iiitirc fre4|iiontly 
Mttaekml by tiiheivuJu.'^i.s and oateuniyoliti^. 

Whenever an attack of o?^loo myelitis terminates in the fonimtH)!! of an 
ahsct'ss imd rho istahhslinieiit of one f)r more listnhf, the itciiti* f cut u it's nf 
tht' initial stages of thi' disorder disapfjear. The ahiitidant discharge of pus 
is followed for a whih^ hy a gradual decreasje of secretion, which again iti- 
croases as the se]iaration of the sequestrum Ix'conies more ami more coni- 
pk'tt'. ThiH XA exp]aine<l by the fact that, as the (h'a<l hone hecumes grada- 
ally detached, the pus-generating surface of the cavity containing the 
pcquestrura becomes proportioniitoly larger, hi the mean time now osseous 
Hubstance is thrown out by tJiose [lortions of the adjacent bone and peri- 
osteum which were not destroyed by Hup|iuration, ami thus a moiv or less 
jxTfect inixilnrrutn is formed aronnd the sofjnestrnm. After complete de- 
tachment of the ik'qnestrum, suppuration is gcuunilly profuse. 



HyuI, '* Dost^TtptiTc Anatoiuir," 1M7U, |i. 209. 



ln»; 



RULES OF ASEPTIC AND ANTLSEPTIC SURGERY. 



/ 



^SOU/ESTHUM^ 



FiiJ. 1 IS. — Diiiymin of i. titiii.svcrM- ^t•c•tion. 
t-liowiiii; rultttions of Hf^piOHtruuk, involu- 
rruiii, A.-'tula, and skin. 



If the affection is extcusive and no spont4iiioous or artiticial relief \b 
vouchsafed for a long pcriotJ, a deep deterioration of the general liealth will 

follow, characterized by emaciation, 
aTii«!niia, albuminuria^ and m extreme 
c;ise.s by amyloid degeneration of the 
liver and kidiioy-s. 

The diaynosix of iJi/> presi^iwe of 
(1 sffjuf'sfrnm can be made by noting 
the diffuse thickening of the affected 
Ixjne, the jjrofu.se secretion from one 
or more tisjtfiL'e, and by direct prob- 
ing. If the direction of the sinuses 
be straight, the silver jirohe will strike 
bare and roughened hone-surface. The latter s3mi>iom, however desirable 
for tjie est^iblishmeni of a po.stitivo diagnosis, is not ahsohit^ly necessary to 
it. Indeed, tlie ca.«cfi are (piite 
common where tortuous chan- 
nels prevent direct firobing. 

Drfarhnif'ui of tJtP sfffucs- 
trum is indicated by its mo- 
bility under the pressure of the 
probe-point, or. when probing 
is iniprueticable, by the long 
duration of the trouble and 
the increasing or profuse dis- 
charge. 

When to Opcraii'. — It may 
be laid down a.s a general rule 

that the best time to perform sequestrotomy is after complete detachment 
of the dead hone, which can be aiiccrtained either by probing or by the 
general a.s[wets of the case, Keeognition of the necrosed parts and their 

complete removal 
are then easy, and 
will be followed by 
a rapid cure. This 
rule, however, ad- 
miti* of iuiportanl 
exceptions. 

\0T«. — Extensive 
necroftes of the lower 
jaw arc frequently ac- 
c'onipanied by » profus4' 
Jisolinr^jc of fftid piis 
inut the oral i^vity. 
Tills iind the iuBl)ilily 
to niasticatf fmnl, do frequently render eurly riMff by operation very ilcsirnblc. The objection 
that to perform a complete operation will neee^^itAle the ^nvrificc of healthy Iwiic i? not tenable. 




Fm. 14(t.— Neuber'.'* HH'tJifKl. Top of involucmm ro- 
iiioved, akiu-fliijKj turned into the bottom of the 

boiie-ctkvitv. 




Fu. ISO. — Scbcdu'« method. Diafn^cn ithowtug relations of orgnn- 
izinif bhiod-clol, 



NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 

ter, aiit] from thi' esohur and t'xuilattoiis in H'vei'LT forms, no sup|mratioii 
will lollow. The modern use of the thermo-cautery in the perituneul cavity. 

»J*i joints, iUid, as a nmttor of fact, in wounds of the most various clianicler 
«ntl. of all anatomical regions, is foliuvved by unintemipted union iu nil 
cas^jg where, at the same time, adequate aseptic meajsuros are emj>loyed. 
-^n eschar or a masi? of dead tissuf, whether produced by litrature. or eheml- 
c*^\ CK)rrosioiii. or red Jieut, will never assume the irritating character of a 
H * '^oieign body," in the meaning of the term as presented by the tenets of 
•^^^ older palhafogy, if the decomposing action of the presence of miero- 
*^*"S'**ni.>im3 is excluded by projier measures. 

I The behavior of superficial burns of the skin i& fully in accoi'd with the 

^^^t^ just presented. 
If a bleb l)e raised, and i.»< left unbroken ami dry, its contents will be 
''^orljcd, ami the epidermis will settle hack into its nornml relation to the 
J^tta^ It will turn into a dry scale, and will peel off with iti ten to twelve 
•y"®, exposing the tender new ejuderrais. 
, IIow diflfcrcnt h the course of a burn if the epidermis is torn otT by acci- 
t ^ or intentionally, and the exudations are thus ox])oiied to the itivasiou 
■^^ ieroeocci ! If the surgeon do not em|tloy timely disinfection and the 
I 1**1 cation of a jirott'cttve dressing, 8ui>puriitioiy of the exp<ised euti**, with 
. '"ts aecompaniment of pain, long-continued granulation, and a very tardy 
**-*iiig, will follow. 



1 



I 



IV. DEVELOPMENT OP PHLEGMON. 



I~ ^rom the moment that a tjuffieient rjuantity of active fungi have eatab- 
^''*ed themselves within the living tissues, remarkable local and general 
^r *• *^<inomcna develop, known nnder the lumie of ittflaiitmation and septic 

Our object is not research into, but rather a tncid explanation of, the 

Jnce of inllatnnuition, as understood and aece]ited by contemporary au- 
thorities, lienee a brief sketch of the leading features of the lu'ocess is 
^*^med suffieieut. 

Micrococci find a most favorable paluiluin in dead or devitalized organic 
^mjstances. Tin- living tissues offer a decided resistance to the nivageB of 
*'he micro-organism. The spontaneous limilation and occasional unaided 
^Ure of Home forms of sn])]nirative intlammation prove this assertion. 

Bacteria can not thrive on the jn'oducts of decomposition : they need 
^Or their susten:u>ce dead but nndecompoaed albuminoid substances. As 
*oon as the supply of dead animal tissue is exhausted, the micro-organisms 
starve and perish. Their spores or seeds arc loft behind dormant, but will 
Ofcorae active if fresh pabulum is offered under favorable eircumstunces. 

This explains the fact tiiat fresh cwltiper)!! or anitnal i<ubfifa)tce.<i in the 
decent stat/es of pulmscence are much more infectious than those that arc in 
oi progrvsHed siatf of tfecompfmfion. Tlie varying intensity of different cases 
of infection seems to depend in a great measure upon the varying degrees 



RULES OP ASEPTIC AND ANTISEPTIC SURGERY. 



of vitalitv of different microbial cultures. It seems to admit littlo donbt 
that the great mnjority of dangerous wound infections are brought jtboul b^ 
tlie importation of considerable muRses of very active, rapidly [iroliferuting 
raiero-or;?unisms in the shiipe of 'Mumps of dirf,"as Lister graphically pti** 
it» taken from various sources of recent putrescence, so abundant in 2*^» 
huraun snrroundin<^g. The dry spores ll<jattn» in the air will bo easily tak^^ 
caire of by the living tissues, if pollution of the wound by ;iroMs dirt — i\» ^^^ 
iSf masses of organic mutter in active decomposition — is avoided. 

Every injury causing a wound destroys the vitality of those cells th- 
lie in the direct path of the cutting or lacerating objuct. The blooti ai^ ^ 
lymfih exuded from the vessels eougulate, and also represent dead matter. 

If a number of active micrococci are implanted into the bottom of tlt^^ 
wound, they will at once multiply, using the blood-clot and its extensioi::*** 
into the blood-vessels, together with tlio a*lju(-'ent dead or devittdized tissui-s^^* 
us a welcome soil for their development. This fermentative decom}K>sitiu ^** 
produces from its very beginning certain alkjdoids or chemical, extremel 'y 
poisonous substances, ihv plomffines, that are very diffusible. By diul o^' ' 
Ihis ditfusihility, the adjaceut vasomotor nerves at once come under tbei ^ 
toxic influence, as the result of which their strong dilatation ensues:, whic^^ 
becomes manifest in the shajx' of an aiiivc hyper(Bmia, " rubor.'' 




Fio, 139.— BikCillJ of withmx (7i)i" diamclore). 
( Koch. } 




hai'illi i,iw> Uittinctt 



\^T 



tKoeh.) 



Tho blood jta-ssing through the adjacent arterioles and capillaries swms 
also to become altered ; the red bloadH2:orpusele8 become packed and finallf 
stagnate in the capillaries and smaller arteries. The walls of theae VMsel^ty 
including the veins, lose their impermeability, and ft number of white and 
often red blood-corpuscles emigrate into the surrounding tissues, denseh 
infiltrating their interstices, thus producing tlie characteristic ntctUing, 
"turgor.'* 

Aa a consequence of the increased blood-supply, possibly also of the 
active chemical process, a marked increase of the local temperature is ob- 
gervcd — " rulor.'^ And, if we add that pain of the parts thus affeeted is 




NATURAL fflSTORY OF IDIOPATHIC SUPPURATION. 179 

never absent, we have completed the classical cycle of the four cardiiml 
symptoms of inflammation — " rubor, color, turgor, dolor. ^' 

Note. — The causes of local pain may be several. The initial pain is very likely due to a 
direct influence of the ptomaines upon the sensoiy filaments. Direct pressure caused by the 
dense infiltration may also have some influence ; but the most acute pain is undoubtedly efTected 
by the actual dcstniction of the nerve-tissue during the advanced stages of suppuration. 

Stagnation and dense infiltration finally produce a very high degree of 
tension, leading to compression of larger afferent vessels. The infiltrated 
portions, devitalized by suppression of the normal circulation, readily suc- 
cumb to the inroads of the millions of micro-organisms, and actual necrosis 
rapidly follows. The last stage of textural destruction is the final liquefac- 
tion of the tissues and infiltrating leucocytes, aided by the exudation of 
large quantities of lymph-serum from the adjacent unobstructed blood-ves- 
sels, and thus the formation of an abscess or a cavity filled with lynii)h- 
serum, myriads of dead white blood -corpuscles (pus-cells), and quantities of 
shreds of necrosed tissues, is accomplished. 

The veins also participate in the disturbance. Coagulation of their con- 
tents — thrombosis — takes place, and existing stagnation is materially aug- 
mented. 

The deleterious part played by thrombi in the causation of metastases 
will be later mentioned. 

When a septic inflammation of sufficient extent and intensity has been 
well advanced, the great tension of the parts will necessarily cause an over- 
flow of the most diffusible contents of the focus into the surrounding effer- 
ent vessels — the veins and lymphatics. The ptomaines, thus entering the 
genera] circulation, will at once produce systemic intoxication, manifested 
by a very marked rise of the body-heat, rigors, sickness, headache, delirium, 
and general dejection — in short, a deep-going alteration of the nervous 
system, known as septic fever. 

V. SPRBAD OF SUPPURATION. 

The way of the extension of septic textural destruction is twofold. It 

t^akes place, first, by a direct infiltration of the tissue-interstices by columns 

^nd hosts of the immensely prodigious micrococci — that is. by an immedi- 

«*to growth and extension of the microbial colony ; and, secondly, on the 

^Xr&y of the lymphatics, openly communicating with the focus of suj)pura- 

"tion. Into these, bacterial masses, or ])us charged with niierocoeei, are 

^forced by the hydrostatic pressure exerted by the tension within the abscess. 

If the parts affected are composed of loose tissues, the spread will be 

rapid and extensive : if the parts are dense, the inflammation will remain 

localized as long as the density of the tissues (fascije, for instance) will resist 

the pressure of the secretions. But, as above mentioned, this very pressure, 

or tension, involves another great danger. The afferent blood-vessels Income 

thereby occluded, and the resulting stagnation generally leads to extensive 



200 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



operation;, then suflicient pressure was not omploved. Suitable-sized com- 
presses of iodciformed and sublimated <:awzo shotild at once be laid upon 
tlie blotcli, ufid shoukl be firndy Jicld dowu by a clean elastic or flauuel 
bandage. This additional pressure by the elastic bandage should not last 
more than an hour. 

Case.— Honnan Albertin, scliool-bov, ii+jei] nine. Ctmtral seijuestrum of lower cod 
of sh:irt of liuiiienisi ttu«3 dissuniinated necrosis of lower epipb^sis due to acute osteomye- 
lit'iH. Necrotomy [)erforrned Aju-il 12, 18y4, at German Hospital, under cLloroform. 
A loiii;itudinal jmiHion five incbes loiifr, coniTueucin{? at IIk' ii]ipt;r third of tlie posterior 
a»]»oetof die left tmiiieriiH, wns fliiccessiveiy carried thronjrb the skin, faseio, and triceps 
nnmele, luitil ^h^^ imiHiiil<>-!*piral nerve w aw expused and freed from its bed. It was 
tnken n[i and held 4iside by u blunt book. The [ierio!*tfUm was incised, turned a«ride, 
and lield up by u pair of Vulktnunu's four-prnnfied Look.-;. Tbe posterior face of tlie 
thickened shaft of the hninerus was chiseled away, exposing an irregular- shaped 
centnd jicqiie^trniti, three indies lonp. The overluppinj? parts of the involucnim were 
furtlier cltiseled off, until the entire f<c<iue!*tnini could be ea>>ily lifted out of it.* place. 
Two sijiiill, i-fjunil sc<|iiestrji vr<-rv removed from tJie lower e|»iphysi8, and the entire 
lr<)Ug[i-»*hji|iL'd eiivity was cjirefidly siniped out with u sluirp sfioon. A small strip of 
iodofonned gauze was placed into the most dependent part of the bone defect, and was 
brought out at the lower angle of the wound. The triceps, tkscia, and skin were 
nnited by three tiern of conlinuouK catgut suture. A ct>iiipres8ive gauze dres^ng was 
banibi^ed arniind tfie bnib, «ml tla- eonf<trii'tinp baud wan removed. The arm was 
held in vcrtic/il -HOMpeasictn for twu lioiirs, uud ufter tbjiJ was phtced in the seuii-elevnted 
pantiire on u pillow. The tcitiperiittire reuiinned noniud tliroufrbout. The first ehanfre 
of dres-sinys wan nmde April 2'itli, a fortnight after tlie operation. The dressing's eon- 
tained only a sinail ciitautity of dried blood. The fillet >*( gauze being removed, a new 
dicMHing wan ajttdied. The patient was riiflchar^ed fr(»m the hospital April flOth, 'witb 
a uniftli, superficially grmmlatin^r wonnd corrcsjtonding to the place of clniinHge. He 

returucil lor naother change of (Jrcs-^inir May 12th, when 
the vviuaiil vva-* f">UTnl entirely cicatrized over, 

111 eaue!? where the surgeon is reasonably sure 
of having jirodueed !iii ns(']itic wound, either 
Neuber's method of iin[ilantatton of ^kin-llaps 
or, what is better, Schode's treatment can be 
t-njployed. 

Xmberfi Mrfhod of Implanfatioti. — Neuber'.*? 
idea consists in the endeavor to cover up with 
skin, if poiisiblc, all the raw .^nrfaces left by the 
operation. Primary union is the object, and a 
minimum uf luieovcred raw tissues is left to heal 
by jEfranidation. Lonf/ttmiinal bow fhfectsy such 
as are csiused by the removal of a necrosed por- 
tion of tbe shaft, are partly or entirelv covered 
by the turnintj in of the edt/tf; of tJu' rntaneotts mound till they meet at or 
near the bottom of the groove in the bone (Fi^. 149). It is necessary for 
this purpose to dissect up laterally the skin on both sides of the incision to 
a goodly cvtent. so as to render it movable and easily held in tbe new posi- 
tion. One or more wide sutures of catg^ut are passed through the skiti at 




Fi«. l.W. — Simon NothaijV ciwe. 
A, Fenestral defcot of tibia, 
a, Bridjfe removed. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



201 



the |>oints of reflection (Fig. 14ft), to retain the tUips in positidti ; juni, wlieio 
this is not Butticient, a well-disinfected nail is ci riven through the edge of 
the flap into tlie bone. The groove thns formed is loosely packed with 
strips of iodoform gan/.e, and the limb is iuciised in un tisepiic dressing. 

Norr,- — Kails are difitifccted eitlier by iKjiling in walvr 
or by beiii™ jiagsed through au ak-ohtitJlnmL* till they as- 
sume II dull-red htnt. Aftt-r this they an* dropped into 
the vessel holdinp; carholic lotion and the instmmetits, 



rteuLA 



Cask I. — Simon Nathiui, clerk, aped nineteen, 
ndiiiitted to rlie (k-rtaan Hospital April 18, 18HB. 
IIjhI iiooii liberated on tlirei< yedrn ago for necrosis 
of tihiM lny Prof. Sclniiihiirti, ol' Kr>i)t<;!»l)erff. A Jist- 
ulu remained uu the iinterior ai«[iLM't of the le|f, thiit 
closvfl up Jiml bri»ke open several times every year. 
The probe detectetl exposed but siinnoth Wnt». April 
2Sd. — The jiatient wad unrostliedzed and the tihiA 
wiisexposeci It was fotuid that the sinus led into an 
oblong detect (Fip. 15-5) of the .>-hal't, through which 
tlie probe conkl be pawed, so as to bo elenriy felt 
henenth the «oll t issues of the calf. The len^rtb of 
this defect vvus a little more thwH un imdi, its wiilth 
half au inch, and its walls were foriinMl bv very hard 
condensed bone. Apparently the sclerosed condition 
of litis bono iiiid its »cnnty blood-sup[dy was the eaiise of the fre<pient ulceration of 
the deciduous finuiultilious funiring within the track. The bridjire ol sclerosed bune, 
tojjorher vvitli the adjarelil condensed parts of tlie shaft, were removed by iiiailet 
and chisel; the edces of the cutjineous wound! were dissected ujj Hufficlently to admit 
of an easy adjustusent within the gap Iwitwoea the tibia and fibula (Fig- 16t5), Two 
■tout catgut sutures were |>it»KM] through botli edges of the skio-wound, »nd were 
broo;rht out by n Peaslee's needle on tfie under side of the calf, where they were tirinly 



}lWOT 



Fiti. 15^.— Simon Niithon'A oiM. 
Implunlut'toii iii'cuiuueons ed^Qs 
iDtii tbe deleet by tnmnflxuijf 
eal^nit suture. 




Tw. Ifi7< — Neuber's method. FrKnk Nkgen^rsfit'B ciuse. Implantation nf triuntrulor flap into tho 

defect of the head of tibiu. 



knott4M] over a piece of stoat drainage-tube. Tha« the edgen of the Hk1n-fla|>s were 
Well drawn into the bottfitn of the defert. To so me what relieve the pressure hy the 
drainage-tube upon the skin of tlie calf, a nail was driven tiirough one of tbo ihips into 
the tibia, and the leg wmh dressed lUitisepticuUy. Slight elevatloDs of the temperature 
without general or local discomfort were observed on the two succewiive days, after 
which the normal standard reiiiuini.Hl unchanged. The dressings were removed May 




202 



Ur LES OF ASEl^riC AND ANTISEPTIC SrUGERY. 



9tb, and tbe skiD-fla|)a wen found fi roily adliurent in their new portion. Some cutane- 
ous ulceration of the sicin »»n the ealf luul taken place. The nail was removed, Tb« 
patient was <lis<'harged eitreil June Int. 

Notk. — A Bcterosed and ill-nourished state of the inrolacruin will often lead to a rcpcatei 
hn.'ftkdown uf the |[;ranulBtiuTi.<i lining an nld mni\». Stimuliiting irtji'Ctiuns will itometime^ effect 
a ciipp, hut iu i-chelliiJiiH eiise.<) }*ijco'ks can be had only fmm a thoniu^h removal of the cnndeneol 
poi'tion'i of the 1>onr' and >iiiiiii^. 

Ca8B J I. — Frank Nagengajif., a;red ei^'ht, a very anannie bi>y. Necrotomy of tibia, 
November 2, 1885, at Mount Sinai lIoKpital. Extraction of a lai^ central aeqaestrum 



:Z oifi"'"" 



Flu. 158. — DJjurrntn illii«tnitin^ Si-heJeV rnfHit«l ap}<lu!cl lo a cj-h; lik<] thiit of Fmnk ?Cat{\.iuju>l. 



coniprfHiii;? the entire llii'-knes!* of the upper lialf of the shaft, a narrow extension 
reaehin^ down to the loiver epiph\>it». Three siiuilJ f*e<[irestra, tnjrether with a lot of 
softened prumihir e:iiieelloiiH tii^sue, were removed from tlie bead id' tlio tibia. Tho 
reiiminln;: post' lior porlioii iif tbe involuenirii was so slender and brittle that it broke 

into several fragments during the 
o[ieration. Lateral impltmtation 
of tho skia by means of transtix- 
ini,' Hidnres by Peaslee's needle. 
Aiitisepfie drensiiij; and u lateral 
>iplint. First e h an ^e of dressing 
November 2;kl. Ilealinp of the 
wotiniT tiy .adhesion eorrespond- 
iiij;r to tbe shaft. Sinuses lead- 
ing into narrow cavity in lower 
f»(>rtion of ti!)ia, and a larger 
cavity in the head of the bone. 
Fractures united with some sag- 
ging of tibia downward. De- 
cember 27th. — Hloody reinfrao- 
tion of tibia ; scraping of upper 
and lower cavities. January JO, 
Wif?*;. — Lower sinus closed; up- 
per cavity rIiows no tendency to heal. February fS, 1S80,— (Menplaatie chsure of 
cavity in head of tibia aerording to Nenb«r. A triangular skin-tlap, containinier tbe 
inBerlion of tlie quadriceps tendon and tbe periosteum, was raised from tbe anterior 
aspect of tho tibia. The remaiuinj^ roof uf tbe cavity was removed by luallel and 



y-nAff 



¥to. 169. — Frank Nai^nffoat's oawo. a, Trinnculor fkin- 
tlap. i», Sl(in-ttap lumed int<^i the mvity ; the durk 
■pM« to hoal by jrninulMiion. o, Viiw «r necn>l<?iiiy 
wound trttat«d according l«> SchvdeVs method. 




DIAGNOSIS AND TREATMENT OF PHLEGMON. 



2C>3 



cjitoel. PrevioHH to this the cai>Hijle c*f the knee-J4iJnt was carefully exposed to avoid 

cnterinp the joint. The irruiiular Jiiilii^ of the cavity was gouged away, anil mdIj a 

«hfll!, coDsifitirijf of t\ie iirlionlitr siirfiue and the fiosterior 

jifirtion of the head of the tibiii, roniained intact. The tri- 

anfmliir »kin riap wbh turned down into the hottom of this 

cuvity, aiid there attiifhed by a nail (Fi^s. 157-161). The 

reniaininji micovered Y-shaped p>i»rtion of the wound wfi.s 

left tn granulate. Utnler an antiseptic tireasinn firm union 

of t!ie llap (o <lte Hnderhinji hnne took jthu'e, and the granu- 

liitinj; part of the wound was firmly eieatrized over hy the 

middle of April. 

Schrdrn Method (Fi^. IG'2). — Selit'do'.s ulun has 
the great advantugc aver Neubtn-'s metliod that i( 
can be omploved successfully under the most vary- 
iftjET conditions, its nim/tlififtf ami inth-ptHth'HVf of 
the pn'stna' or alfse/icf* of k Hufftriruf vaverhoj lnj skin 
rommfnd it to the attention of the aurgeon. The 
author found Neuher's plan iniule(|uute wliere much 
integument hud Ijeeu lost, and was replaced by un 
extensive cicatrix. 




Flu. lUO. — Auterior view 
of Kniiik Nn^ujrucl'f \v\i 
alter oom|)lole(l fure. 



Cabe L — Frank Ilytnnn, aped twelve, received, in May, 

lftS6, a hlow on the left tiliia, itfter wtiieh eentral nHteornye- 

litid developed. Auiftmt IHh. — Necrotomif. Two large se- 

ijiieHtra were removed from the upper half of the shaft, 

requjrinjj three neparate parallel iiieisionB for their extrm^tion. The wound was very 

cufi failv <v,ieiiateJ of idl ^ruuulatujiis, and disinfected with a 1 : l.fHHl Holution of eor- 

ronive siildimate. Stui|do suture of tlie eutaneous 
inrisiiitis ; a sniatl drainajre-tiibe wa.H plrieed into 
thr op[>er angle of the longest inrision. All tfie 
ineisiouH were covereil with 8tri|>s of disinfeetinl 
rubber tif*8ue, and the liuih was dre."i**ed with sub- 
limnted gauze. The first dre.Hwrig roniftiued un- 
"■hijnged for lour wt-eks, when only a shallow fi.«*t- 
ul;i renuiiiu'd at the jOare wiiere the druitiage-tube 
lial Iain. This was scraped, nud it promptly healed. 

The hirge eavity tweanie filled with a 
hlnud-elot, which orguni/ed without t?up- 
luiratiou. 

The treatment of the osteomyelitic pro- 
cesses of the /V/nwr and their secjuela?, nota- 
bly of necro.sis, presents peculiar dillienltieji 
(vf teehni<iue mainly due to the deep site of 
the hone. Ijong incisions are usually indis- 
L Flu. '«i-^;jj^/;*;;:^;'' ^"""•k jionsuhle, access to the remote portior.s of 

^^m the bone is difficult, and the necessary injury 

^H t4» many muscular brunches of the femoral artery, and the difficulty of effect- 
^^ ivf compression of the muscuhir masses, render the rjuestion of after-hn'm- 

k 




orrhttge rather serious. It is, therefore, advisable not to deplete the limb by 



2(>4 



RtXEM OF ASEPTIC AND ANTLSEPTIC SURGERY. 



an eUwtic bandage of all itn blo<)d before upplving £aman;h*s constriction. 
Each cut resgel will then poor out a smaU qmstitjr] 
of b1o<jd, and can be rettdilj seen and ifeBgntgHL 
Thtf sa/eMt appronr.h to the Ixynt w frmm the erterm<U\ 
fiMpfrt, preferably above, or belov the hsBrStriii^ 
On the inner aide, HuntfifM cawxl requiref emn^mt* 
atUntion on accoant of the femoral arterr. Tbe 
seqnestrum is generally located near the posterior 
ad{ject of the lower end of the shaft. Shoald it even 
occnr that the popliteal abecen perforate on tbe in- 
ner aspect of the thigh, exposnre of the seqnestmra 
from the external ?ide will be safer and more easy. 
By the free d^ of the chiisel and mallet, sufficient 
accc^.s can be gained to remove the seqaesitrain. 
Even the most expert operator will occasionaUT Cafl 
to find a j«mall aeqnestrnm, or will not succeed tn 
itrf entire removal. The eventual necessity of a repe^ 
tition of the operation should be pointed oat from 
the outset to the patient. 

Inferior Maxilla. — As a rule, osteomyelitic foci 
of the lower jaw commnnicate with the oral cavity. 
This makes the preservation of the aseptic condition 
of the wonnd rather difficult, and sometimets notably 
in the presence of a neglected and foul set of teeth, 
, ^^^^^^w%m an impossibility. Where the process is extensive, an 
f ^.^^^^^^llal I external incision ii? preferable. 08 it lessens the dan- 
ger of the entrance of blood into the respiratory tract, 
nnd fucjlitateii complete and clean work. 



Fio. IflS. — lllumruting Mio.'i --1 - <*. jw of iirlie<li.''« ilnWm?. a, Nocrrttnmy wound, b, Proteot- 
iv(<. C; lodororirio'l uuitA\:. i>. SubliioiiU' kmuzc. k. (^ ompU'te div^'^inif. {i.'u~c of Samuel 
Kroneoid. Pliotni^niph^ tiikcn ten days altar opcntton.; 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



205 



» 




Care. — I. F^.-kert, tailor, aged twenty-three, ruiitnuU'.l truurnntic aontc osteomye- 
litis of Hiw liorizuutal ranuin of tbe left side of tlie lower jiiw, uftor the extraction of a 
carious tootli, dune November 2, 1886. Tht^ intensti pain of tliu begiDnioi^ wft*i rfjievetl 
by a spontaneous diselmrge of pna into the oral cavity. The author saw the patient 
November 2.1d, when tlie thickening of the jaw, the profuse secretion, an<l direct, proli- 
ing piit tlie iM'cHeiice of a sequestrum heyoml doiiht. SfijVfstrotomif perforvted Xurcm- 
he^r ^fdh. The mouth had been prejmred for a day or two by frequent riiisinjr.'i with 
salt water; the fai l* had het-n sijiivfil. The back of the aufeBtlietized patient's ht-ud 
was rested nn a li*w, liard rfill made of a blanket. The hair was wrap]ied up in a liuod 
made of n towel dipped in corrosive nuhruunte, tbo eliest protected by annthcr wet 
towel. The skin of the jaw was well soaped anil rubbed off with mercuric lotion. 
Then an incision two inches and a ludf in lenjrth was made alonjf the lower edjje of the 
horizontal ramu.-*. The facial artery was exposed, separated, secvirwl by two pairs of 
artery fnrce]is, cut tbrougli bc'tween, and doubly delijrated. The j>eriustenm was 
inci>«cd to the entire len^jtli of the fXternal cut, and was reflected upward witJi an ele- 
vator. Before opening into the oral cavity, n sfmoge held by n long sponge-holder 
was thrust into the mouth to the ■vicinity of the liatuta, to receive any blond that niiffht 
eHca|>e that way. .\n oblong ipiadran^^le of the exterjial lamdla of the alveolar procoas 
and body of the rnuius was chiseled away, expc».siii|<; a cavity containing three se<|ue.stra 
and a muss of ulcerating fetid granulations. Tiie cavity was carefully scraped out by 
the sharp wpoon, irrigated with corrosive sublimate, the 9oib"d sponge in the mouth 
having first been substituted by a clean one. The opening' freely communicating with 
the oral cavity was plugged with a .strip of iodoforraed gauze, that reached jnst within 
the focus ; the external wound was closed by a number of catg:ut stitches, a short drain- 
age-tube being tiriit jilaced in its posterior angle. Ikcemhtr Stl. — First change of dress- 
ings. No reintion ; no fever. E.xternnl wound wn.s found cloticd, t!ie drainage-tube 
was shortened, and was found still containing a dark-red blood-clot. The iodoform [dug 
was left undisturbed, and was removed by the patient's family attendant at the end of 
the second week. I>i84.-harge wa» scanty throughout. Patient cured December 2Uth. 

Bone Abscess. — Circumscribed acute osteomyelitis of minor ititensity, 
caused very likely by infection with a very limited number of micrococci 
deposited in the metiullary stibstunce from the blood, docs not have ii pro- 
nounced tendency to induce massive necrosis. Breaking down and emul- 
Bifit-atton of the uflfected parts are tardy, and thus opportunity is given 
to the snrrottndinj:^ tissues for throwing up around the focus a protective 
wall of granulations. The extension of the abscess is slow, and the local 
as well as general disturbance effected by it is of a chronic character. 
Nightly exacerbations of ft'ver, with occasional chills and sweats, and local- 
ized, deejj-seatud pain of a throbbing nuturo, gradual hypertrophy of the 
bone, with atrophy of the pcrtineut muscles, trophic chauges of the skin, 
MS glossiness and local sweats, and increasing emaciation, are the character- 
istic symptoms of tlie affection, which extends over months and even years. 
The marked thickening of the bone, tlie s]>ontaneous local juMn, augnieriLfd 
by pres.sure on i>crcussion, and the absence of listula are mainly to be con- 
sidered as to diagnosis. Therapy consists in doing what is to be done with 
all abscesses — evncuatiint and eventuaUti drattiage. 

The conspicuous thickening of the bone servos as a convenient guide to 
the purulent focus. After the application of Ksmarch's constrictor, a free 
28 



'jmi 



RULES OF ASEPTIC AND ANTISEPTIC SUR(iERY. 



incision, mailo accordinnr Lu tlie nilo.-i described in the para^riipli on iiecroto- 
ray, oxpose^i tlie bone, the surfacu of which is j^LvntTally faimd cuvcred with 
(istutiphytie excrt'sceiiceri, that somtnvhiit impede the rai:«iiig uji of the f>eri- 
(►steiiin. All the soft parts being held iiway by sharp retructors, the thick 
layer of new-formed bone is puroi] otT with tlie chisel^ liiycT by hiyer, until 
the cavity containino; pus is exjiosed. SometimeiS a number of discrete or 
communieuting foei are present, and the surgeon must make sure of not 
tiverlooking any of thetn. It is best, accordingly, to expose ihe medullary 
space throughout the entire extent of the thickening, liy entirely removing 
the roof of the cavity, it is converted into a more or less sh»11ow troagi), 
all parts of M'hicli are exposed to ocular inspection. The smooth pyogenic 
membrane lining ihe abscess is carefully removed to its last shred by vigor- 
ous scraping and gouging with the sliai'p spoon, and by subsequent irriga- 
tion. A linal tlusliiug of t!ie wound with ii strong (I : 500) solution of 
corrosive suliliniati- will make sure of the destruction of all liugoriug germs. 
The wound is sutured and dressed according to 8chede's p!an, and, if the 
removal of all diseiu^ed tissues and infecti<ms secretions wjus thorough, rapid 
and uninterrupted healing under the bkjod-clot will take place. 

Oa»e 1.— Richard \io»^ metal-wurker, a^ed thirty-eight. Chronio puinful thick- 
t.'nin« of tlii« sliatt iif the liiuiiL-riis <»f two yiMirs' slvimiiiig. (tlrtssy sliin, Htropliv of the 
imim'k's vf tht* unii nw\ riiri'iuiii, foriiiit'iitMJn. ami li> (n-hiirnsis, (tifjfttii.-r with parotic 
symptoms affectiixfT 
prindpally the iiiiis- 
ciilo - spiral nervo. 
Niyrhtly exiioerlm 
tiiiiis of local ption 
and hei'tif eiiiai'iu 
tiua. I'ehiitnr;/ ii". 
IHS7.—Ai llm Ger- 
inuri tiospilal, expoB- 
nre by chisel and 
iTiallet i»f n lioiie ab- 




FiiJ. Ift3. — KxivK^nny hI" tliit'ki'iii'il huincnin i-oritii'miiiv» u i-cntml Unii; jil'^ri-*, Kla><f'u' (-•onatrictor 
tifil ubovi> the iii-rouiiou. uti<l lh«rice |m»j«odi uromiU ihurftX into the opjxxsit*; uriupit, whcro 
it i» secureU by riDothcr liin"t"re- 



8oe»* occupyinif the niiJillf and upi>er part of tlio nioihillary cavity of the left liunie- 
rus. Scheile's method of dressing tiio wound. Felirunry 17th. — First fhatifje of dreaa- 
ii^gs. Wound imiio<] by the 6r»t intention. Two isopeHifial drnmagf-tiil»e» were 



DIAGNOSIS AND TREATMENT OF PHLECJMON. 



iJOT 



->^ 



kt 



.^'^^^ 



rPTnove^l, March fit/i, — 
PtUieiit iJiwIrarjj'etl jh'i- 
tcvllv fiircd wilh iin- 
proving funcEtini of the 
tjxtreruity. (Fijjs. MV.i, 
1t;4, and 165.) 

Cask II. — Samuel 
Kronifold, scfiool - Imy, 
ttjjeil twflve, had had, 
seviTii] years ngit, corii- 
[diund disJocatioQ and 
jwiite mippiiration of tlie 
left elbtnv-jotnt^ comiili- 
catcd witli acute oste<»- 
uiyetilis uf tlu* Iowl'P 
epipliysia of the huuie- 
nirt, in cyUBequcjuce of 
wliirh uereral seqneHtra 
had to he removed liy the 
aiitb{ir. Three iiumths 
airo a painful thirkeiiin<r 
of tho shaft of the tiii- 
inoriis atijH'ared, fiiUHing 
marked detcrio ration of 
Uiti hoy's health. February tS, 18H7. — At the (it*riiian IIo.spital, a central hone uhswess 
ocTiipnn^j the middiL' piirtiun of the niedullary space of the' InunerLis was exposed and 
eva^'uatwl, and wiw treated hy Sclrede'j* niethoil. Fthrudnj Mth, — The first change of 
dres><infjs took |4fuH^ and the entire wmuid was finuid iiealed m itli the exrcfUion of 
Ihe slit li'ft (iiit'ii f(ii' ilrnlii!!''!' *it Il<»- Imwit fiiiirh" <'l"the wmirril, u hi«Ii w,*(s cicrhiih'd bv a 



^^^ 



F»iJ. Ifi4.— Cavity chiiM:-k'i) o|wn. Ita couteuU- n.itiovfd witli Uiv 
sliiir^) .s|Hioti. iliii'lmnl B<>»<8. ) 



Pio, \9ft. — ICiclinrd Bowi'n wnnnd treattxl nixnirdinu' to 
f^chedi-'* iiiclhiid. PhoU>^ni{ili lAki:U Fi;tiruiirv I7tli, 
fllU'i-n Aa\n iiller op«nitii>n. 



(I 



fresh • h>oking hlood -clot. 
^•nrli C,(h. — Patient dis- 
charged oiiinplclely en red, 

Thf remarkably short 
aiifl t'oniiilt'lt' cure of 
hotli of tlu'He ciu:c8 ia 
uiidouhtrdlv t<> be at- 



tributed to the ado[>tioii of Srhede's \i\iu\. V\\\»f(\x\» of and iiitrodnrinp 
drainage-tul)OK or niiy foreign siibntitiirc jnU) llii' boiu' ravity arc dniw awuy 



*2lis 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



witli, ami organization c»f the ma.'ifjive blood-clot goes on uninterruptedly 

to the greatest advantage, 

CinnhixionH. 

Prevention of inffction contains the spirit and aim of aseptic ttnrgfry : 
the object of nntifn-piic nuryi'vy is disinfection and the conjtrrvation of 
hiferted tissues. The first object is attained by a severe di.sei])line of elffiU' 
ti'ness ; the second by the still more .severe dit«cip]ine of early iurisinns andi 
adequate fintinmfe and disinfeciion, 

A clear eon>|irehen.=iion of tlie proccs^L'ji determining; suii|uiratniu must 
result in tlu' tirin conviction tlnit an early ami free incision of every focujj 
of septic iniliinimulioH is the most conservative form of treatment. It pre- 
vents local dealh and genertal intoxication, the latter only too oft^n the 
eau8e of geiiem! death. If this conviction will liave entered into the "x«r- 
enm et samiuiuein" of every pliVfjician, imbiic o{>inion will gradually yield 
to u better understanding of individual and tlie public interest. 

NoTK. — The eliantte in the surgeon's altitude towanl tlie tmitloTiuoHt uf inciftotu for septic 
inlliiDiiniilivf {>roi'Ci<!^ert ij* ebanielerjzed liy llius'e stntoria?!* : 

/•hniifrf'/, topical itppHcalioiis wi-re llie nniiti rdiatK-c, incision only n last and oxtmnc 
reaort. 7%*" intrflcou huti to thow eauar tpftt/ tin iiicifion hUohIJ be nuulf. 

Al prrnml, relief from tenf>ion and escape of the noxious aubatancei^ IhraugU incision uttd 
drainiif^ is tlie clear indication to l>u fii Killed. 77i<' Kurpfmi miut »how enu»f irAy an incifiom 
t/tmUJ no/ hf viaitr in the prem'nor of iscptic iudiiniitiation. 



2. flihyinniinits Affertions nf tiomr Spvrial Rrtjions, 
a. Face. Floor of the Mouth. Neck. Temporal and Mastoid Regions : 

Anatomical ArvHnt/i'tneuf t{t' (he Ct>jineriirr-TiMtuf Phuten of thf Xri-i: — IK-nke'* 
olosHioal cssfly i» tlio best guide for tlie dear couipreliensiou of this subject. He injocteil 
tho liitl'eretit iiilerspnees of a onduver with liquid gelatin, and sttulied the nianiu*r uf 
ite extonnitm In-twci'ii tlio sei'urnl orguns by exposing the congealed masse**, and exarniti- 
iD|yr their rolutionn in situ. The chief interspaceft of the neck arc clas«iilied by Uenke 
an ftdlovvH: 

1. 7Vkr' Ciijmiilf of f fir Suhmnj illary Salirnrij (Hand. — It fornisa oornplck-ly closed 
envelope In the glaoJ, from which cuntiouiitions extend (<• the Mi|icr6<-inl mid Uo«p 
cervical fHsciiB. 

2. " Preritftral In tfnpaef.^'— The ponneotive-tissne plnne or interspace sUnated 
lu'twiH'n tlio ]»relnrvo;rtMil group of longitmliitnl tnuscles (iiyn.thjToidfS sternohyoids, 
iind Mernt»-lliyroids» unleriorly, jiud llie l^irynx. thyroid gland, und trachea |M"i«teriorly. 
It cumuiunicnlca with tlie aulerior nKHliaslinmit. Perforation of u suppurating thyroid 
gland lettdii to iuvaftiou of this »paoe, with Huhse^inent compression of the trmchca. 
iKIg, ion, o.) 

C*AflK.— ^. C.t ftgnd Mrmitocn. The ptticnt wk.« trmunl by Dr. C Lcllmann for typhoid tevtr 
\n the (<«Tiiinn IlofipitAl. In iV»c thini week of the di.4c*.<>c dcrcrv dyiipncMi dereloiw^, with a 
pecnlliir wlKHiJni; wMind «oconi|ian¥ing rr^pinulon. On exAiuination, a diffoao swelling was 
noted in fropt of the nvoll. Ineioion rvnointeil an iibsce4!> coramumcating nich the interior of 
the ihyi-oid gliinil, wlmoa parforntion inii»t have Inkrn pUcr. Immediate nMief followed. 

8. ^* ffe(rori»etr*ii InttTuptnt.'* — The interspace Wtween the pharynx and trsoph- 
Mgu«t id front, and the vcrt<>hral oobinin behind. It ooiumunicate.*. with the posterior 
intHUiiMtiouu). (Fig. Kilt, a.) 





jii;.'nlar vein. It i-otiiTtiiinicates with tli© unterior iiuMliustinuiti alonj^ tlie cuiirseof llitj 
hiryir vyfi^fls, Jim] is iinportanl on nccount of the fre'iuynl siicjuirutiou of the group of 
lvriii)h!itifghirH]» sit- 
uated iu front of, 
and exterimlly to 
the jiigiiltiir vein, 
Ahpoesses of this in- 
tiTt^ptW'f displaoc the 
sterno-mastoitl niiis- 
cle outwartl; tliey 
extend alonfj the 
vcgseln dowinvanl, 
ami, left to them- 
selves*, cither jier- 
forate through the 
deep on<i the super- 
fieinl fa-ii'ite find the 
skin near the davi- 
<?le, het vwen tlie low- 
er end (►f the stern (»- 
niasruid musele and 
tlietraehea, ormftke 
their vvny along the 
vessels into tlie an- 
tenur mediiistininu. 
(Fig. 1«7.) 

5. " Intrrmuaeu- 
lar Spa^ey — An interspace sitnated at their crossinp. between the Ii>\ver tiiird of the 
alerno-tnastoid and the ouio-hymd niusoles. This spiioi' ovven its nrigin to the aliding 

of ther*Q eontifiuona nuis- 
OMOHroio 



SUBCUTANIAN 




S^ICNIU. 



TRAPCZIU5 



Flo. 107.— Perl viist'tihir iiit<Tflptici!. 
tFri>iii IJeukis.j 



Trnnnversfl auction. 



lies u|)on etich other, mid 
19 limited po.-iteriorly hy 
the setileni. Jt rootuins a 
gnrnj) of lyninhatie glands, 
seated near the i>o:iteriur 
edge of the lower third of 
the sterno-niiistoid uiusele 
(siipradaviciilar glands), 
nnd eonimunieates inward 
and upward with the 
retro visceral space, and 
along the siihetaviaii ves- 
sels with the (i.xiilary eav- 
ity. Snpraelavieiilnr iih- 
seesses iisuully e.xteud into 
the arm-pit. (Fig. IfSS.) 

(«) Face. — The 

most serious form uf 
cutaneous and snl>cu- 




Fto. li»8. — LnU'nuiuculsr stwce. Lateral untern-porteri'ir iectina 
ftroui llvnkc.) 



sac. It has a daskT 
red color, and ife a|icx 
is marked by one or 
more yellowish discol- 
ored s]Kjts. which an? 
snrroimded by a blui>ii 
halo. Septic thmmbo- 
sis extending through 
the jngTilar veins into 
the cranium is to bv 
feared in this affec- 
tion. The systemic in- 
toxication is geuenillv 
very intense, high fe- 
ver being the rule. lu 
some of the wors^t cases the intoxication is so doej" jis to cause sympt^mig of 
collapse, with low, poraetimc!* even sulmormal, teraperaturej*. 

In this condition an early and most energetic treatment is urgently 
iiulicuted. and is almost always followed l>y elimination of the infectious 
proee.v^. 

A crucial incision, or, in extensive coses, a number of })arallel incisions, 
carried in length and deptli bejond the indurated area, will relieve tension 
and permit the escajx^ of the contents of many .^mailer or larger incarcerated 
foci. The incisions should be packed lightly with strips of iodoformcni 
gauze. In cases of aniemia, where loss of blood would materially increase 
the danger, the actual cautery should be so applied as t^ convert the entire 
infected area into a dry eschar. This or the incisions should be enveloped 
in a moist dressing, which ha.< to be renewed according to the amount <>f 
secretions. 

• NoTi. — Tlic following bloodless trcntukcnt applk'd hy Slcsarevv^kij in fonv-four case? of car- 
Iniiicle 8cem» to deserve trial, hs it yidJotl ron' goixi results in h[» band? : In!<pl«<«>ated ontstA 
lirsl rcojovcd, then the dieea^eit surface is spriiikUil with from thirty to sixty (grains of oorroriv 
Hiihlimato |)owder. Tlir diiitky halo (<urroundtn<! the i<entrr of the eore is ihicklv coverrd with 
blue iiiDtnu'tit. and tlu- wbu!e in envetoppti ici a compre^^ soaked in carbolized uil (I : )0), fa'>t- 
cned with a roller bandiipe. In fa-«»« of severe |)nin, an icc-bng in plac<Ml over the dre«»injr. 
following day, ooire^ pond ins 'o <he appliration of the mercMrie salt, a pray, very dense cschtt 
will be visible, whieli will sepanitc ten daTu later, ami will Im- followeii by rapid healiii; 
Slesan'wskij never obrserred mercuric intoxicaiioo (hiring nr after the application of ihi* method 
of treatment. ("Centralblntt fQr Chlrurgle," !«««, p. 8tKi.) 

Case. — The author lont, of a ronsidornMe nnmlwr of caw^s treat»;il by inrision, only 
i»MC by septic plilebiti» uf the right luleral ninns. The patient, n ini<Mle-ii;red cijjHr- 
rnaker, was seen in con!«iiltatiun with I)r. L. Weiss, and an enorraons curbuoelc occupj- 
iiij; the right side of the ap|»er lip and check w»» fmind, witli exfen-jlvo lederna of iho 
eyelids and the right side of fnee and neok, which wa.<) due to genernJ thnMnbotiis of 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



211 



the perlinyrit vehis. Tlie [nitieiit wms sctin-nnnatosc, someH'liat i-jHiiorted, and had » 
]MHir pulse, lie ImU ub^titmtely ui»po.sed any tntisive treatuient for six dtiv!*, mid t!ie 
ruae seemed flefirlv beyi>nd ttjp reach of surgicul skill. Tlu' incisions caihsed very ItTtle 
hteiiiorrhngL*, ns most of the divided tii^ues w«re necroaed. lie died uf eollnpse on the 
seventh djiy of his illness. 

TJje jiiitlior has never tvieti any Mf the *' mattiring " forms of treatment 
in this affection, and would uuUesitatin»ly declare meaBUres which are apt 
to stimuhvte suppuration, such as poulticing, to be always risky, and some- 
times positively dangerous. 

(J) Neck. — (a) Fauces and Pharipix. — The tonsils and the connective 
tis.«ne in which tliey lie imbedded are the most favorite site of .sujK'rficial 
and deep-seated septic processes. Diphfhvria is very likely u niicrohial 
afFcction due to the colonization of niicroeoeei upon the .•surface and in the 
follicles of tonsils, that arc in a state of catarrhal or scarlatinal ijillammation. 
It is characterized bj' superiicial ordeep-rroinif putrid uecrosi.sof the affected 
tissues, often extending: to the pharynx, larynx, velum, pillars, and the nasal 
mucous membrane, and is generally accompanied by a serious general intoxi- 
cation* The systemic intoxication is most prominent when parts having 
an abundant sujiply of lymphatics* as the pillars of the fauces, the velum. 
piiuryiLX, and nasal mucous nienilirane, are involved. The scantier de- 
velopment of the tonsillar 




. 



and laryngeal lyrr)[ilj-ves- 
sels seems to Ik; the cause 
(tf the min(>r intensity of 
the sy.stemie ,<!ynipt:oms ob- 
served in affections legal- 
ized in these parts, t'liar- 
acteristic intumescence of 
the deeji cervical lyni|ili- 
L'lands is a regular conse- 
ijuence of the affection of 
the first grouj) of localities; it is 
more rarely observed in purely 
tonsillar or laryngeal cliphtbcriu. 
An invasion is apt to leave be- 
hind a certain disposition ti» re- 
newed attwks, whicii is perhaps 
due to the fact that (piie.«cent spores of bacteria remain imbedded in the 
reees.^es of the f(dlieles, to develop their activity whenever a tunv calarrhal 
i?tllammatinn and exudative jiroeess prepares the ground for their multi- 
plication. 

But, on the other hand, fret|nent attacks, and the accompanying 
formation of cicatricial tissue within the textures of the ti)nsi|.>, .><cem 
to lead to a certain immunity from the graver forms of the disea.se. As 
a rule, persons who never had dijdithcria suffer more severely I ban those 
who have gone through many attacks ; and diphtheria of cliildren for- 



Fio, I'i'.i.-r.Hi'tcrl 

with ]iiitreM4.ttucu (lUO «iiiuufU'r»>. iKoili 




•212 



RULES OF ASEPTIC AND ANTLSEPTIC SURGERY. 



merly frct^ from i\w di**ease is u much more serious condition thau the 
80-cjillt'*l liubitiKil *"follieul«r toiiisillitis." Wliile a first attack is usu- 
ally, liabitual foilicular tonsillitis is rarely, complicated with ^Inndular 
enlargement. 

The condition of things here is conii>nr;ible to t!iat which wa^ mt'jitioned 
as the '' hubituatiou of the hands of anatoniistri to septic infection" {eee 
page 183, Note I). The disease is highly contagious, hence isolation of the 
patient is iinpcnitive niiurover po.ssible. 

Aided by a sustaining and stimulating general treatment, the disinfec- 
tion of the local a^ptic state should bt^ most energetically pursued. Accord- 
ing to tlie age and diyposition of the patient, this will have to be done dif- 
ferently. In small children of a good disposition, prneilings of the affecte^d 
parts with milder or stronger solutions of corrosive snblimate repeated every 
hour, and, in case of nasal diphtheria, hourly syringing of the interior of 
the nose, should be practiced, A mixture of corrosive sublimate Oij3. 
alcohol SS'OO (or one-half grain to the ounce), can be safely used for ]>encil- 
ing the tonsils and pharynx. A tejiid watery solution of 1: 5,000 for t?yring- 
ing the nasal cavity will be well borne. Care must be taken to keep tho 
nostrils well anoiuted with vaseline to jirevent eczema, and never to use 
sharp, loug-hoaked syrin;vt>. Ihiring the struggles of the resisting child the' 
mucous membraue is eiisily lacerated, and the hsemorrhage and certain infec- 
tion of the part thus injured are not indilTerent in an affection where the 
least complication may suffice to fatally determine the case. The safest 
manner of douching the nose is by attaching to the nozzle of the syringe 
a piece (six inches in length) of soft rubber tubing, such as is used on 
infants* feeding-bottles, its distiU end being first provided with a few lat- 
eral holes cut into it with scissors. The syringe is filled with the warm 
lotion, the well-greased flexible tube is introduced iuto the nostril and 
pushed back until it is felt t^> touch the posterior pharyngeal wall, ihe 
child's head is inclined forward, and then the contents of the syringe aro^ 
briskly thrown into the nasal cavity. Tiie immediate reflex closure of 
the larynx and isthmus faucium will prevent the entrance of considerable 
quantities of the lotion into tliese organs, and the energetic stream will 
aid the detachment and expulsion of crusts, membrane, and liquid 
secretions. On aceonnt of the swollen contlition of the roncous raem- 
brane, the entrance of acrid secretions into the Eustiichian tubes need not 
be feared. 

The throats of larger children or grown [>erson8 can be cleansed by fre- 
quent gargling with a tepid solution of (1 : .'>,00il') corrosive sublimate, con- 
taining one teaspoonful of cooking salt. Tho principal weight should be 
laid upon a frequent application of the gargle and a stimulating, nourish- 
ing, general regime. 

Whenever the aspect of the malady is very threatening, the appli- 
cation of the actual cautery to the affected parts is advisable. It is, 
aside from the necessity of a short anaesthesia, a safe and rational process. 
That only a jwrtion of the patches are accessible, some of them being 



DIAGNOSIS AND TREATMENT OK PHLEGMON. 



313 



beyond the siir^'eon's reach in tbo nasal ctmt}', is no vulid ivasun why 
those that are aiueiiable to this very etfective mode of disinfection, should 
not thns be treuted. 

The l>est way of cauterizing the tonsils and pburytix h the following 
one : 

The head of the anix'stlietized puticuf is drawn over the underpudded 
edgo of the table until it assumes the dependent, or Ruse's, position (Fi^. 
1T<»). The snrcreun introduees? a bent tonjiue-dejiressor, or tJie In-nt hnmnp 
of a titbk'rfpoon, well back into tlic fauces, and instructs the luuvsthe- 
lizer to keep the ton|!fue oat of the 



':rr: 



ii 



K 






'^r 



i 



Fl«. K". — Rtlne'ri [Hi:<itiiill. JkrUil <k-peliilunt 

irnm tlie edjfe of tlio upemtinjf table. 



way by it. Tliis will ex[nj!!e the 
pharynx in au a<lniirable fashi^m Lo 
|M?rrait of the exact and thor<Mif,'h a])- 
phcittiun of the thermo- or ^'alvano- 
cautery to the patches tlnis exposed. 
If the disease be limited to vi.sible 
parts of the oral cavity, and all the 
patches can be thus treated, a rapid 
imijrovement of the general state of 
intoxication will, as a ride, at once 
follow the procedure. Where only a 
part of the ]>atches is thus treated, the 
ini])roveinent will not be as complete. 

The glandular eidargenierit alw 
requires attentinn, and nhonld bo 
treated as W!i.-i exjihaincd elsewhere. 

If tlie process <leseend to the larynx, very alarming dyspnom will grad- 
ually develujK It should l)e ccanbated with extenial hot applietitionfl to the 
throat, mid the iiihahttion of nioi.st, warm air generated in the 8ick-rooni. 
The patient's strength should be carefully husbanded by frt'e[uent doses of 
liquid nourishment, and the avoidance of unnecessary excitement, exposure, 
and, most nf all, xlrmuj fmctirn. tlic abuse of which has cost many a ctiihr.^ 
life. In most cases the mendmine will get detached piecemeal, or will 
come away in one or more large masses, and relief will follow, perhaps only 
to Ik" pncceeded by another t)r several sulfocative attacks. As long as there is 
no lung complication, the jiulse fairly good, ininbdtwn otTers fair chances of 
success. Where the patient's strength has been consumed by a very long, 
ceiLselesa struggle for air, or the de[ircssing use of emolics, the chances are 
liy far nujre sletuler. Yet even tlie most desperate cases sometimes yield 
jiuexpectcdly good results. When intubation is not fejisible, tracheotomy 

to be performed. 

Prnwvtirr Trvaiuieid of Tnusillifis. — The tonsils are the points where 
the first pulehes become visible in most cases, and whence the local infec- 
tion extends to other contiguous parts. After frequent attacks of tonsillitis, 
the surface of the tonsils becomes iiTcgularly indented by cicatricial retrac- 
tion ; the tonsil itself is enlarged, and oftt*n yields on pressure one or more 
29 




tmtmkwlihittm^. v^ ka4 kkaad the eorpae. 

aftemMr tW Itftar, mhmm cmJSimm wm enSkai 
§m- ti^te m ttmr 4aiw^ Ai tfc>— e iiae. • —tei 1 1 1 Mi »i twwtanmemhmct 
tW fiHBtilr eoacrarfted «>«« ckrvMtt of TirioM J tyw* •< immmtj, Mid tb* boose Itatl 
fheAmimti. A thtmk w^ tm mUm oBtd m Am mmit^ thm^ iiur thm thM\^ 
iJBlfc to f^ > Flat << €— fciwcft. TW —Kt — Mwg — e <f thiiii iMhttiii wadow 
vhk BafifHHt ApltfMvn, wmi Asi ia a ^j ar tvo of seftiocMia. 

DestPOTiag the entire sufwe of tiw toaal, together with the conU'nt^ uf 
tb« foUielee bj the applicatioa of the setosl canterr, voald seem to be 
ratiooal. And h»s been found a safe and effectire meak<Qrr for lessening the 
disposition to renewed attacks of diphtheria. It is infinitelj s«fer than a 
bloody ablation of the tonsils, «8 the dangers of bKmorrb^ge and diphtheria 
of the wound -surface are therebr aroided. The smooth, deme cicatrix thuM 
produced offers a rerr good protection agaiart new infection. 

In adaltd. or even in half-grown childiVD ameDable to control, the reduc- 
tion of the tonsil can be gradually accomplished without general aoiestbc- 
na. the procedure extending over a number of sittings. The throat is pen- 
cilled with a cocaine Mlution until local amestbei^ia is produced; then a cold 
palvj4uo-crtu*tic burner is introduced. It is placed against the part to be 
treated, the current is turned on, and one fourth or one third of the tou- 
Billar surface ie thoroughly seared. For an hour or so, small pieces of ice 
should be swallowed by the patient to allay the slight {laiu. The sittings 
can be rc!|K!uU'd about twice a week or ofteuer. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



215 




Quinry mre throat (peritouaillitiiji) is a ])h!egmonous process established 
in the tonsil itself, or in the loose connective tissue in which it is imlwdded. 
The tonsil is found eidarged. projecting into the pharynx, und ditipJacing 
forward the anteritir pillar und voluni. Dysphagiu and umva or less saliva- 
tion with high fever arc regulurly present, and do not terminate until 
thorough evacuation has taken place. In most cases confluence of a number 
of small abscesses and simnltant'ons evacuation is observed. In olhcrs, 
especially when the tonsil itself is the seat of the affection, a number of 
abscesses develop and open one aft<3r another, and retard recovery for a 
week or two. No local treatment short of incision can effect a substantial 
improvement, and the ditTerent gargling nii.\tures are ardy useful in clear- 
ing the throat and mouth of the foul, sticky slime aggravating the patient's 
sufiferings by exciting very painful reflex movements at deglutition. Hot 
salt water (one teaspoonfiil to n quart, ahout H: 1,000) is the best, as tt is 
the most sulvent gargle, and can l>e ejisily procured, As the exact location 
of the abscess can nob be ascertained easily beforehand, it is wise to wait 
with the incision until the swelling is well developed. A digital examina- 
tion of tlie swollen region is always advisable, lis it is not rare tluit the tip 
of the tingor detects a pitting spot at which incision will release pus. If 
jiitting can not be detected, an examination with the tip of a silver probe 
will pussibly la-lp to ascertain the most jtiiinfnl spot corresponding to the 
focus to be incised. The relative distribution of the swelling may also serve 
a-s a guide in determining the seat of pus. Acute enlargement of the tonsil 
itself with diffuse oeilenia of the pillars and palate indicates suppuration 
withui the tonsil. Displacement of the relatively normal tonsil inward is a 
sign of retro-iunifilJar suppuration. A combination of both will show the 
worst association of distressing symptoms. 

htrisim/ Tnn-'iiUnr Adsrrns.—X lancet-shaped pointed bistoury is pro- 
tected with strips of adhesive plaster to within an inch uf its point (Fig- 
171), the tongue is depressed with the left index-Hnger, while the right 
hand thrusts the knife into the base of \hv swelling through the anterior 
pillar at the point 
previously deter- 
mined. The an- 
ter<i-posterior <ii' 
rection should he 
rigidly adhered to 

on acconnt of the vicinity of the carotid artery. If the hrst puncture be 
unsuccessful, a second one slnnild be made in another likely place, and, sis 
soon as pus apiwars, the blmle should Itv 1 urned ituvanL that is, toward the 
niedian line, and should be withdrawn, dilating the incision in that direc- 
tion. A nundwr of tihers belonging to the levator palati will be thus divideti. 
and their retraction will create a patent orifice, favorable to good dminage. 

Retro-phorifnfpal phkifmon is a comparatircly rare suppuration of the 
retro-j>haryiigeal connective tissue, due to septic infection of the glands 
normally imbeddtd in it. It is mostly observed in small children. The 




¥\<i. 171. — Laricet-Hbuix'd bi>tourv wnipiK-d »\< in mlht-Hivc plaster for 
incision "if toiiKillur ul)HfL'H.s. 



188 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



of the a,b.sces8, This examination is very importimt, and upon it 
depends the locating of the druinajie- tubes. Counter-incisions are made 
over the tij) of the left index. %vhich pushes np the skin from witliin. J// 
squeezing of the ahisccss at thh sfage of the oprraiion should be can/nfl^ 
avoided. After the (ilacing of tlie drainage-tubes, and a thorough irri;:u- 
tion, no pus should bo contained in the abscess. If, therefore, ^nik- 
external jirossure causes the escape of new masses of pus, this i.< a siffn that 
one or more recesses, communiet'timf by small openings with the main airittf, 
remain vndrnined, and nevd further afffitfion. They must be locat<>d, and 
aopamtely incised and drained. 

11 fluetnation ]>crsist over one or more places in the vicinity of the cen- 
tral abscess, it will be found thutgiuopened, ituiependent absces,ses rcquin" 

additional incisions. 

ingdovvn of septa of tiftsue with- 
in the absoesa by the aurgeou'ci 
finger is unsafe, on account of 
the nnnecessary haemorrhage it 
juovokes, and becauee it may 
lead to jmlmomiry embolism. It 
is belter to nuike a sutlicient 
number of countor-inci^iiona. 

77)^ sffuei'zinfj out of absceas- 
cj* through an insufficient spon- 
taneous or artificial o])eningcon- 
f^titutes wliul may be called fur- 
ijirttl Imrburisin, If the opening 
is too small or improperly [daced, 
the abscess can never be drained 
by the aid of the law of graTity 
alone. External pressure murt 
be employed to remove its con- 
tents, and this must be oft4»n 
rr|)eate<l to prevent refilling uf 
the abscesg. As "squeezing out" 
is a very painful process, the {m- 
lient will niiturally shrink from 
it, and will let matters go. The 
abscesa becoming nearly filkMl, 
only the overflow will et^cape 
through the insufficient aper- 
ture. The result is slow exten- 
sion of the suppurative procc 
with continuous fever. Dressings of any kind will only make matters 
and no relief will follow till another more properly located artificial oi 
taneoua o])ening supply the defect of drainage. 




Fio. 14.1.— Completed dresainn of ccrviciiJ abticcss. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



217 



L 



vessels and the aliirminp; (lyttptKca left iiir ahernattre Uxit death from suffotiatiou or un 
incision of the Mbscfhs frina without. Mureh 9th, »tt 2 P. .V.- — This was d<mo, cviirunt- 
ing ttbuiitlmlfan ounce <if"pus. A dmiiiagc-tiibe was introiliiced into the hottotiiof tlio 
cavity, »««!, to limit the oozing, u oorupressory dressing wsi* applii'J. At 4 ^- J^« — 
Scanty but continuoui* hjBiinjrrfiafjt< sot in from the drainage-tube. ThiH being removed, 
the cavity was phigged witli RlrJps tif iodufurnied giiuze. Jind ih^i bleeiHiit? odges* of the 
incision were seared with the thermo-cautery. At 8,30 P. M. — The «.iiild died of amite 
iinieniia. 

March 10(h. — Pogt-mortem examination by Dr. A. Seiberf in the presence of Dr. 
L. liopp iind the author. < >n tho neck, oloiw to tlie posterior edge of the left stemo- 
Tmi>toiil, a cnlaneoiis incision was found one incli in length, ite edges marked by a 
dark-red, Motidy infiltration. A jirolie entered tin* retro-plmryn^jreal upace, where it 
roiild be felt with the finger placed in the oral cavity. A skin-Hap lieinp raised and 
turned upward, a couple of intiiniescent, dark-red Ivriiph-^hinds, situated near the an- 
terior edgti of the sterno-inastoid muscle, were exposed. The sterno-ninstoid iniisele 
was eot away at its Jower insertion and was turned upwaril. Tlie vascular sheath was 
opened, and the deep JTijrular vein and carotid artery were carefully examined and 
found intact. A wall of tis.sno one third of an inch in thickness was found interposed 
between these vessels and the track occupied by the silver probe. The prevertt-bral 
interspace was (oimd distenrled by a dark, massive, and soft clot, exteudiuir ujuvard to 
the basi- <if tlie cranium, and downward to the level of the third tracheal cartilage. 
Cervical vertebraj normal. 

Doubtless it was a ease of hfeinophilism. 

(A cBso of retro-pbarynt^eal iutiltratiou, simidating; the symptoms of abscess, was 
seen by tlie author in the (!erman IIospit:d, in which acute infectious onteomyeliti* 
of the «eromI ferrieul rrrtehrn was the cutise of the trouble. Henry Liidwi;"', bartender, 
affed twenty-one. Ftbruari/ 16, 18f<5. — Hi{j:h fever set in with a chill and sterlorous 
breHthing. The face was slisbtly cyanosed and the voice bad a thick sound charncter- 
iBtic of retro-pharynfreal swelling. TFie patient held his neck rigidly, and in moving 
mipp<irted it by his hands. A typhoid condition prevailed. The house surgeon of the 
Geruian Hospital made a free inci.Hion into the swelling o<HMii>ying tliLi ret rii- pharyngeal 
region, but no pns escaped. In spite of weight extension, sudden death occurred, .March 
20th, from coitipre9si<ia of the medulla. I'ost-mortenr exiimination revealed a far-gone 
destruction of tho second, third, tmd fourth cervical vertebrie. The odontoid process 
was detached, and hod fatally compressed the luedultu. } 

Acute in/f't'iionn oslraimfcrifis of fhc Jowfr jnio occurs eitlirr in the adult- 
after tmumati.sm, such ais for instance fracture of its entire tliickucss by 
violence, or iujury to the alveolar process caused by the extraction of teeth ; 
or sixintaneously in the adolesceut. The latter form h quite frequent, atid 
results ^euerully iu more or less estjeneiTc neeruHis and the furmatiou of 
abscess. Perforation usually takes place toward the orid cavity, though oc- 
casionally invasiou (jf the subnuixillary cup^^ule or the vn.Hcular iuter.space is 
observed. Early iuei.sion will allay pain, relieve the fever, and wit! prevent 
the extension of suppuration. 

The treattneut *)f necroi^e.s of the niuudilvle wu.'j disposed of el.newhere. 

ifi) SiihmttxiUnry and Parniid (Ujminrhr, — Hidh ilie subniaxillarv and 
parotid eaiivary glauds are inclosed in complete and very dense fascial en- 
velopes. On account of this auatoniiral peculiarity, and in tlie cane of the 
submaxillary glaud. the vicinity of the tongue and larynx, puridcnt inllam- 






txeept in the diimeminatf/l f'onn of tieeroms, v/hvre a imiiilM'i' of email foci, each oanUin 
jiiMlneatruni, auii all oonnefted hy more or less narrctw antl torttious i-hannel?, an? scattered 
a w»(li' area of the affected tx>ne. JJut even tbese dittioullits Can be Overcome by ihe exerdfc 
cireiiitiHpeetton and painstaking, favored by artificial antemia, which renders detection of 
colored b<me and the eiitriiDCO Uv lioive iiiiiui>e.<* eomparalively ea!>y. 

What Chisels to um. — The chisels generally sold by surgical cutlers ha 
little to couimend them for efficient and nipid work. Their shape and sL 
are ntismitable. "Albert Riu-k's warntnted chisels.'* Jis sold by most 
Wiire deulers, and generally used by carpenters and joiners, are well te 
perod and excellent. They should be fagtenod to an ordinary, smoot 
wooden handle, without indentations, to insure the possibility of perfe-^ 
cleansing. The author has found a set consisting of a one-inch, a hafl 
inch, and a third-inch chisel, and of a one-inch and a half-inch gouge. 
answer every purpose. A light wooden mallet, perfectly smooth, \t& be^ 
made of boxwood, can be bought in any house-furnishing establishment, ai 
is much preferable to the small metal mallets of the instrument-makers. 

The Moiteni Manner ttf I't'rfunninrf Necmtuniif. — The following descri 
tion may serve as an elucidation of the technique of a sequestrotomy. Tb 
parts being well cleansed with soap and hot water, shaved, and disinfected?''^ 
by mercuric irrigation, after Esmurcirs band is applied, an incision is ca ^ 
ricd down to tlie bone over or near ihe fistula'. The length of the extem:^^- 
incision should be projiortionate to the extent of bone thickening. 11^^ 
thickened bone slH>uld always be attacked where it is most superticiid, Ih^^ 
site of iht} incision beiny deiermined rather by the question of accnonhilit^^ 
than btf tht; lomtion. of Ihf. Hinuaes. Where the bone is snperficial, us. fo- 
instance. the tibia, the incision may be at once carried down to it. Wbc 
there is a thick mass of overlying soft tissues, the incision should begmdn: 
and preparative, and all cut vessels should be at once ligatured. The |jerj 
osteum rs [irieil ui> on both side:? of the cut with an elevator, and, where i^^ 
is fouivd adherent tjy cii-utricial tissue, is cut away, until the entire affeot«i^ 
area is well exposed. Integnuient and jieriosteum aiv held back with u piiitf 
of Volkmann's retnictors, and the roof of the cavity containing the seques — 
trnni is chiseled away. This can be done very rapidly by a workmanlike^ 
use of the mallet and chisel, until the sequestrum is comjdftply exposfd^ 
This being done, the sequestrum is lifted out of its bed with a pair of for- — - 
ceps. The irregular edges of the cavity are next smoothed off, overhanging:^ 
parts are removed, so as to permit a careful and thorough ocular exam ins- — ■ 
tion of all its recesses. Care must be taken not to leave behind any dea^ 
bone. The sharp spoon should be used in vigorous strokes to clear awajal'B- 
granulations or softened osseous tissue, until the entire wonnd-surfact* pre — 
senta a bleeding, clean, and healthy appearance. Debris and shreds o^ 
granulations are flushed out with a strong irrigating stream, and. to mak^ 
sure that no detache*! particles of tissue are left behind, the cavity should- 
be mopped out with a clean sponge. 

Where the operator is not certain of having rendered the cavity perfectly 
aseptic, it is t^a^est not to apply suture, but to till it with a looae pAok* 




4 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



HVJ 



in^ ossutiied RlanninK jiroportiotia. Sutldenly ti>ilt)tiia ol' tlie |!;]uttiH u{>(>eiired, and the 
PiLHc wttii trunsfcrrtHj to the ftiirifu'jil division. The loft side and frontal rejrion of the 
neck were found dt'iiJ^eh' in lilt rated and very hard, and tniclientomy htid to hu jier- 
forined uader uniwual difficidties hy regimental surgeon Dr. Fillenbautn. A number 
of&hKiessea were encomitered, nnd purulent iierirhondritis wa?* found to be the iuin;edi- 
ato caase of tht> a'dema of tho glottis. Tnirheotonjy relimed fhu dysjjuieii, but the 
pnticnt (lied soon afterward of Hepticiemia. 

Case II. — Jacob H,, farmer, aged twenty-one, admitted ti> the tieriiitin IIiis|>iiiil 
January 19, I88li, prcsenttnl n eirrinn.Hcrihed red swelling of the left suliiu«xilhirv 
region, that had appeared with high fever two days l>efore fKlinissiou. Faee eyauosed, 
expression dull, breutUing stertorou'< ; the jnouth half open, tongue protruding, Woor of 
mouth ttdeiuatous. Temperattire, 104'5'' Fuhr. Iiuniediate innHion according to Hil- 
t<>n-Ro»er's method in anre.^theiiiu. About half an ounce of thin iciiorons pn^ eseapeil. 
The incision was entarged with a prohfpi tinted knife, and drntaage and m moi^t dres«- 
ing were (ipplied. In the night n sliurt suffocative iittaek a]ipeared. Jiinnnrtf iioth. — 
Temperature, 101° Fahr. CjiinosiH and ledenia of the floor of iiioutli npprectiihly 
diniinished. Improvement continued, no neerosis foUowing, and patient was di.Hc barged 
enred Feliraary fltli. 

CAt^K III. — William II., clerk, aged twenty-two. Snhlingiuil cynanche, rliuracter- 
ized by protruaion of limgue and very liigh fever. The fainily attendsuit had treated 
the case for ten days by poulticing, and .\pril 3, 1884, had iniined the swelling in tlie 
Hubn;axillary regiim. Kelief followetl, hnt in the nigbt alarming dyspnAoa, due to arte- 
rial Iia?niorrhage, supervened, that rapidly distended all the intenspaees of the left side 
of the neck, and threatened siiffo<'ation. April 5tb. — Early in the laorning trache- 
otomy wa-H lui-Htily performed by the author, who found the left side ol' the neck eimr- 
niously swollen, and some bloody serum oozing out of the small external indaion and 
from the oral cavity. The tiouree of the hitter bleeding waw found iu a sloughy per- 
foration of the fliKir of the njouth. A.h hiemurrhage had ceased, only a draiuage-tidie 
waa placed into the external in<'ision, and a moinl dressing wan applied. The patient 
was doing well April 7th, when he was seen l>y the author the last tiuio. Later on, 
the family attendant informed the author that another cxlernal lueuiorrhage had 
occurred during the proces- (tf detachment of the nnmcroUH slouglis, requiring deiiga- 
tion of a spurting, protmbly the l'»u"ial, artery. Patient recovered 

Ca8E IV. — L". S.. watohumn, ageil tbirty-twri. Sublingual eynauche of thirty-six 
hours' standing. Extensive hard infiltration of anterior and left aide of neck. Dys- 
phagia, dyspnu'si, t^mgue f>rotniding. May 5, iii86. — InciHiuii by preparation at (Jer- 
nian IIoBpital. The thickened cjiymule of the submaxillary ghmd being divide<l, a small 
cavity containing about a lialf drachm of ichorous pus and lifhrtM wjw cxpuscd and 
drained. It Just admitted the tip of the inde.x-finger. Itnmediate improvement of all 
symptotui). Patient was di-wharged cured May 20th. 

I*((ri)tli{ ('}/naite/i*\ — This niay dcvfloji iudojiciidptitly or cornidicnted 
with orchitis during and after aeutf infectious dist'jLses, suth iin typliuid and 
scarlet fcvert 8mull-])ox, or the mesisles, or may Ix- t)ie direct coutiimatiotj of 
an attack of nium]w. It 18 not !i.< aiiinniiig in nijiidity of devi'lo])nient nd 
the finb]in;jrual form, hut is apt to be much more ledums on account uf the 
gradual brenkdown of the lobuliiled structure of the jmrotid gland. One 
IoIk! after anolfier succumbs to the suppunitive j»r<»ces.*^. and an intermina- 
ble seriert of abscesses muke their appearance. Generally perforation out- 
ward 18 the rule ; occasionally, however, jierforation into the spheno-max- 



i 



r 



2H) RULES OF ASEPTIC AND ANTLSEPTIC SURGERY. 

illary fo^a, a»d extension into the intermnscular )ilaue$ of the tieck, with 
all its dangers, ensnes. Necrosis of the interlobular septa is a common 
occurrence. On liccount of the necessity of avoiding tla* temj»oral arterr 
and facial nerve, long incisions are impracticable. They must be small, 
and several should be made to afford sufficient drainage. 

Case. — II. S., inerohauu aged fifty, coinraenced to sufter about Chriatiuaa, 188.^, 
from a fnrnncle of tlie external meatus. This le«i to Bnppnrntion of tLe lympbAtic 
gland norniutly found in front of tlic nieatUN and, under a poiiltioing treutment, to 
an involveineiit of the pnrotid uland. Tlie patient was seen by the anthor JnoUArr 
11, I88ti, and exhibited a lartre, non-fliictuatin^, very dense swelling of the righl 
parotid rej^on, with a tcinperatare of H>4° Fahr. His right eye could not ha clu*o4 
entirely (paresis of the facial nerve), and he was unable to separate the Jaws to Hit 
slightest extent. Besides, repeated chills, sleeplessDessi, and the intent pain ra<li- 
aling to the diveriMJ branches of the trigeiuinal nerve, bad demoralized the mjui cotn- 
pIC'Tely. A vertical incision placed just in front of the external meatus by carefal 
preparation released a large \uhas of pus. The relief was very great, and the patient 
left the house five days later to be treated at the author's office, where lie rejMiired 
daily for many week;* longer, as the involvement and breaking down of new lobuh"* 
of the (larotid gland made frequent irrigation and constant drainage a necessity, lie 
was discharged cured March 28th. By October the paresis of the orbicularis pHl|>e- 
bruruiti bad disappeared. 

(y) Acute Glandular Aftscesses of Ihf .Inferior and Lateral CervicaJ 
Reyhns. — Tliey are caused by ab.S(>rjjtion of acdve micro-organisms deiJond- 
ent on inllanunatory proccs.-^os of the oral and na»ial cavities, the pharynx, 
larynx, the lower jaw, and the uui.'<toid region. They have to be well dis- 
tfnguii«hed from cold or chronic ab,sce.-«8e.s of the same regitm. Their onset 
is sudden ; puin and ft^ver r!J})idly dov(dup, with deep-sea t;t»d dense infiltra- 
tion, and gradually the corrc.^jwnding side of tlie neck becomes oadematoiu. 
Inflammations in the oral cavity, the tongue, the larynx, and the lower jaw 
produce an involAcment of tlie glands in ilw perivaKfuUtr space. They can 
be felt Bomewhat in front of the stcrno-mastoid muscle, extending upward 
toward the angle of the jaw, and are commonly known as ** submaxillar)'" 
glands. Affections of the temporal, auricular, and mastoid regions, and of 
the pharynx, nasul cavity, and o.'soidvagus, on (lie other hand, are generally 
followed by intumescence or suppuraliou of the glands situated in the in- 
termuscular space. They can be felt behind the posterior margin of tlie 
sterno- mastoid, and their suppuration is apt to extend in the direction of 
the smpraelavicular space. 

The ijiipstion of when to incise these al>scesses should not be made de- 
pendent upon the presence of fluctuation, sis the worst and most virulent 
cjises wdl have wrought infinite rai.*!chief long before the api)earance of 
fluctuation. In very virulent cases, marked by violent general symptoms 
and rapid local spread, incision should Ik? made at once after Ililton-Roser's 
method, as relief from tension is the most urgent recjuisite to prevent slough- 
ing and possible erosion of vessels. Anfpsthesia is indispensable. 

Whore the svmptoms are less violent, the spread less rapid, maturing of 
the abscess may be awaited in case the patients are very averse to an incision. 



DIAGNOSIS AND TRExVTMENT OF PHLEGMON. 



221 



■ 



But the responsibility for the consequences of delay should be declined by 
tlie physician. 

Cask, — Loni^ Lebowitsch, nged twenty-seven, [irossor. December 15, ISSH. — Pain- 
hartl swellings tleveloped in the [>rtftraclieal and bctth eubmaxilkry rtjcious with a 
^rer© cbiU. Previous to thia the patiem lia*i Wi^n sitfTerinj; fruni a "sore tliront" lor 
ft'W day?*. The fmnlly fibysif^ian uflviscfl poiilticinp, wbicb, an iisunl, wjjs enthusiaHti- 
cally nttemloti to by tlio piitient's ffiiiiili- relatives. The swellings ountimieil tu grow in 
sizt; ftn-er and .ilt'ejdfssnesa were iiuabated. December 25th , — Suddenly an enonnoiH 
increase of the swelliiifj::* in frnnt atuj an the left side occnrre<l, witb dyspnu^a and 
dysphajfia, wbich induced, [)ec*eml>er 29th, the patient''^ transfer to Mnunt Sinai IIoh- 
pitab Following? a imsty suuiinons the autbor found the patient ftittinf: up in bed, his 
bead held erert, the neck iuereased to double its eircumferenee, its skin red, Bwollen, 
and shining like a larpe-sized sjvusafre. fioffjjy tiiictuatlon everywhere. Most intetise 
thirst with absolute distibility to swallow even fluids ; wheezin«?. loii.jr-ilravvn respira- 
tion with considerable dyspna}a, wliieh beeaiiie aiifrnwnted to an alaniiiiijj degree by 
the ret'lining posture. Examination of the fanees revealed a sweltinfr of the retro- 
faueial soft tissues, and almost complete contact of the slightly intiimewent toiisilsi. 
Two ineiskuis, one behind the posterior margin of the storno-niastoid nmsele, the other 
ft little bebivv the tliyroid gbind, ri-h-asod idxMita ipiart of a dark-red {^ory liquid, streaked 
witb pus. This wa^ fidbnveil !ty an imuiediate disappearance of the tlyspn«ea, and the 
fiatient was aide at onve to allay his thirst by vnpious <lrafts of water. A digila! ex- 
amination of the cavitiert npened liy tJitj inciwions showed them to conununicate freely. 
The pulsating carotid could be distinctly felt, lying exposed behind a large, rotmdish 
mass of hlood-clot, freely projecting into the lateral cavity, and wjeiuinifly attached to 
the pharvnpeal wall. 

Two stout dniinage-tul)e8 were placed in the incisions, the rvtnaining clots were 
washed out by gentle irrij^ation, and a kirgc, moist dressing was applie<h The fever 
fell at once from lfi;S' P^abr. to iou" Falir., but rose the following day to IfKi ' Fahr., 
•a the incisions were clearly iiisntiirient for the drainage of the enormous cavity. More- 
over, tliere was still considerable oozing present, and therefore it was deemed proper 
to anajsthetize the patient again, for the sake of a thorough exploration, drainage, and 
poiisibly prevention of further bipniorrhiige. A tlactuating place just above the clavicle 
was incised, and was found i-ojuuiunicating by n narrow chaime! with the upper earity. 
Both of the lateral incisions were now united by prejuiration, the external jugular vein 
Wing first secured by double ligature and divided, and thus by this long incision tlie 
interior of the large abttcesa was expose*! to view. The cavity extended from the 
clavicle to the base of the cranium. In it hiy exfjosed the i-arotid artery and the Jugu- 
lor vein, to the upper portion of which anteriorly a large, tirni, ami irregular clot was 
found odhering, indicating where the hjcmorrbage had come iVuui. The loose dots 
were all cleared out, but the one adherent to tlie jagidar was left undisturbed. Copi- 
ous oozing from the abscess walls wa^ observed, and checked by a lotme pnckingof 
iodoformed gauze, preceded by thorough irrigation. Tlie patient was discharged 
cured on January 27, 18H7. 

The preceding ease vividly illustrates the dutip:er5> of protructed poultic- 
ing in dcep-sciitod tytnpliatic abscesses. Shmghinj,' of the wull of uu adja- 
cent hirge vein caused a most serious catnplicntion hy seiMituhity lui'morrhjige. 
Arteriul liJi?tnf)rr!i!i^'e would have undoubtedly jiroduced ni|»id sulTocation. 

(5) Glandnhtr Abtta'ttaeii of the Ttmporal. Mnntoui, and OvripUnl Rr- 
gions. — S!i]>])«rative pixjcegses located in the external ear will occasionally 
80 



202 



RLLES OF ASEPnU AND ANTISEPTIC SURGERY. 



9tb, and tlie skin-flaps were I'ound firmly adherent in their new positioo. Some cotAc 
ops ulet<rii[ti«in of thf skin (in the calf hud tiiken filaL-ti. The nail was reraove^l. 
pntieut was discharged cured June 1st. 

NoTK.-— A wlerost>d and ill-Qourmhed &iaU'. of tlic involucrum will often lead to a 
brcakdnwn of the gramilatioiiin liniuf; an old Hinu!*. J^tiniuliiting injoctions will iiomctiaie^ el 
a cure, but in lebelUiiud easen tiuaM;3.s can be had only from a thorounjh i-c-ruoval of tlip wo'leas 
portioQi! of the bone and i^iDus. 

Case II. — Frank Napenuast, ajred eipht. a very aiuciiiic bny. Necrotomy of til" 
NovemlxT 2. l^ti^S, iit Miuint Sinsti llofipitah Extraction ofa large central si'qat^l 



ontsvMSX 




■^^: 



Yw. 16B, — Diafrram iliuHtnitnig tk^ticcic'n method iqi|<liL-d to u oa^e like that of Frank Ni 



coni|>risinir \\\v entire llii'-kncss of the upper hnlf of tlio whaft, a narrow e-Xtcnsirf^' 
reaching il own to the Iow^t epiphysis. Thrue sinal! sequestra, to;rethor with u lot ^^ ^ 
softened granular cancellous tissue, were rt^moved from the htvid of the tihla. Tt'*^^ 
remjiininR (jostTJor portion of the iiivoluonim was so sleniler and brittle thai it brot<* 

into several fragment?) doringtl*^ 
uperntioii. Lateral iiuplaoUtion 
of the skin by incaaH of tnutfifix- 
in;; sutures by Peaslee'* noodlt. 
Antist'ptii" dres-iinjf and a lateral 
!>pl)Dt. Fir»t chancre of dreieing!* 
November 2.Sd. Healin^r trf" tW 
woiiinr by (KlbeHion rorrt^puod- 
iug tu the shaf\. Sinuses lead- 
ing into narrow cavity in lowvr 
portion of tibia, and a larger 
cavity in the head of the boDi^. 
FraL'tiires united with sonic «a^* 
ging of tibia downward. Ik- 
cember nth. — Bloody relnfrar- 
tion of tibia : .<«crapiiig of upper 
and lower cavities. January lU, 
i.956.— Lower einus closed; up- 
per cavity ehows no tendency to heal. February ?;?, 1SS6. — OaUtijtlantic chmure cf 
eatitij in htuif of tihia an-nriUiuj fo Xf.nher. A triangular skin-Hap, containing the 
insertion of the qnudriceps tendon ami the perir^steum. was raised from the anterior 
aspect of the tibia. Tlie remuiniug roof of the cavity was reroored \ij iDnllet and 






Fio. lii'J. — Fruiik NiiijunitiistV aw*,'. A, Trianffulur skic- 
fiap. B, Skin-tlajf tiinit'il into the cavity ; the dark 
Hpoco to hftttl by (.'runuliitiou. c, View of noerotwmy 
wound treated "nwordhig to Sthwie'-s tncthotl. 



J 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



223 




Case II. — E. N., nieTchunt, aged twenty-tivc. Had beeo suffering from purulent 
otitis nu'd ill for a I<ing tinit'. Sup[mr«t'njn ul" the iiiaHtuid ccll.s and fonnatiou of an 
external inrrarna^toidal absces.*, led ti> iDcision. whicU was done by Dr. E. Grueinog, 
under whose care thf patient Imd been for acime time. A phletfiiionoUH iuHatnuiatiun 
of the neck following, Jiuiujiry 2'2, 1882, a cuusnitatiori was culled, wlien ji nntiiber 
of deep ineinions back of the sterMo-uiastoid innsck' wero rnmle, and the ftb^^(x•sses were 
drained. The prol>t« felt Imre bone in the rriustoid notch. Snbseqnently a conjiiderrtblo 
ijiiimtity of brmy f^rits passed away with the secretions, and the curbolir lotion injerted 
into tht' »lr»ii)uge-tnbe?i entered the oral eiivity. End of Mareb, the patient wn^i dis- 
charged flirted, and remained well until .September, 1886, when he wa» seen by the 
author suffering from dementia. 

A. Mammaiy and Retro-mammary Abscess. — Excoriations and fissures, m 
common upon the nipples (d' rnirning vvonncn, ure the portalji through which 
infection etiters the multitudinous lymphatics of the mammarv gland. A 
preparatory treatment of the nipples during the last period of prcgnmnc-y is 
the best preventive of the foruiatiou of Jissnros. It should consist in niolli- 
fyiiigt and removal by bathing in warm soap-water, of the thick layers of 
etfete epidermis, usually present around the openings of the lacteal ducts. 
The tender epidermis thus exjiosed will bo hardened, and will become lit to 
resist the manifold injuries unavoidable during lactation. 

Should rhagadcs develop, a thorough disinfection with corrosive-subli- 
mate lotion (1 : KTOO). followed by touching of the H.ssui-es with a well- 
sharpened stick of nitrate of i<ilver. will in most eases, lead to a cure of the 
painful disorder. Nursing should be eitlier stopped and the milk removed 
with the breast-pump, or, if continued, should be only permitted with a 
nipple-shield, until the fissure is closed. 

Disregard of these precautions will frequently lead to suppuration* 

A large ]iro|iortiou of the inflammatory processes of the breast are non- 
suppurative, the intumescence, redness, and occasionally smart fever being 
set tip by a retention of the thickisli milk of lirst luctatiun, Hometimca 
fluctuation will be felt, and, if an incision is made, no pus — only milk — will 
escape. Absence of an infection by micro-orgtinisms must be assumed in 
these cases, which, as a rule, get well without suiJpuration by sim])lc topical 
treatment, consisting of the application of moist heat and methodical com- 
pression. 

Hence, not all ca«es of acute mastitis terminate in abscess. Winckel 
saw, in the Dnsden Lving-in llosjiital, ninety-one out of a total of one 
hundred and tiiirty-six cases of mastitis get well without i?upimration. 
Therefon?, topical treatment with the ice-bag or cold-water coil (by both of 
these the seerrlitui of milk is materially reduced), or, if op]K>sition to these 
be enconntercfl. tepid or warm applications, aided by support and gentle 
compression of the breast, should be first tried. 

Should, however, fever and the local symjitoms persist or increa.se, and 
tlnctnation become apparent, incision and drainage are the measures to bo 
applied. 

Abscesses of the mammary gland proper are oiiher .subcutaneous, then 
generally located al»out the nip[de; or arc more dfrpsfatt'd^ that is. intra- 



224 



RULES OF ASEPTIC AND ANTLSEPTIC SUROERY 



ijlnndular. A third form of bietist abscess is the Huppuratiou of the loose 
connective tissue found behtml the gland : rtiro-mininiinrif nbsrt'ss. 

Itss loeation in tin* vicinity of the ni|»j>le and tlie eiirly n]i]>earance o( 
welUleHned tiuetuation will readily chHracterize the sulieutaneoiit; al 

When the deeper parts of the glauduhir tissue proper become the *eat ol 
nn abscess, general swelling of the breast -gland is most prominent. Tbe 
8kin of the mamma becomes red and a?dematou8, and one or more ]>itting 
points can be soon detected. But the brm.tf /v frfrh/ movab/e ax a wh^f 
upon the pec f oralis fascin. 

In rdro-mamwnry Mupptirafion the hrett^f is inunovahh, and firmlr 
attached at its base. The glandular tissue is soft and nornnil, utiles a 
combination of mammary and retro-mammary suppuratiou be pre-esent. 
Deep fhictuntion can be detected by careful jiulputiou. 

Imtsion fif the t/toir rxte)isitv absce^smes of the breast should always br 
fiutir untier {lufsnthcua, us the unavoidable pain associated with thorough 
work is too great to be endured ; and the measures must be thorough to 
give a prompt re«ulL as nothing is more unsatisfactory than an in^nthcient 
or iuiprot>erly placed incision. Suppuratiou is not limited thereby, new 
l^oints of fluctuation develop, and the interminable process, with fever, 8hv|)- 
le>i.sness, umJ the ilniin upon the system, lead to eerious emaciation and 
lamentable demoralization of both patient and jdiysician. Anti»fptir prr- 
rnutioris, consij^ting of a thorough scrubbing of the surgeon's hands and of 
the patient's breast with soap and bruvih, and subse«]uent rubbing off with 
corrosive-sublimate lotion (1 r 1,000). should never be neglected. There are 
microbial cultures of various intensity of virulence, and the touch of an 
unclean finger may intensify an otherwise comjiaratively bland form of tiU|)- 
pumtion, or tnai/ add fhe poiMtn of erysipelus to (hat of simple suppuration. 

All incisions penetrating the glandular tissue should be placed radially, 
80 as to avoid injury to the hicteal duct« as much as possible. 

A place of fluctuation being marked, the knife is rapidly thrust into the 
abscess, if tine thickness of tissues to be cut through is not too great, lu 
tlie latter case, Hilton-Roeer's method is safer and preferable, on account of 
the possilMlity «>f hajmorrhage from a deep-seated vessel. 

Note. — liillrotli rccouiitH a t^ase in wbit-h lio cuuhihI utifontrolliihlc and very »«rioua bcioor. 
rhagv b}' cutting a large brunch oF the external maiiiiiinrv artery. The loiis of blood w»« Alarm- 
ing, and BO beyond control that, after baring nni^iiocp.ssfuUy f ni>d a niiiiibcr of the usual meMuroL, 
be finally injefted the abscess cavity with a quantity of turfionUni' oil, that happened to 
within reaoh The bleeding wa;* (stop|>ed, but a formidable gangrcooiw phlef^on brougiit the 
patient very near the grave. She recovered, however. 

As soon as the well-dilated dressing forceps is withdrawn, the index of the 
left hantl is slipped iritev the cavity, and a gentle exjdoration of it^ interior is 
carefully made. Wherever a recess extends toward the skin, the tissues aro 
raised upon the tip of the left index-finger, the skin and fascia are inciscHl, 
and the dressing forceps is introduced ulojig the grooved director in the well- 
known manner. In this way a number of sliort counter-incisions can be made 
M'itli very little hfemoiThage. Stout drainage-tubes, reaching just within 



DIAGNOSIS AND TRELVTMENT OF PHLEGMON. 



225 



the cavity, are next introduced, uikI the abscess is well wiished out with the 
mercuric lotion. Oozing from the abscess nulls, which is sometimes con- 
siderable, will iilso be checked tliereby. Alter this the breuat should be 
gra>f)ed and gently comt»ressed between the extended hands aa a test, 
whi'ihfr all rnresst's had bicu duhf n/i/ifictl ur not. Tlie appeiinince of 
sidditional musses of pua will be a proof that sometliiiig was overlooked, 
and renewed search miiist be instituted to find and drain the overlooked 
recess. 

Note aa'd Case. — The observance of this simple nile IlhI to the recognition of a rery itvterestiag 
and rare form of aupjmratix'e iiiiiHlitiH. Mrs. C F., primipara, rt(Jtiiltte<l to Mount Sitiai Hospital 
two WL'oka after her confinement, with abneefSH of the breast. Had very little fever. She was auivsthe- 
tizctl December 2ii, 18Ki5, mid, four Huclimlinp s[»ut» f*itimti.'d jii:<t above ami nenr tlie niiiiile fyein;^ 
incited, the finger was ulipijed into urie uf the incision!*, and found the irrepilar and tortuoufl 
cavities eoiiiinuriica«ting with each other. A large number of stnalh-r cavities oeenpyiug the 
upper hnlf of the luutnmary glntid were entered, and the intervi'irinf; bridges of tissue were 
bniken down with the flnper. Iljeniorrhage wa« very ficiinty. The cavity was wrtsihe<l our, aad, 
gentle prestsuve being applied, an udditional large mass of thick pun e*'caiK»'J, k long incision 
uniting the two most distant prituarj iiidstiona, and pulsing through the entire width of the gland, 
will* now tnade. It exposed the cavity, which was found lined with necrosed fhreds of glandu- 
lar tissue. The absoesa walls exuded oti firm pressure frimi hundreils of invir-ible op^enings 
separate drops of creamy pun. A [Mtrtion of the imluratwl wall of llie cavity waj* pared off, 
until pteniingly healthy ti»8we was eiicouDtered. Firm pre^jinre Innng repeiit«Hi, the aanie exuda- 
tion of pus from innumerable pores of the cut surface was oliiscrved. The section had a deep- 
yellow tinpe, nnd prei«ented the density of tibroniatous tissue. The lower half of the breast-glnnd 
was noniial and r'ecreted iidlk. An iodoform dresntiing wa» applied, and remained undi^jturbcil 
until Dfcoinber 27th, when the patietit complained of pain and exldbited some fev^r. The 
dn'.iislng!* I>eing renic^ved, a new ab.-^oeii!* vmn found and incised near the upper margin of the 
long indi^ion. The old ab>icc?«H cavity wkk granulating, but ilH walls still exhibited (he peculiar 
•Pf>earance of a largj- nmober of dixtinct pua-ilrops "n pri's.><urc. The wretched general con- 
ditkm of the patient, and the presumably intenninable duppuratiuu to be expected under the 
drcun)t4tance!> suggested exacction i)f the affected parts of the breast a.s the most rational 
niea>*ure. This !?te]f, however, was strcuuouf<ly opposed by ihc patient, and she left the hospital 
uneured. 

Afiparently we had in this case a form of purulent raastitia wlicre the 
suppunittve process was primarily located in the lacteal ducts, the intersti- 
tial connective (issue tiAsu mi n^ the character of shrinking- tihroi<l or cica- 
tricial tissue, jis in non-suppnrating interstitial mastitis. The contraction of 
the interstitial tissue led to closure of the lacteal ducts and to retention ; 
this to ]KTforalion of the lacteal ducts and extension of the suii[niration into 
the iuterstitial ti.^sne ; this, finally, to the formation of a large number of 
disseminated abscesses and necrosis. Throughout, the case exhibited un- 
nsnal eharaeteristies : well-eircumseribed localization, low fever with appall- 
ing destruction of tissues, and their curious jiermeatioti with canals, tlntt 
could be nothing but lacteal ducts, filled with creamy pus. As drainage 
and disiinfection t)f tlie infected lacteal ducts were impossible, ablation of tlie 
diseased pjirt of the gland wius clearly the proper way to terminate the 
process. 

Retro-mam ma i'tj affsrcssex u.snitlly point near the lower margin of the 
breast-gland. Thvy .shuuld hti Ireated like other deep-seated abscesses, by 




2§(5 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



incitiion iuid druLTuige, care being taken to eetublish the latter iu the most 
ilependcnt position. 

When the o|wriition la completed, safety-pins are thrust through the pro- 
jecting ends of tlie driiiinigL'-tnbos noar tho surface of the skin, and they are 
trimmed off short. A amall ring of iodoformcd gauze is plac^cd underneath 
the .safety-j»in around the drainage-tube, to prevcTit its being overlapfied by 
the edges of tlie wound, and a mm'sf antiKvptic drcsaintj is applied. In the 
absence of fever and pain, and if tlie dressings remain unpermeated by secre- 
tionsj they need not be changed before three or four days, when the drain- 
age-tubes om be either wholly removed, or one, liaviug previously beeo 
somewhat shortened, can 



be left in the most de- 
pendent incision till the 
following change of dress- 
ings. 

Where shreds of ne- 
crosed tissue are still ad- 
herent to the walls of the 
abscess, secretion will be 
somewhat more copious, 
and permeation of the dres.<iiigs 
will recjuirc daily changes nniil 
the necrosed ptirts crune .•i\\.i\. 
During this time, however, if 
drainage be adeqtiute, all thr pns 
nccreted should he contained in ihr 



I 






i<8 



Ki«. Xl'i. — Drcssinji^ lor mammary abeoL-«<, 
inT empyema. 



drpssintjs, and none in Ihe wfntnd. After detachment of the necrosed parts, 
secretion will become scanty and watery in character, and removal of the 
tubes will be followed by rapid closure of the wound. 

In cases wliere drainage is inadequate, fever and pain will jjcrsist, and 
secretion will remain profuse. The dressings will need frcijuent renewal, 
they will be rapidly soaked with pus, and the wound itself will contain 
more or less of it. This can be easily ascertained by gentle pressure, which 
will cause a cojiious tlow of |»us. Frertuent irrigation is a very imperfect 
substitute ttf proper drainage ; Iberefore, fhe making of a well-placed incis- 
ion shonld remedy the shortcoming. 

c. Empyema. — Infection of the pleura by pyogenic organisms, either 
through metastatic processes or by direct extension from the bronchi and 
lungs : from without by injury, or from i»urnlent atfections of the vicimil 
regions, as, for instance, peri nejdiri tic or liver abscess, leads to the forma- 
tion of empyema — that is. an accumulation of pus within the pleural cavity. 
The diagnosis of the affection is Ijasod u]>on the fover, dyspnoea, the absence 
of rcspimtory murmur, the dull pi-rcussion sound, rigidity of the alTected 
side of the ihorax. flatness of the intercostal di- press ions, and more or loss 
marked o'dcma (►f ilie integument over the site of th*' accumulation. 

Probatory pnncluro with a hyjK)dennic needle will usually vnld pus. 




DIAGNOSIS AND TREATMENT OF PHLEGMON. 



227 




The proper trcjitment uon^^iats of timely incision, disinfeetian, and drain- 
age under antiseptic cauteltv. 

Managetnfnl of RfCftit ('asft( ttf Empyfitm. — The thunix of tht; anaesthe- 
tized imtient iri clean.sed and disinfected, and an incision is made, from two 
to three inches in length, in the eighth intercostal spaw. parallel with the 
ribs, and a little bm-k of tlie nsillary tine. The skin and muscles are grad- 
ually divided down to the pleura, which is then incised. The sndden push 
of i)ns is checked and moderated by the pressure of the tip of the tinger. as 
too sudden ovaeuatiou of the tense accumulation may lead to rupture of ves- 
sels, or, in the case of empyema of the left pleural cavity, fco fatal embolism 
of the pulmonary artery. In these cases tlie heart is disjdaced to the right 
side, and any clots that may have formed within the right auricle could be 
easily deUiched by a sudden change of the heart'js position. This accident 
has occurred once to the author. However, it did not take place on the 
operating-table, but hapiM'ued several day;* after the operation. 

Case. — Helen MuUtT, ligcd t>lt'vi*n. ETujjyenia, with two tiKtnhc, of mx years' 
stamJinjr. Great errnifi at iun ; rotcntion of fetid \n\s\ (lie lieiirt dl^jtltM-Ht tn tlie right 
side, trbruarif 37, ISfiS, — Ex.st'ctiou of two ril)^, iiuihijjlu iricif-intls. and draiDiiv;^ at 
thfc fetid rtbftcess. I>aily irripation i>r(»daced a marked renii^sion of the lever, and 
overytbinj; seemed to progress favorably, whtn, Marrlj flth, wljile (daying in bed, the 
tihild saddeidy bocaaiP eyftDOfted, and lell batik dead. No post-nmrtura exaininatimi 
<uiild be had. I>eat]i was dotibtlt'sa enused by embolism of the pulmonary artery. 

The pleural incision .should be ample, a.s otherwise voluminous fibrinous 
pseudo-membranes may clog the exit of pus. A largc-calibercd drainage- 
tube, rctii'hintj juat tvithtu the pleural »ac^ is inserted, am! is ut tutrr ttt'curt'ti 
With a stmit iiajt'ty-piu, to prevent its being lost in the abscess. This 
occurred in one case treated at the German Hospital, and a good deal of 
trouble wsis experienced in finding ttie lost tutie. 

C'ask. — Fridoliri Jaeltle, laborer, aged forty-ttiree, mirMted tmjtije ma o^ idi^hX weeks' 
standing. Fehruanj !f, ISS^. — f'osterior inritiioii in the eighth intei-eostal space ; evaen- 
ation of a birge (|uatjtlty nf pus. A druitiage-tubo was inserted, but slipped tuit oT i\w 
(inherit, and vva»* lost in ttie cavity. The itu-i&tan Man siitliciently enlar^jed to admit two 
fingers, and then a sort nf a (liaplirai;;ni eoiild he felt se|)ariUing two intereuiniiuinicHt- 
tii)j curities. A eoanter inoision was tnado in the iiuiuunary line, and tlie tust drainage- 
tube was extraeted therefrom. FfraiuaRe-tulfes properly fastened witti sufoly-piriH were 
inuerteil, and the (^nvity was irritrated with earltoM*': lotion. Moi!*t dresninfrs were nj)- 
plied. April iSth. — l*atient vvsis disrhiu-jred onred. 

Washing of the plenral cavity with warm mercuric solution (I : 5,(KI0) 
thrown from an irrigator should be dune, until the fluid returns in a limpid 
state. Then a tinal ilushing with eorro.sivc-sutdiniate hjtittn of the strength 
of 1 : 1,000 should follow, and good care should be taken to drain ofl the 
last ve?t!ge of the rfolutiou tiy turning the [mtient so as to bring tlie incision 
nethermost. .\ very amjde moist dri'ssing shunhl envelop tlie [latient's 
thorax. 

As long as the temperatitre remains normal or slightly elevated, and the 
dressing cleati, r«o change is necessary. Usually, however, the dressings 



22S 



BULBS OF ASEPnC AXD ANTI.SEPTIC SURGERY. 



vill be soiled within tweuty-foar boors, and then tbej most be changed. 
Bat irrigation ghoald not be employed so long as the patient's temperali 
is normal. Onh\ if renewed fever appear, or the secretion assome a feti< 
odor, will repetition of the irrigation be necessary. In fresh empyemata,! 
eepecially of children, one irriijation tht>ritughly done at ike time of' thr 
(iteration will be found sufficient. But in some favorable cases of adaltj< 
Uie «ame smooth conrse of healing may he observed. The di^baiges will 
gradnally diminish^ they will lo% their pnmlent character, and will beoomeJ 
watery and scanty. As eoon as this is observed, the dniinage-tabe should 
be removed, and within four or six weeks from the operation the cavity will 
be healed by renewed adhesion of the coital and pulraonal pleura. Thaj 
long will dilate to its normal extent, and the universal adhesion of tliei 
pleural surfaces will gradnally give way to constant attrition, until the 
mobility of the lung and the normal state of things are re-established. 

Case. — Henry Fennell, fiimitnre-dealer, aged thirty. Etnpreiua on left ^de of foar 
weclu' daration. Fehrunr^ i, 188tt. — Coinninnic«tion with a larger brunchus spoiX' 
taneoaslv e!«tabli«hed. pving rise to ancootroilable fit* of coughing, which Imve e»- 
hnnsted the patient to a dan^vroas decree. February 6th. — Incision, drainage, and 
irrigation with a fire-|K>r-cent iMdiition of carbolic acid. The cough stopiifd at xncf ; 
the fever fell off. Fehrnary ITtfi. — Discharge very scanty and watery ; dminagC'tiibv* 
were removed. February lOth. — Sudden rise of leuiperatnre, with chill. Ftbmarf 
£i)th, — Pleuritic troug e f union on riffhttidr. March l»t. — Eflfnaion on right side begini* 
to bo absorbed, l^^ft lung dilated to nearly its nonnal compasii. March 6th. — Exutb- 
tion in right pluara ha^ disappeared. March ISlh. — Patient was di^iiorgcd cured. 

Latrrrd curvature of the spine is a prominent symptom of long-continaed 
empyema, and is very hard to cure. The moderate amount of lateral curva-' 
ture that got's along with recent empyema disappears with the restoration 
of the functiun of the comjireKsed lung. 

Old Eutpyema. — Ca><e8 of inveterate empyema with or without sinu» throw 
much greater difficulties in tlie way of the surgeon's efforti? to close the cav- 
ity and fistula than recent cases. The retraction and consolidation of the 
lung, and its envelopment in more or less thick coats of pseudo-membrane, 
fru:-trate all attempts at closure of the thoracic cavity. The unyielding 
lung cun not expand, while the contraction of the partially yielding walla 
of the thorax, accomplished by lateral curvature, by a close crowding to- 
gether of tlu' ribs, and a corn'S|>onding flattening of the affected side of the 
chest, ha!* its limit;*. Tims a secreting hollow space is maintained within 
the chest that can not be obliterated by the unaided efFort!* of nature, and 
iiUimntely the patient's strength and life will be sapped. The injection of 
uTituting fluids, or the packing of the cavity with strips of lint or gauze, 
are of no avail, and the only mMtix of effect iny a cure in multiple exseetion 
of the rihif arcordituj to the plan of Eatlantler. 

The rationale of this plan is to do away with the rigidity of the thoracic 
Willi by removing suitably long sections of as many ribs as are found to be 
fiirn-jinnding to the cavity. Thus the limbered thoracic wall may be 
del Mv -rti. '*"<' <'"U ^' brought into actual contact, or nearly so, with the 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



220 



N 



','■'•. — ritiitrjx ill u ftv-ii 
at' KtitliiUfkT'^ np<?rr.tu">ri 
for inveterate thorufic ha- 
tii\a. t.loliu .Sjiriii|ifr\ 



opposite or pulmoual surface of tlio 

carit}', where it will bt' fastened 

doivn and retaiikcd by cicatricial 

adhesions that will f(trni before the 

recouatruction of the exsected ribs. 
In dne course of time the at- 
tached Uing may even regain u large 

]iropurtiuu of iu former funetinnal 

fajiiicity by distention and uerution, 

and the more or less complete re- 

estahlishment of lnn<T capacity is 

manifested by the disappearance of lateral curvature. 
Cask I. — John Springer, clerk, agetl twenty-i.»ue. Etii 

pyema of loft side with tlioriiric tistiilu. Profuse t^LTretioii 

of pus, e!iru]>ijig tliriHigh an insutKcicnt (iii-isiun. Kxten- 

sive liurrwwinii iif jhh iinder latissimuH ilor.*! jtml st*rnilu* 

niHscIes. The pruffs^i wiis ufotic year's stundiny, tu\d Imd 

fjuised IntcrHl etirvnturo aud tur->:ont' eruaeiatioti. Avt/u«f y, 

Jg5, J87!>. — Incision and draiim|ie uf tla; exttTiud abi^ecssLS 

and of the Jeft [deimil ftivity at (lie Gt'rtnan Hn«f»)tal. 

Exseetinu ultlif LMiflith nl> lieciirne! n^ceesiiry, as tin.' intiT- 

Of^wlai spat'o was ton jiarrow to pfrnnt of a aat'e adjustnifnl 

of iLc dniinage-liilH'. The operation brought on nlaniiinp j.'nl!ap«e, wliifh was i>vit- 

conie by energetic stiitiuhttiun. Hits externtil ah- 
Hoosisos liealeJ, and, though the secrotion from th« 
pleural cavity bootinii! much ditniiiijthed, no tend- 
ency to a diiiiinatioii of tlio t^apacity of the sue 
r-iiuld be noticed. IJy New Year, 1H80, the [ja- 
tient's {leniirrt! coa<litiun had bei'ume excellent, aud. 
n>i improvement being visible rejfardinjf the beal- 
inp of the thoracic tistiila, .Taniuiry 3, IflW, EbI- 
liinder's operation wuh ]>erronned, By aa ample 
VLTtiral intiHion, cotnineniing in front of the uxil- 
liiry spaee in the pectoral fold, the third, fourth, 
tifth, Histh, and seventh litis were exposed. Their 
periostcuiti was atit up longtiuditially, un<] Bections 
of from two to fuur inches* of the ribs were re- 
iuove<l, the removed pieces beiiipf proportumal to 
the entire length of the several rilis. As emm ns 
the ribs Were reirioveth the thoracic: wnll could be 
well dejiressed Into the hollow of the cavity. In 
order to retard the new forunition of bone, the 
external wound wa"* piicked with carbolizod fraaze, 
and heided by granulation. The pleural hollow 
lic{;an at fujce to diniinish in nize, and April 11, 
IHHij, patient wtw diecharf^ed cured. He has re- 
Titained well ever since that lime, and presented, 

l-n.. .;4 — ic^siilt ath r Krtitiifiikr'.s April 23, 1887, when the accoinpfluvinj; photo- 
'J:rTl7.ph.l::";^Xrbn'"s;:?'„r.^: ^"-aphs were taken, the following. t^.tu^*: A scarcely 
ntM.:) iioticcuble trace of hitenil curvature ; the respira- 

:il 





:im 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



tory ©xcnrsioDs of Imtli si<lfstif rlie tkcmix iileiitical. All exseoted ribabad reformed 
imd occupied a nuniml position. Kespiratory niurrniir oould be heard all over the left 
side uf the thorax, (bigs. 17B and 174). 

Cabe 1L— Mjt»8 Eva 0., aged thirteen and a half. Thoracic fistala of two and aj 
half yenr>' duration, leading into a Bmall iiuvity lioldinfi about three ounces of flnid, 
thut hud resisted idl tifforts iit cure. Mat/ l^, IfiSl. — Exseetion of sixth and sevenih 
ribn at Miuint Sinai Hospital. Sepfemhrr JfH/t. — Patiorit vr&» discharged cored. In 
August, 1882, the healed fistula eaiuc open, vviib piiin and fever. Septtvtber 26, ISSt. 
— A seqnestrnni two inehes in kiigtb, (!unsi!*tiiip of a portion of the seventh rib, wiw 
extracted. Tbo wound healed promptly, and the girl's bealtli remained sound. 

The author's rather incomplete record of ull forms of empyema of chil- 
dren embraces twenty-two cases. Ail of those recovered with the exception 
of two — one died of basilar menin^i^itis ; the other of pulmoufiry cmboli^nu. 

Of the rune ctifies of atlntts, fonr were cured by simple incision : two bj 
multiple excision of ribs ; one, a ciise of perfoi'sitiou of a tul>crcular lung 
cuvily into the pleunt, died of fatal hcemorrhuge into the pleura ; and two 
eases were discharged imiiroved. hut not cured. 

To conohuk', it may be .said that the earlier the operation, the safer it is, 
and the belter the reHulti:!i acliievwl by it. 

d. PMegmon of the Palmar Aspect of the Haud, of the Arm, and AxiJla. 
— The hand, on account of its exposed Pituation. is the most frccjuent phico 
of small or more seriou.s injury. The necessity of the continued use of a 
slightly injured hand, and its contact with septic matter, lead to phlegmo- 
nous affections of ditferent degrees of intensity. 

More serious traumatisms, like incited or lacerated wounds of the hand, 
become in numerous cjises the scat of septic inflammation, in consequence 
of the improper and iineleanly primary treatment they receive from laymon 
and some |>liysiciiins. Neglect of tliorough cleansing and disinfection of 
a small wound often leads to direful coiis{M|uence3, that i>erhap8 the most 
skillful and incisive therapy can nut remeily. 

Of the manifold curious practices commonly eniployed for st-anching 
ha*morrhii£re and dressitig injuries to the hand, only two may be mentioned. 
FivKl rotfU's the: use of strjptic j<oluiionjf. They are unnecessiry. liecause 
di|.'ital compression of short duration ia capable of stancJiing even profuse 
arterial hemorrhage. 

The xernnd practice ia the favorite closure of soiled wounds about the 
hand with strips of adhesive plaster or a suture, without precptling disin- 
f erf inn. 

Some of the worst forms of palmar phlegmon observed by the author 
wore due to similar ministrations by lay or medical advisers. 

Cask I. — iTohn McG., liquor dealer, aped thirty-nine. April M), 1880. — Hmpped 
ofl" the ti]) of hift indei-tSnger with a hatchet, and was attended to immediately by a 
medical quack, who fltrnpped the injured part with a structure of neatly-arranged 
stripN of ndlic-ive piaster ttilliotit previonn rleansing. The wound was a smooth and 
clean-cut ont', an«l ofri're<l the most ad vuntapeous conditions for the avoidance of infec- 
tion. Sevi»re pain, .'^welliuir, and fever sufiervencd on the following day, tmt, at the 
advu'e ot the iDediml attendnttt, the dre!<8ing wan left uti undiaturbcd for four dijs. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



231 




May 5, 1886. — The patient came under the car© of tlio autbor, who found the wound 
and its neighliurluHH] tiplitly I'cnnpres^^wl by the adhesive jitrftppifjf?, and a phlejjiinni of 
tht; i^hfittti of tJie tifxor and uxtennor tendons of the index extending tuto the iiiter- 
uiiisoulur phiDeH of the ball of the lliuiub. A number of inciiiioiirt expowd tlienccroMr] 
tendona, and resulted in a tardy cure after their expnJaion. lie wan discharj^eil toured 
Jidy 10th. 

Case II. — S. A., laborer, ajrefl tliirty-live. Presented himself in .rauuarj, 18RI, sit 
the Gennan Dispensary with im incised wound ot the pahuar tt'^peet of the tLumli, 
and an extensive subaponeurotie phk^jnion of tlie palm and forearm. The htemor- 
rhjijie had been un.«ucces9fnlly eomhated by the patient himself with ap[»licati*»ns fif 
t'obwebe* and vartiish. Finally, the aid of a drngfjirtt wa^ sought, who j^oaked a ])iece 
of lint in perchloride-of-iron sohittou, and heruieticaily f^ealed the wound therewith. 
Phle^^mon set in [iromptly. and rapidly extended to the palmar bursa. The styptic 
dressing remained undisturbed, but the palmar swelling was treated with diligent 
poulticing. At the Gernjan Disjjensary various ineisions were done in aiiie-sthesin, fol- 
IdwcmI liy a tedious after-treatment consisting of repented connter-ioei>*ioiis until rare 
was effeeted. The removal of the atyptit; lint, intimately matted together with living 
and neeroiied ttasuett, was exceedingly troublesome. The function of the thumb was 
partially restored. 

Dorsum. — On account of the loose aiTangemeut of tbc subcutaneous 
connective tissue of the dorsal region of the hand, its phlegmonous aflEec- 
tiona present characteristics similar to those of niiy other subcutaneous 
phlegmon. The presence of a large number of firtir-foUicle."^ favors the 
localisation of septic processes in the cutis, which lead to the formation of 
typical furuncles or rarely a carbuncle, 

Pnlmxtr Aspect. — The peculiar features of the phlegmonous processes of 
the palmar Un-ipect of the fingers and hand depend upon the anatomical pecu- 
liarities of that region. On 
the fingers we find, instead 
(►f the loiigitudinril and loo.se 
arrangement of the subcu- 
taneous tissue of the dorsum, 
a dense net- work of slu>rt, 
thick fibers inclosing a num- 
ber nf small acini of fat. The 
main rlireetion of the eourse 
<if Hu\>?e fiberfi is ft-dni the 
cutis down to the periosteum, 
or to the sheuth of the ten- 
dons, to which they are close- 
ly attached. The direction of 
the lymphatics coincides with 
that of the connective tissue. 
Upon tins centripetal course 
of the lymphiities depends the pronounced tendency of digital inflamitui- 
tions to penetrate to llio bone or the tendons. The well-known tendency 
to necrosis and the formation uf cutant'ous, tendinous, or c),«;.seous setpicstra 
is. on the other hand, caused by great teuiiion due to the rigid and detise 



Fio. 17S. — Truiisvirsc si:ct.um ut i.L:rjiiiiui! }>liulanx, dhow- 
inir iimin^inent und tlin-^^lion ol et>nnective-ti»8ue 
flivem. (From Voijl.) 




arrangement of the i«ubcutaneons 
connective tissue. (Fig. 175.) 

Tlie manner of the exteusion of 
irhk'gmouous iuflummation within 
tlie teudiuuus sheaths of the pul- 
iiiur aajiect of the band is also j»re- 
Hcrihed by their special arrange 
meiit. Fi^. 170 shows the sheathe 
of the tlexors of the thumb and lit- 
tle Jitujer in open coram unicatiou 
with the common palmar bursa, 
thnnigh which jmsa all the flexor 
tendons of the fingers to and un- 
der the licramentnm capsi transvcr- 
isnm, iind hence to the forearm. 
The sheaths of the flexors of the 
index, middle, and ring jingertt 
represent separate and rlxtsed r^ 
leptitvU'x,, wiiifl) tcrniiuiite on the 
level uf tlie inetacariJO-phidangeal 
joints. For a short distance Ihv 
,.., . .. . , . ^ . vond these sacs the tendons thjs- 

rio. IT<1. - A, Hiltui rniiinifrt «t shcBtn* of tlie in- * '. 

.ii.x, miaaU', mill ritijr ttiiin^rs. n, c. sJiitaitb* of 8e.^s no slicath proper, but are im- 

i:;Hr;::h::L-tl;j:"^K;rt,;7''"""'*''''^ mediately inclosed by loose con. 

nective tissue. We see eorrespond- 
in>; to ihi'Mi' Ihrt'c rinsed saesi three pointed extensions of the common pal- 
iniir bumi, into which the tendons enter 
aftn* |ifi,'<sinji; throujjh I he shenthless part 
lif their eourse. (Figs. Kil and 171.) 

Thumb and Little Finger. — Upon 
IhJH arnuifiement is bjised the great ini- 
|Mirt "tf the wni>pnrutiorvs of xhv thumb 
and lit lie UnpT, mentioned by the old- 
odt mudiewl writers, and well known to 
the eomtnon iieople. While gatheriups 
of the index, the middle, and ring fin- 
gei-H often jwrfonile sjiontaneously near 
or on the level tjf the finger-balls (when- 
the blind end of the closed tendinous 
fllieatli coincides with the thinnest jwr- 
lioi) of tlie pjihnar aponeurosis), snppu- 
rutions of the thumb and little finger are 
very apt to, and txst a matter of fact often 
do, extend at once into the palmar bursa. 
The knowledge of tliis peculiarity is of 
the greate.'<t practical importance. 




Fio. 177.— Cntnnwm pnlnmr bona ii^AOted, 
nuil ^llonrill|r cvteitiiionf U>wan] thtiall 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



233 



Aside from the ueutetiess uf the symptoms, phlegmonous affections 
located on the palmiir aspeet of the hntid uiid ling^erH present some pecii- 
Imritied, tlie di!i<;^uostie aigiiitieunee of wJiicli must be mentioned. Rnltirss 
of iht akin is (jeneraUij absent, to ;i]>])ear only when the process has worked 
its way up to the .skin. Gtdima is nnnh'i'ttic, jind t>s often ovetlooked hy id- 
experienced ttb.Herver.% wlio are misled by tiie ledema and redness of the dor- 
sal soft parts to look there, and not on the palmar aide, for the focuB of the 
disturbance. 

The subjectivG symptoms are very distressing, high fever and intense 
pain being the nile, 

Treafmenf, — Prevention of phlegmon by guarding against the infection 
of large or small injuries of the integument is very proiituble. SmuH 
excoriations and shallow cuts should be cleansed and touched with acetic- 
acid. Punctures should be well sucked and bled and sealed with an acetic 
acid eschar ; or, if there be the least suspicion of infection by an unclean 
sharp-painted object, dilainfion uf thf xmaU hnle, thorough wiping out of 
the track with sublimate lotion, and drainage by means of a few short pieces 
of catgut laid into the bottom of the puncture are to be employed. In thi» 
httti'T fht.ss of case'-i n tuoisf (/retiring ix appropriate. 

In the presence of an inflammation that is evidently gathering mo- 
mentum, all attempts at an abortive treatment are risky, as the deceptive 
relief afforded by hot applications is very apt to induce patient and physician 
to be tardy witli the application of the best and surest antiphlogistic : tfte 
knife. By the time that the unbearable suffering Anally compels energetic 
treatment, sujipuratton requires a long incision, and necrosis of a phalanx 
or tendon njay be estahlis^hed. At Jirjii it titiifht Juive bn^n prrventtd by a 
tmich amaller incinion — in ftwt, by a mere punrtnre. The cases where a 
timely deep punctni-e with a tenotomy knife released one or a few drops of 
pus to the most intense relief of the patient were very numerous in the 
author's dispensary experience, and he can not recommend this truly con- 
servative procedure in warm enough terms. Instead of a terribly painful and 
t^'dious illness ending in more or less of destruction, ra])id healing of the 
small wound under the moist dressing will be the rule. And. if we consider 
that local atiivsthesia by cocaine or the ether spray (both more effective if 
condjined with artificial aufemia) has deprived incision of all its terrors, 
hesitation and poulticing become a culpable offense against the dictates of 
comiuon sense. 

The diagnosis of the ex4ict lomlity of beginning suppuration is easily 
made by the aid of the unmistakable ;<ensatious of the patient. Gentle 
pressure by a probe upon different points of the affected region, made to 
cover successively and in a methodical way the entire area in the shape of a 
spiral, will soon detect the most (minful spot. If one or two rejietitious of 
this process confirm tlie result <»f the Hrst search, no hesitation need be felt. 
The jHiint thus found is marked by a shallow scratch or otherwise, the 
finger or hand is ana^sthetiKcd, and the tenottmiy knife is boldly thrust 
down to the periosteum. If a few drops of pus cscai>e only, this will 





VhCtttlM 






rnilargfii, 

Aa the a iliBC ti ua 

•honld atwBjn 

befcwigitwdirnl to *Toid 

W afaD pgo^ptij and tnM- 

(F%. 17»> vm be foud verr odefut 

«a tke imuJH ucm which fiboald 

it of the au|iii< 4 « l pd- 

It b litiiahtd brtvcen the 

9t the CBpital M that 

Alhtr the 

aaj poiBt of the pafan can be 

the Bmb naihed oat o& Fig. 

\7^ bj HniBii BWfi'^ 

adTMable evea at thr ndt of 

the i«laiar nch, at the hcnonhi^ 

be eanlT slofiped by li|ratnr- 

ta^ the voiri ia aa wmpto ineiiioo, and £»- 

'« baad vfll dbetirdj pteivxtt nsdae 

las of hload daring the opefaiaon. 

ThcK m ao Rgmi of the haman bodj 
vhere «wciM» pmhioi^ of pbkgmoDS bni 
^ and tunelj ineisum can du 
vore good, thai m the foln. 

Cmol^-IL X^ — iiHir. aecJ sixty-lire k«i is 
the lOfcr pwt ef Aa^Ht. IS8S, m boO of tbe latsc 
whkh he VM ia ibe b«bift of ibiaMi^ liiiilf At 
ibe tHBe time b« iafbetad a aaal Miatdb nf U« 
rifbt fwiiegti. firoai vbieb dtm i efmS a Moa. Tbe 
tmmfy Mtmdtmn crAeni p oohiriag , adi n i o— JyT 

)88a, Aboot tovBtr-faor bo«r» b<€o«» 

cotire ana pra w ted a torible eoDdhiao f»f 

B» jaial, vas free bwa •appaiataao, mnI 

the iftia vai czlcnaiwly ArtachM ia4 nytv- 

I aaabw of flaaBcr 

Dipblberiaoribc thrMl. toagM, Ml Mootb barf 



VMca pav wMMa 



•bo <l«Tvb}pMl tbt di^^ b«4bco lb* (Mflahatb*. Md the vrN«bed fcocral coafilioa of 
lb*' f a riwl pat aaj i iyara rt ta lai wi ii oat of n m w fkia Tbe iaqniry, bw cacb a ctato 

nf Ihtagi tttJ-| nin i* — '. -* ^ — rV '*"* **'* pleaitr of ofOHagik tbef 

la dWycM jWi^oad aiaife, aad tbareioto aoTi^cal laterfcrMiee vaa I 



Ktf ti ded c«se«, «berv the sapfMtnure proocos has attained iride pro- 
pWtkM» ahmild ba Inatod oa gmenl priociplea laid dovn regaidtng the 
KKMnymat of coipliBalfd abac caw H i All reeesBes abould be foand ont, 
pepiiraMy iMiKd. wid draiacd. Where in the ootuae of a ktng-continaed 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



235 



■ 



prooNB tibe s?oft tissues liuve been more or leas? permeuted by the sei)tic 
poison, und multiple small abscerfaes with a sanioun discharge have estab- 
lished themsclvoji, tlie enormous swelling will render etticieut drainage very 
difficult or even impOi'Kible. 

Vertical auj^pcnsion an Vofkrnaun's itrm-spliiif ivtfh rmiliuuoux irriya- 
ii<m will often do here very effective service. Its detiiil in ai* follows : 

After the proper incisions are ma<!e and the requisite number of drainage- 
tubes have been inserted, the arm is enveloped in gauze, ia loosely atlaehed 
to the splint (Fig. 179) by a roller bandage, and isi suspended from the ceil- 
ing or a suitable frame. One or more irri- 
gators tilled with a very weak sublimated or 
salieylated loHon being also Buspended, their 
nozzles are connected with one or more of the 
uppermost drainage-tubes. A rubber blanket 
is so arranged beneath the sufjpended limb as 
to catch all the drippings and to conduct 
them into a bucket placed alongside the bed. 
The How of the irrigating fluid is regulated 
by pushing a match-stick or a straw into the 
nozzle of the irrigator. In this manner, ac- 
cording to necessity, a free current or the 
e8ca]>e of the fluid in tlrops can }w effected. 

If the entire limb re»|uiro irrigation, the 
use of many irrigators can be obviated by a 
simple contrivance recommended by Stareke. 
A tin tube, open at one end, and jirovided 
\vith a number of nijijiles, is connected with 
a large irrigator. On the nipfdes rubber tubes 
are slip(>ed. and are condm^ted ti> the several 
d mi nage- tubes, with which connection is cs- 
tjdjlished through short pieces of glass tubing. 
(Fig. 180.) 

Cauiinuons immersion in a weak antisep- 
tic lotion is a very .>;imple and eflfectivc sub- 
stitute for permanent irrigation, although it 
jireclttdes the advantages of vertical suspen- 
sion, The lotion should be changed from 
three to four times daily, and its tem|x?rd- 
ture is to be regulated by the ]»atienl's sen- 
sations. Sonic will have it warm, others will 

prefer a cool bath. By placing one or two alcohol lamps underneath the 
tin vessel containing the bath, an even tempeniture can be maintained. 

Case I.— Hugo Tt., laborer, aged twenty-eijrlit, ndinir.tfd, March 11, 1880, to the 
German I]ij!^[»ital witli extensive |)hle(;;moii of the paUti, cnnsLMjut'iit upon an injury tu 
the middli' linpL-r, The correspond) nir metacarpa-phainngt'fti joint was <K'«trny«;<!, Tho 
house-Hurgeon exarticutated the third tUn^cr, and made a niiait>er of incii«ioas in the 



/ 



Fia. 170. — Vnlkniunn's arm-splint 
for verticfll wii^i]K;imion. 




21G 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




symptoms are those of retn)-pharyugcal abscess from tolx^rculous caries ^^ 
thf wrviciil vtTtebnp. but it^ appeamiice is much more ra(»id, accompann 
\\\ bigli si'ptiu fevfi* and more acute local distress, causiug difficnlly 
deglutition, regurgitation of food through the nostrils, and alarm! 
dy^lJiioeji. The most characteristic symptom is the peculiarly rigid attitnJ 
of ihc liead, wliieli is eruct, and thrown back ta a certain extent at the <aiij 
time. The voice is thick and guttuml, as though a volumiuoius foreif 
body were held in the throat. 

In some cases tlie suppuration extends to the " intermuscular space, 
and causes the appearance of a lak'nd external swelling behind the ^-tenn 
mastoid mnscle. The transverse diameter of the neck then appears wideu 
lnsj)ection of the pharynx shows that the posterior pharyngeal wall is di 
phiced forward, is densely infiltrated, and sometimes fluctuating. 

Incision should be done through the oral cavity if the inflammation 
confined to the retro-pharyugeal region, but will bo more advantageoas 
done from without mid behind the sterno-ma^toid muscle in eases whei 
external swelling of the cervical region is noticeable. 

In the first case, the children should be held a^t for ])ODciIing of t 
thrniit, mrd the person fiaving charge of the head should be instmctcd 
thnnv it forviard at a given signal, so as to favor the escape of pus an 
blood outward from the oral cavity, and prevent it« entering the larynx. 

If lateral swellings appear, proper incision from without will affo 
eflicJeut drainage, and at the same time will help to avoid the dangers accr 
1)1 g from the entrance of pus into the larynx. 

The manner of incij-iou is best illustrated by the subjoined cases. 

Of a large number of cjises treated at the (iermaii Dispensary, and a f( 
seen at consultations in private practice, only two have terminated falall 
and in both serious haemorrhage occurred a few hours after the incision. 

Cask I.— S. P., aged eighteen luonthg, seen May 17, 1883, with Dr. L. WcU 
Eetro-pharjngeal and submaxHlury abscess developed during tlie florid sta^e dT 
violent acarlatina witli diplitlierin. Lh'»phagi!i atid dyBpaopa. Small bteral ioci 
tlirougli the skin iind fiisoiti imnJIcI to, nruJ bvliind tlie posterior margin of the i 
sterno-mastoid inust'le. Succesirifiil 8<iurcli fi>r pus witli a st<nit hypodermic needle, carri 
inward ;ind a littk* biiekward townrd the retro-plmrynjteal space. Insinantion o 
prooved director along tlie hollow needle, followed up by the introduction of a«a 
pair of dressing tbreeps, wliicli were withdrawn tialf opened. Eseape of Hboat o 
ftn<I a hnlf ounce of pas nnd introduction of a drainjige-tube. Two hours after inciai 
copious secondary lueinorrlmj;fe set in, aud rnpiilly teriiiinHted in dentli. Giving ftw 
of tlie wall of a «iloiighing vessel must l»e assumed to have caused this iiwue. 

CiVBB II. — Henry W., aged tniir and u half months, a healthy child, «lereln; 
Mnrcdi 4, 18S3, fever and dvHpliagirt, due to the preseuce of a number of small nb 
situated in the retro-pharyngeal connective tig.sae. Several of these were incised *'J 
Dr. A, Jacobi, with uppurent relief of short duration. New foci appearing, the incisi*-*"* 
were re[ieated March (»tlj and 8tli. March 9?A. ^Dysphagia became conjpletc ^»x*« 
dyspn<cn alanntng. Altltough tin* inctsions through the retro-pharyngeal space <^< »/»* 
tijiued to bleed, increasing the danger l>y the addition ot Ij&ntiorrbage to theot.l»t.-r 
symptoms, the extension of the jirocess to tlie connective-tittsne plane of tlie \i^W 




DIAGNOSIS AND TREATMENT OP PHLEGMON. 



237 



k 



■ 




lension. Asick* from the Iftr^re a bar esses, a uniform jniruUnt injiltrntion of the titsueH 
was fuuni}. Anffiiitf 18th. — Numerous inelsions werv nifule in anfpsthesia, t!ie entire 
forettrm exLibiting a state uf ichorous infiltration. Nocrosed portions t>f the skin jiiid 
of various muitcles were ablateiL, and a number of drainapo-tubei^. were inserted. The 
arm wjw kept continuously immersed in a tepid bath for four djiys witfiout an appreci- 
able irnproveineiit of the loful or genend tiisturbanee. Augnitt :3uth, — The nnn was 
vertifuliy su-^pendtHl, and continuous irri;;jitinii by u weak ruernirial lotion was estab- 
lished and kept up until September I8tli. Tins ehimjie was followed by slow but 
nnmiistcikable improvenienl, interrupted by occasional rises of temperatore dae to 
retention. The entire intognment of the volar widu of the arm was lo«t bj necrosis, 
and tlio defect had to he eovi-red by a uuiuljer of Kkin-pnitl.*!. The j^atient was die- 
ehurfjjed cured November 2!lth, with slifiht mobility of the wrist and the inetaearpo- 
phahingecit joiuts. 

By these means many a limb cati be saved. The detuchraent of sioiigh- 
inp^ tisfjuos should he facihtalod hy the use of .-icissors aiid forceps, and the 
rule should be uphetd not to suvrifice out) part of the liamt ihat h rmblc. 
Even the most sorry-look in*;, shajieless, iind immovable rudiments of this 
useful (ir^rnn will be of great value to the patient afterward. 

^Should all these means be of no avail in clieckiujc^ the progress of sup- 
puration, ampiitiition will have to be considered as a last life-saving remedy. 

Case. — Ernst H., shoemaker, ajred !<ixty-nine. Ilud been for years attended to at 
the German Dirtpenanry for a ehronic funj^ous artection of the wriiit. In the fall of 
ISSi) H jthlepinonouH intlanirnation started froui one of the maay fisttilas present, prad- 
nally involving the entire hand, wrist, and part of the forearm. A larjje number of 
inx'isious hud been ntnde, but the trouble crept steadily from one j<iint to another, 
and along the tendons, until the hand presented one swollen, shapeless, festering mass. 
Frhrnitrt/ Id, 18SH. — Amputation ui the forearm was done at iti< up|>er third. Primary 
union followed throufrliout. 

Jot'nfs (if f fit' rppi'f Erfrimitji. — Injury and itifection (A the itfclarftrpo- 
p/itihtHi/rnl or Jifj^t iulrrphatanfjml joints freipiently take place during a 
rough-and-tumble fight, when the ftst of u tighter hits the incii<ors of his 
antagonist. The author has treated four eases of this kind within the last 
seven years. In one, syphilis followed a very obstinate suppuration of the 
first iutt^rphalangeal joint of the right index. 

But often enough secondary sujipuration of the finger-joints is caused by 
extension of a neglected .subcutaneous or tendiucul phlegmon. 

NoTS. — k very aeiixc pUei/mon of the flftow-joint cftiuc under the obHervntion of the autlior 
at Mount Siuai HospttHl. A eotnpoiind diHloeatiou wa.s freshly ndniitteil, and was ri'^lucfHl and 
dr«9^>d «o-eulle<l "toUiscptiiully" hy a jiininr uuMuber of the house slnff. SupjfUiation followed 
promptly, the sutures had ti> he reiiinviil. n uuinber of indsions had tw be n>ade, and s liuxly 
nirc was effecteil, resultiup m hony iioebjiopis of ihe elbow at an aeute angle. (See euse of 
Samcicl Kbonooui, p^e 207.) 

Suppurntiun of tin' ftujrr-jfnniH usually termiruites in anchylosis. In 
many cjirfes this unltfwurd result can he prevented by rxxeciion and subse- 
quent careful treatment l»y passive and active movements. However, this 
©{■jomtion shoifhl twrcr bf nntU'rlakcn before the phlef/niariomt proceaH has 

terminntfd, and suppuration has assumed a bhind character. The author's 
»2 



I 



218 



RULES OF a>;eptic and antiseptic surgery. 



matious of these organe pp^ent some poculiarly grave features worthj 

special attention. 

Ilumuu saliva oortualiy cuntaiu^ a chemical substance akin to the pt 
niaincd or to nnake poison, that, like the latter^ seeme to play an Jiniiortai 
part in the jirocess of digestion. Whether an undue development of th 
albuminoid .substance, or exclusively the dirwt absor]ition of septic mat 
from the oral cavity \s at the bottom of the septic inflammations of the ail 
vary gland.^^, h not known — .suffice to say, that occju-ioually one or the olh 
of these glands liecomes tlie seat of suppurative inflammation. Their re.« 
ant envelope leads to incarceration of ichor and pus, to the development 
enormous tension aud its deleterious local and general eff<K?t^ — whicli 
dense infiltration and necrosis of tlie cfmtigaous soft parts, with dy!^>hagi 
and enflfocative attacks, and a highly septic fever. 

SuMi/Kjual or Suhmrtxilftiry ihfnnnrhe {LudtPiq's Aiufitui). — A ]>ainfafl 

deep-seated, hard {jvvelliiig of the f^ubmstxillary region appears, and i((f|aicki 

followed by cli ill's and high fever. I he swelling raj)tdly increasiug in e\te 
and hardne.ss, and the skin over the subraaxillary gland turning dusky re 
As long ai! the patient is up, his head \s held rigidly In one |K>sition, th 
eyes moving in wide circles if he wants to see an object out of his range 
vision. Or, if he be unj^uceessiul, the entire body is turned round slow! 
to bring the desired object within sight. The mouth is held slightly ope 
the tongue is dry, the floor of the month somewhat u^lematous. SjH'ecb 
difheult, m Q^n be .seen from the jminful twitcbings f)f the jiatient's i\ 
whenever he has to say something. After a while he will seek the bed. Th 
fiiee will appear slightly unlematous and eyanosed, the eye ha:< a dull an 
-(u])id expretJsion. the dry tongue is found lolling out of the month, an 
saliva escaping alongside of it. The floor of the mouth is very oedematou 
itnd by this time the entire submaxillary region will have become e-woUew 
and as hard as a board. The labortid snoring res]>iration of the patient give- 
watming of the extension of the oedema to the soft palate, fauces, and th« 
vieinity of the larynx. The temperature indicates very high fever, and tha* 
|iutient is unable to allay his burning thirst, as swallowing will have becom*^ 
ini[)ossibkv. At this stage cedema of the glottis may cause asphyxia in souje^ 
cuHOs, rctjuiring immediate tracheotomy, lu other cases extensive slouph — 
iiig of the involved parts of the neck will supervene, and fatjil ha*morrliag» 
may be caused by erosion of large vessels. The gnive septica'mia alone, or 
tiie extension of septic thrombosis to the cranium or right auricle, may end 
ill death. 

All dilatory measures^ such as hot or cold ajiplications, w^ill bo useles 
or )iositrveIy injurious, and the jiatient's salvation de|K'nds on a quio 
appreciation of the true charactei" of the trouble, followed by prompt am 
energetic action. 

Cask I. — It wfw observed by the nuthor during liis military service in CJarri»on H 
intal Kn. 2 at Vii>niia, Austria, in November, 1872. r>unD{roonvnle»cence from oseve; 
form nf Cv])ltold fuv«r, sviiii>toiM!» of stdiliui;iirtl rvniincht* a[»|H'ared in si younfr iwWif * 
trcittcd tu tlie divhiun for iutoniul dtr^iLses. l<*ottiL>iitattuiit* Lt'iug employed, tfic fHoll- 



.^zA 






DIAGNOSIS AND TREATMENT OF PHLEGMON. 



239 



Exiirptttion of ike vnlire group of affecUd Ii/ntph-f/lattd« by careful 
prepanition is thtnr best thcrupy. As rupturing of one or more of the 
broken-down ghmds, and soiling of the wound by their contents, can not 
always be avokietl, closure by sutures is best omitted. Thorough irrigation 
with corrosive-sublimate lotiou, ;i loose packing with moist gauze, and a 
moist dressing are ap|>ropriate. 

Case I. — Emma E[vple, servant, aged seventeen. Admitted tc> German Hospital 
March 31. 1886, Ab the consiecnience of a ** ruu-aroiuid " treated by puultioiiip, su]»- 
ptiration of ilie lymphatic ghituJs of the left axiha dt-vcloped. The arm-pit was tilled 
with a densely iiiHhrated largo mass of intuineseent and very |jainfid glands. The 
continuous f<;ver and eleeplessness liad produced an alarming degree of aniemia and 
debility, characterized by nipht-Bweats and loss of appetite. As no tliietuation eould 
be made ont, and prenuniably all the affecteil ^landtt were in a state of suppuration, 
extirpnfitm ftf tho entire t^landiilar iiihkh was advisi-d, Hn<] carried into effi<et April 3d. 
Dissection of the tiinror from the axillary vessels vm* rather diffictdt, and, one nf tlie 
teuaeida lacerating one of tlie brittle glands, a few drops of pus exuded into ihe 
wound. After thorough irrigation with corrosive-sublimate s<uluttou, the wound was 
elofied by suture, and an antiseptic moist dressinf; was applied. Previous to tins a sepa- 
fftte incision was made at the most dependent, portion of the cavity for the reception of 
a stout drainage-tube. A sharp chill and nmch puiu follmved the next day after tlie 
operation. Undoubtedly, infection of the cavity by contact with the escaped [his' had 
taken place. The dreflsings being removed, pus wa.n seen oozing out <if the drainage- 
tube. Daily change of dressing.** and irrigation nf the cavity with mercurial lution was 
followed by rapid ini]»ravoment, and the patient was dischnrged cured, May 7th. 

Case II. — C. 11., butcher, aged sixty-two. Slightly cut the dor>*um of his left 
die fitigor, OcttduT lo, IHsf), witliu batchcr-kuife. A ])hleguom develojted, and 
was treated by the patient himself with ()Oulticing till October 27th, when spontaneous 
evacuation took place. For a few days previous to this date, intumescence of the ca- 
bital lymphatic glands was noted. Octoher S8th. — The patient came under the author's 
care with an angry swelling of the region of the cubital glands. Incision was proposed 
and declineil. After a couple t>f wretched t>ig!its the i>atit*nt consented to incision, 
which wns done nnder chlorofiirni, October SIst, A stoall amount of ]ius came iiway, 
and a drainage-tube and moist dressings were applied. The momentary iiii[)roveuient 
soon gave way to renewed attacks of pain and swelling, apparently duo to succes- 
sive soppuratiou of several glands. Much ditliculty was e.\perieuced iu keeping the 
ilrainage-tuhe in ititu, the external wound showing a great tendency to cicatrization, 
while the slow ulceration of the glandular tissue was slill progressing. An extirpation 
of the glandular mass would have l»een more serviceable in this case thuu a simple 
incision. After a te<lious and troublesome course of treatment, the case was filially 
discharged cured, December 27th. 

e. Suppurative Affections of the Lower Extremity : 

(ff) Inguown Toe-Nail. — Tiie mo.*it cotntnou cause of tbis distressing 
aflTcction is the improper care of the toe-niiih". Sweating feet, in combina- 
tion with hick of cleanliness, imjiroixrly trimmed toe-nails, and narrow-toed 
*hoes, offer the best conditions for the development of ulcerative jtrocesses 
near the anterior edge of the nail. Whenever the nail is trirnnred otT too 
short, the adjacent skin will overlap its angle (Fig. 181). The epidermis be- 
ing macerated tind soft from the ]irofuso sweating, a small amount of friction 
between the edge of the nail and the skin will be sufficient Ut cause an exec- 




240 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



f la, 181. — A, Wrong way of trimmmg 
■' B. The 



toe-nail. 



nght way. 



riation. The pyogenic germs, so abundantly present in the fetid epidennidal 
mjisses of Hweating feot, will not only L-onif in woitact with the raw surfac'o, 
but will be nibbi'd into tiie opou lynipbatics by each successive step taken bv 

the individual. An ulcerative inflani- 
niation of the parts will result, which 
otfersi pour conditions for natural drain- 
age. Retention of the septic secretions 
leads to chronic suppuration, and to 
the extension of the process backward 
toward the root of and also under the 
nail, until metre or less of it becomes 
undermined and detached. E.xuberant 
granulations, subject to frerjuent ulcer- 
ative destruction, spring uji from the 
hypertrojthied and inliltrati'd overlap- 
ping .skin, andf if unchecked, the disorder termtnute.s in the Iossj of the nail. 
Occajiionally an ingrown toe-nail is the starting-point of pldegmon or erv- 
sijielas of the dorsum of the foot. The initial stages of the mi.schief can 
often be RucceHsfully met with a careful hccal treatment. Disinfecting baths 
sprinkling of alum and salicylic powder (alum, usti, 3 ij ; acidi salicyl.. 
3 S8 ; bismuthi subnitr., ? ijss) into the stockings, which should be daily 
changed, and the packing of salicylatcd or iodofornied cotton or lint under 
the edge of the nail, frequently result in alleviation, if not a cure, of the 
affection* 

More inveterate or extensive cases in {wrsons unable to devote the necc;! 
sjiry care and time to the treatment of this trouble will be !>est cured by 
operation. After careful ^^crubbing and disinfection, the toe is rendered 
aiia^raic by constriction of its root with a jiieee (}f rubber tubing. Local 
anaesthesia is produced by either an injection of a cocaine solution or the 
use of liichardson's ether-spray. The 
point of a bistoury is (Fig. 182) 
placed against the exuberant tissues 
adjoining the nail, and is thrust 
through the margin of the toe. It 
is carried forward until the integu 
ment is sepamted in the shajx' of a 
longitudinal flaju Then the knife 
is reversed and carried back well be- 
yond the matrix of the nail, where 
the tlap (c) is cut otf. 

The pointed Iilade of a straight 
pair of scissors is placed under the an- 
terior margin of the nail (Fig. 183, a, b) just beyond the limit of the disease,] 
and, being thrust under it, cuts through the nail in an autero-posteriordirec-j 
tion well back of the matrix. One blade of a stout pair of dressing- forceps is 
next insinuated into the slit in the nail and under the loose segnicnt. This, 




Fio 

und iiiutrix. 



I9:i. — 0[)vrttt'u!U for in^njwn t/>c-(uiU. 
B, Line ol' sevtiun through tb« nul 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



241 



being firmly grasped, is evulaed with im outward rotating motion. Good 
care must lye tiikeu not to leave behind any shreds of the cut-off matrix. 
Any gnmulatioMri are scmped away with a shai'p spoon, and the wound i.s 
well irrigated with mercuric lotion. A stri]) of rubber tissue well soaked 
in curbolie lotion, and just large en<>n*,Hi to cover tbe wound, is ])]aced next 
to it ; over thia eomea a strip of iodoformed gauxe and a small disinfected 
sponge, the latter to exercise elajstic jJiTHsure for the prevention of undue 
haemorrhage ; finally conies a light, compressive jmn'sf drvaxuuj^ fastened 

I by a roller bandage. Wbile the patient's foot i.s held elevated, the rubber 

hand is removed. The first dressing can be left on for a week or even two 
weeks. Being moifit.» it will {>cel off easily when removed, aud, according 
to its size, the wound will be found either partly or entirely cicatrized over. 
Care must be taken not to compress the toe too much, as necrosis of the 
skin by pre.ssure may develop and retard the healin_g. 

The author has treated over a hundred of these ca-ses in the niiinner de- 
scribed with the best resultij, the majority being jiatients of the German 
Dispensary, who walked to and from the institution during the time of 
treatment. 

{h) Chronic Ulcers of the Leo. — Neglected excoriations or abrasions 
of the skin belonging to the lower third of the leg are the most common 
starting-point of ulcerous processes. Varices due to stagnation of the venous 
circulation render the progressive invasion of new areas of tissue by micro- 
cocci, ever present in the putrescent discharges, especially easy. Conse- 
•luently, ulcerative destruction develops. The successful treatment of this 
condition must be ba.'^ed u|>on an elimination of the causal factors. Pre- 
vention or elimination of decomposition by antiseptics, and an improve- 
ment of the circulatory conditions by elevation of the limb or its elastic 
compression, form the cardinal jMiints of our thcrajjy. 

The affected limb is enrefully cleansed with soap and a soft flannel rug 
until all the crusts ut inspissated secretion and ejvidermis are removed. This 
process will be greatly facilitated by pticking of the }mrts in strips of lint 
saturated with vaseline or iiusalted bird the night previous to the cleansing 
bath. Plain water should never be used on account of its irritating (juali- 
ties and its liability to cause eczema. After the bath the soap-suds should 
be simply wi|>ed off with a soft towel. The ulcer is well mopped with a 
1 : l,Ot.M» solution of corrosive sublimate, or, where the stench is very intense, 
with a 4 : 1,000 solution of permanganate of potash. Iodoform powder is 
dusted over the ulcer, and a suituble patch of rubber tissue is placed next 
to it. The eczemaUms skin in the vicinity is well anointed with vaseline 
or ttu astringent salve, and a regular antiseptic dressing is snugly bandaged 
on to the ulcer, the roller bandage extetiding from the toes to the knec-joiut. 
This dressing need not be removed before two or three days, I he frequency 
of renewal being dependent upon the (piantity of tlie discharge. As soon 

Iae cicatrization is well advanced, a simjiler dressing, consisting of a straj)- 
ping of mercurial plaster covered with a ]>ad nf absorbent cotton, held down 
by a Martin's elastic bandage, can be substituted therefor, and the patient 
I 



222 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 





extend to one or more lymplmtic glands, aubfascially situated in front 
the extcrnitl meatus of Ihe ear. uud in close vicinity to the |)arotid glaa 
They produce very violent general and local symptorais, and require 
attention, a.s a subsequent involvement of the parotid gland is very apt 
occur. 

Snppuratioft of the mastoid trlls is tlie moat common form of extensio 
of a purulent otitis of the external or middle ear. Its symptoms bear 
resemblance to those of acute osteomyelitis, and require prompt attention o^ 
account of the possibility of necrosis and the iuvotvenient of the menin 
brain, or lateral sinus. Where intense swelling indicates the presence 
purulent periostitis of the mii*toid process, a free incision of all the soft part-^ 
down to the bone will often give great relief. But, where the interior of th^ 
cancellous .structure of the mtistoid process is the seat of the disease, nuth 
ing short of a free opening of its interior will avail. Formerly, this oi«ei 
tion was done with the aid of the trephine, an instrument the penetratior 
of which i.«t somewhat beyond the supervising control of the surgeon. A 
present mallet and chisel are used for this purpose with greater advantage 
The chisel should be held tangentially to the external surface of the inaaitoicsp 
process, thin layers of bune being pared off in succeasion, until the suppuratj:^ 
ing focus is freely exposed. Thus injury to the lateral sinus can be safel^' 
avoided. Copious irrigation with a zvarm solution of corrosiTe snblima 
and a moist dressing are advisable. The cases in which early operating h 
prevented necrosis will heal very promptly. Necroiiis will retard the cu 
considerably, and may require a second or even a third ojxjration for th 
removal of sequestra. 

In neglected cases spontaneous perforation through the jieriostenm wif 
occur, and an external abscess, located posteriorly to the sterno-mastoi»> 
muscle, will appear. The tendency of it:» oxteusion is toward the **int* 
muscular space,'' that m, downward into the supraclavicular fossa. 

Occasionally the process extends backward and upwanl uiK>n 
occiput. 

Oabb I. — Fred. ItnthH, bnker. Aged eighteen, admitted to car deportment of Genni 
lIiiH[iitat, rk'fCMiiher 17. 1883, wltfi [ninilr'nt caturrli of Hit* jtiiddlt? oar uod suppiimtii 
of iiiustuid ctUs. Wilde's inciaiua aod extruetion of Boiue seijuestra from the extern 
meatus were practiced by Dr. J. Simrock. A plilegmon of the left occipital regio 
starting from a sinus below the mastirul prooeK-H, having set in, pfttiviit was transfer 
Mflrrh 25, 1884, to tlit* mirgicjil departriietit. Marrh '26th. — High fever aud rjole 
ht'ftdacho with voiiiitiug. Spveriil irit-isiious hud (»peiii an trreguliir ravity situated I 
tiind the ear and extending downward toward tliu neck, tin pressure. » hirge rioanti 
of pun ooxed out nf a roces.** lietween exul>erftiit grunulHtiims near the lower aiiteri 
angle of tlio pftfietjd hone. These being scraped away, ti eequeHtrum, about one sqn 
inch in ciretiinferenee, ftud eomprising the whole tbiclcne»« of the skull, wras ext 
Pulsrttion of the bottom of the cavity tfius exposed was clearly discernible. Heal 
progres'^ed without Interruption, the purulent diHcharge from the middle ear cea>-»>*^» 
and pdiient wiiw di(«.ihargod cured, .Vpril 17, 188i, with ii deeply indented sciir. ''' 
Octoher, I8N(|, lie presented him3elfi€Oiuplainingof epilejitie seizures that had appe**"^?*' 
in July, 1886. 



tl^cr=d 





DIAGNOSIS AND TREATMENT OF PHLEGMON. 



243 



^ 



^ 
^ 



estublifihed in the vicinity, as, for instance, ucute osteomyelitis or a subcu- 
taaeouB or bursal pblo^inon. Idioputhic aicute suppuration of the knee- 
joint is very rare indtH*d. 

The invasion is marked by one or more shurp chills, >'cry high fever, 
and a sudden painful intumescence of the joint. Tlie limb ia rotated out- 
ward, lying on its outer aspect, is flexed at an obtuse angle, and its position 
is carefully maintained by the patient, as the constant pain is terribly in- 
tciisibed by the least change ttf pusture. General onlema and reddening of 
the integument soon follow, the septic intoxication frecjuently producing 
delirium and a typhoid condition. 

1'lie iutra-articular tension iucreni?ing, perforation of the capsule, gener- 
ally upward through the bursal extension of the joint beneath the quadri- 
ceps tendon, occurs, and is marked by a temporary remission of the in- 
tensity of the local and sometimes of the general symptoms. One or more 
subfascial or subcutaneous abscesses^ located on one or botli sides of tlie 
quadriceps, appear, and rapidly extend upward and outward until |>erfoni- 
tion of the skin permits the escape of the enormous mass of jient-uji jius. 
Occasionally the matter perforates backward into the |>o])liteal sjuice, thi.s 
way being marked out by the burste situated beneath the pujditeus muscle, 
which are frequently in open communication with the knee-joint. In this 
case the absecs,« will extend dowuAvard along and beneath the muscles of Ihe 
calf. 

Spontaneous perforation will not bring about complete and lasting relief, 
as the drainage is and must be inade<iunte. Profuse suppuration and a con- 
suming fever, with fre((uent chills and colliquative sweats, will in a short 
time so depress the patient's condition, that amputation will have to be 
thought of as the last resort for saving life. 

The treatment should be that of deep-seated phlegmon, modified by the 
requirements of the anatomical peculiarities of the knee-joint. The cavity 
of the knee-joint naturally consists of three disiinct recesses: one b^low, the 
other above the patella; the third is un extension of the suprapatellar space, 
and is known by the name of the bursa of the t/ufulritr/ts. In llexion, 
where the knee-pan is firmly held down to the condyles, the infra- and 
snpra-patellar spaces become practically non-eommnnicating, Andrews of 
Chicago, to whom we owe a most excellent treatise on the subject of injuries 
to the joints, mentfon.s a case* of traumatic suppuration of the infra- 
patellar recess of the knee-joint, where, by means of continued flexion and 
thorough disinfection and drainage of the same space, general infection uf 
the joint was etTectually prevented. 

To effect adequate di'ainage of a phlegmonous knee-joint, each of these 
recesses must be sejtarately incised and drained. 

A double incision of each of these spaces will be much more ctTectivo 
than a single one, as it will jiermit more thorough irrigation. In very 
infections cases two additional incisions will drain away pus retained in the 
reflection of the capsule from the vicinity of the crucial ligaments. 

• AaliburstV " Eney*;lu]«"ilin of Surgery," vol. ill, p. 72:J. 



244 



RULES OF ASEPTIC iVND ANTISEPTIC SURGERY. 



The first incision should be made in the suprapatellar space on the 
inner side, where the cap«;ule is the most ample. Ilfemorrhage is generally 
profuse, hence it is boat to penetrate the tissues gradually, and to «eecurd 
ciifh bleefling vessel as soon as it is cut. As soon as the joint is entered, » 
drc's.>'in;r ffirce|>s is thrnst tbroufrh it to the correeiwnding point of the other 
Bitlcof the joint, where the second incision is to be made through the tissoes 
raised by the pressure of the forceps. The point of the forceps emerging 
from this incision, a stout draiiiat:e-tnbc is grasped with it, and drawn into 
the joint just far enough to clear the sjniovial membrane. A similar piece 
nf drainiige- tubing is inserted into the first incision, and the protradiog 
ouds of the tubes, being truusfixcd with safety-pins, are cut oflf on a lercl 
with the skill. The inirapat^'llar and submuscular spaces arc treated 
similarly, and, if necessary, the lateral i>ouches of the joint arc alao ib- 
cised and drained. The cavities arc thoroughly flushed out with corroeire- 
sublimate lotion, a large moist dressing is fastened on, and the limb b 
secured to a posterior splint to insure rest and painlessness during unavoid- 
able changes of jwsture of the patient. Wherever perforation of the caj)sule 
and ftfrmatioii i>f n circumarticular abscess luis occurred, this must be se|>a- 
rutoly incised and drained. 

In the great majority of cases, resolute and eoniprehensive meaisures of 
this kind will be rewarded by prompt im])rovemeut. Daily change of dress- 
ings and irrigation should Ije practiced until tlie disappearance of all the 
intlammatory and febrile symptoms. As soon as the discharges become 
scanty and serous, the drniuage-tubes can be withdrawn one by one. Where 
tlio affection is due to osteomyelitis, anchylosis will result as a rule, oepe- 
cially in grown individuals. In children, jirompt and adequat<^ drainage 
frequently results in preservatiou of nujbility. 

Cawe I.— ("tiarlos IlnmJeiitiiiark. ajjcrl four. Acute sn|ipnratJon of knt^- joint caused 
l)y u blow iipoii lit'tid i>l" tilna. May 67, 1S75. — TJirecs incisions — one on each side Into 
the suprapntellur !<pacc, a third one into this quadriceps bursa. Daily cliaoge of moist 
cjirboliied (Irosainps and irrigntion. Ra()id iniprovt'tnonl. Junfi 15th. — Draiua^e aban- 
doned. July Jfth. — ['iTtiH't rccoverv noted, witli free active use of the joint. 

Ca8E II.— .loiiM S., grocer, ugcd ninftceu. Acute Hiippuration of knee-joint, with 
terrible puiri and typtioid »yii>ptoiaa. Tiie patient was brougbt to tlie German IIo*- 
pitiil Jjintinry 10, 18H0, by Dr. Soliwedler, wlio administered cbloroforttt during the 
triinst'er, to allay tlie pwtient's suffering from the jolts of the earriatfc. Ituraediatc typi- 
eul multiple inoinjons and driiiniiife. The index-finper detected a roujrhened pluee on 
tlie jirtii'idar wurtiiee of the Inner condyle of tho feiuur. Undoubtedly on account uf 
the oHteoioyoJitir process, tlie febrile symptoms receded very slowly. Pennanent irri- 
trntion of the joint rendered the frequent, ti-rribly painful ohanf^e of the dreaaines 
nnuecesisary. A few small seipiostra belonging to the cflneellons tis»«»c of the feinoral 
epipbyHiH eume nwny on the twenty-third day. Patient was di.scharged cared, March 
20th, with linn unoliylosis. 

In cxctiptitmally neglected cases, where the jirocess has a^unied the 
clmnicter of a gencmt purulent infiltration, incisions and drainage, sapplo- 
niented with continu<ius irrigation, will not In* followed by as prompt im- 
provement a-* is desimble. The continued high fever, the fortnation of 



i 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 245 

new abscesses, will certainly bring utw^ut a fatal terminatioiu unless tlie 
limb is amputated clearly l>eyond the liraita of the disease. So-called con- 
servatiTC measures — as, for instance, exsiect.ion of the joint — art- entirely 
inadmifisiblo and dangerous under these circumstances. Tiiuy will fail to 
remove from the afFeeted parts the elements of contamination, as the most 
rigid anti.*cptic measures of the ordinary kind are here utterly inadequate. 
The phlegmonous process will attack the ncvvly-madc wonnd-surfaccs, and 
the patient's life will be placed in the greatest jeopardy by secondary lia-mor- 
rhage. The following case forcibly illustrates the weight of these remarks : 

Case. — Mai Loffrnuim, butt'her, jigenl twenty. Adniitteil, Octnl>er 25, IRRfj, to 
Moiiut Sinai no9[rttul. Ottofier 12th. — The stilmiinscular recess of ttie knee-joint \vm 
arciflenlally incised with a likby butcher's knife. Some synovia escfipt'd i'nnn ibe 
email puncture; after the accident tbe patient walked home. Snpiiunttjon of the knee- 
joint fvet in the followiiifj day, with rlgorn and pf-neml dejection. Tho notmd was 
dressed by a JorHt-y City prftetitioner witti iin adhesive-jdnster drcisinji iiliiced over tlie 
incision. Tbe piitieiit wa^ a<hiuttt'd to the liospitiil in a liifrldy sej»tie fondititm, lurj^.- 
riniintities of thin, ickonjii» pus escaping from the joint on sli^'ht pressure. Imniedi- 
Htely the patient wixf anjestbetized, and tyj»ieal incision nnd drainage were done. The 
synovial lining of tlie joint wnn. roated with a (rreenif*b-iLi;rfty adhercut und putrid mem- 
brane, in looks identical with tlie nieiuhninotis coatiuf^ )ti pbarynfjeal di[di(berta. A 
nnmber of small, pnrcdent foci were opened hy the incisions mad« for drainajre of the 
joint. A rnoi;<t dresmng .ind dorsal uplint were applied. In spite of frefpient irriga- 
tion, no renitSvsion of tiie high (ever or local pain following, aui|mtation of the tbi^fh 
was profmsed, in view of the visible fuilin|jr of the jiatient's strength. Thia, however, 
was resolutely declined by the patient and his widowed mother, who beggeii for an 
attempt to nave the limb. The author, against his better judgment, performed essee- 
tion of the knee-joint, November 1Mb. Esmiirch's band was applied to the upper third 
of the thigh without the previous use of the elastic roller bimdiige, and u continuous 
Atreani of oorrosive-snblinotte lotion (1 : l,t>Oy) was kept playing ii])on the wonnd doring 
the entire operation, wliieh was rapidly hut carefully performed. Care wa« taken to 
operate in healthy parts, and all the involved tissues were removed. The wonnd 
was draine<l and closed in the usnid manner, and the drcH>«ed limb was llxed npon 
a doFMil splint. Sii|ipnration of the woniid followed, requiring frequent changes 
of dressing nud irrigation, the secretions retaining all the while their pccoliar thin, 
ichorons character nttted from the outset. On the afternoon of Noveiidier ]Hth, ]»ro- 
fiu»e arterial basmorrbage occurred from the wound, which was temporarily tdiecked 
by the house-surgeon with the ap[ilication of EsmarchV hand. Being hastily snni- 
luoned to the hosj)ital, the antlior found the patient Idanehed and collapsed. Abont 
twenty ounces of a *> : l,t>tni watery sicdutiou of cooking salt were transfused into hia 
median vein, ami resalted in a notable im[ir<ivemeiit of the pulse. .VinputatSrm of the 
thigh was quickly done as a last resort. The patient, however, expired before the 
renioi'al l^f Esmarrh's band. 

I'o*l-morteiiJ examinuliou revealed a sieve-like jierforation of the popliteal vein 
and n large oblong defect of the popliteal artery, both of which were found exjiOsed 

I and snrroundiHl liy a nniiwive bloo«l-clot. The walls nf (be cavity containing the clot 
oousiftted of broken-down and necrosed tissues. 
TJieru iis little doubt that an early aiupntation might have saved the patient's life. 
(e) SifpriiATiox OF the Ixguixal tSL.w'os.— Two groups of lym- 
phatic glands have to Ix* distinguished iu tht.* inguuial regiim — one situat^'d 
r 



22r. 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 






incision and drutiifige, care being taken to establish the latter iu the mo* 
lie pen dent posit ioti. 

When the opt^ration is completed, safety-pins are thrust through thep 
jccting ends of the drainage-tubes near the surface of the skin, and they a: 
trimmed off r;hort. A small ring of induformed gauze is placed underneatf 
the safety-]>in around the dnunage-tubc, to prevent its being overlapjied bj 
the edges of the wound, and a tnoist anihepiic drettsinif t.y applied. In th- ^-^ 
absence of fever and pain, and if the dres.siugisi remain unpermeated by secrKJ^'^ 
tions, tbey need, not be changed before three or four days, when the drain .^^^ 
age-tabea can be either wholly removed, or one, having previously beei^ M 

somewhat shortened, can _^ ^j 

be left in the most de- 
pendent incision till the 
following change of dress- 
ings. 

Where shreds of ne- 
crosed tissue are still ad- 
herent to the walla of tlie 
absceBS, secretion will be 
somewhat more copious, 
and permeation of the dressings 
will rcfjuire daily changes until 
the necrosed parts come away. 
During this time, however, if 
drainage be adequate, all the pus 
Kfcri'ted should be conimited in thf 

drpsstngsy and noitp in the wound. After detachment of the necrosed part&<»- 
secretion will become scanty and watery in character, and removal of th^^ 
tubes will be followed by ra])id closure of t!ie wi^und. 

In cases where drainage is inadequate, fever and pain will persist, anc^ 
secretion will remain profuse. "^I'lve dressings will need frequent renewal -^ 
they will be rapidly soaked with pus, and the wound itj^elf will contaif^ 
more or less of it. This can be easily ascertained by gentle pressure, whicl"^^ 
will cause a copious flow of pus. Frequent irrigation is a very imperfect- 
substitute of proper drainage ; therefore, the making of a well-placed inci*-- — 
ion should remedy the shortcoming. 

c. Empyema. — Infection of tJie pleura by pyogenic organisms, oithe^^ 
through metastatic processes or by direct extension from the bronchi anc^ 
luuf^s ; from without by injury, or from purulent affections of the vicinft^ 
regions, us, for instance, iwrinejihritic (vr liver abscess, leads to the forma.— 
tion of empyema — that is, an accumulation of pus within the [ileunU cavity- 
The diagnosis of the nffection is based upon the fever. dy--jpniea, the abseoe^^ 
of respiratory murmur, the dull percussion sound, rigidity of the affected! 
side of the thorax, llatness of the intercostal depressions, and more or le^* 
marked (pdenia of the integument over the site of the accumulation. 

Probatory puncture with a hypodermic needle will usually yield pus. 




Fiii. 17- — i>rc><sini.* i'fT fuuiutiuiry 3^»<x•9.•', 
or etupycuu. 



DIAGNOSIS AND TREATMENT OF PHX.EGMON. 



247 



accepted ns an indicfltion of the «ituatii>D of the source of the suppurativ*.' process near 
tbe lower thonwic, or tlie ]iiriibar vfrtebne. 

8, Tfir third tjfoup eomthfa of ahice^aes that take their origin irit/iin thf boundnrku 
of thf iliaru» mvjiclf, which ocraipies the iiiti^rnal aspect of the ui* iiiuin. Their exten- 
sion is pres4Tibetl by the limits of the iliutu*, and they commonly appear on the surface 
below the anterior superior s[«ne of tbo ihiiai, or more rarely in the loin nt the exter- 
nal inarp;^iu of the (jtiadratus lutiiborum. The ab!*ccsses jKtintirn; hel«nv the anterior 
superior spine have no ficrilonL-al investment, and can bo freely ineined without fear I'f 
iHJnriui^ the peritonanim. 

T<» sain up brietly, we tnay nay that retro-peritoneal abseesses, as, fur instance, peri- 
typhlitic or periinetrUif patherinps, will generally point above and corresponding lo the 
inner twt> thirdn t>f Poti[iart's ligament. 

P»(iaH alwcews, indicntintf atTectiont* located on the front part of the thoracic or lum- 
bar vortehrtD, will extend below Pou]iart's lif^anient to the front of tbe tliifyh. 

Ilia<'al abscesses, raiised by suppurative aftectious of the o« ilium, the sacro-iliao 
symphysis, or the saerunv, will ffenerally point below the unterior sajierior wpiue of tlie 
ilium, occupying the outer third of the space above I'oupart's ligament. <Jccasion- 
ally they will puint iu the lumbar or gluteal region, or, when the abscess is very great, 
in two or all of the regions indicated. 

Itiflamtiiatury or nlcerativc affections of iho mucous membrane of the 
caecum or vermiform appendix, moatlv <^lue to fecal impaction or tbe pres- 
ence of foreiji;:!! bodies, are often followed by phlegmonous proee^ises estab- 
lished iti the retro-peritoneal connective tissue located just behind tiie tliiek 
put. Occasionallv, but on the whole nirely, similar processes obtain on the 
left tiide of the abdomen, in the connective ti.«sue behind the descending 

b colon. 
Most commonly during adolescence a deep-,«cated, painful tumor de- 
velopiJ in the tliac fossa, with more or less high fever, and gradually ex- 
tends to the groin. As the process approaches the surface, o'denm of tbe 
integument and fluctuation appear. With very few exceptions the gathering 
U retro-peritoneal, and works its way outward along the posterior surface of 
the perittuiieuin till it reaches to the unterior reflection of this metubrune 
on a level of Pntipart's ligament, where it beeonu's stibfuvsctal ami subcutane- 
ous. This dissecting up of the peritonaeum by tbe abscess will assume very 
extensive proportions if the tension remains unrelieved for a long time, 
llie author has observed burrowing of n ])eritypblitic abseofis into ihc ]ire- 
vesical connective-tissue .space (case of Henry Murks). 

The danger of perforation of a perityphlitic abscess into the unaffected 
]»art of the peritoneal cavity is present, but on the whole not very greats 
Only one case of this kind came under observation. 

Cask. — H. t)., (derk, aged twenty. Subject to alvine slugtrishncss, contracted, after 
, Jk more than asnally severe spell of constipation, a (leei)-8eate<1. hard, piniifid, peri- 
TyphUtii- swetlin;:. Catiuirties tailed to relieve the bowels, lUid, high lever with vintiit- 
ing liavin^' set in. the initbor vvjis ruusulted. Mai/ 1, JS7ii. — Typical swelling of a 
cylindrical aliape wii» iiiaile out in the right groin, and a nnmber of repeated large in- 
jections of tepid water into the gut were employed vvitboiit success. May 9iL — The 
|ieritoneal symptoms, notably v«niiiting, beeaiue very distres^inK. wherefore this therapy 
was abandoned ami ojiiuiu treulmeut begun. At the same time an ice-lia;: was plaied 



2S8 



RULES OF ASEFriC AND ANTISEFnc SURGERY. 



i 



will bi' soiled within tweiity-fout' hours, and then they must be change^^ 
But irrigation sliould not be employed so long as the patient^e temperate ^a 
is iionniil. Ouly. if renewed fever appear, or tlie secretion assume a fe-^^/j 
odor, will repetition of tiie irrif^'ution be necessary. In fresh emj)Temj*f;» 
especially of children, one irrigation thoniutjhly done at the time of z^, 
ojn'ntHon will be found aufficifnt. But in some favorable ca^s of Bivlb 
the .same smooth coui-se uf healing may be observed. The dischargOii yrill 
gnuliiidly diminish, they will lose their purulent character, and will become 
watery and scanty. As soon as this is observed, the drainage-tube should 
be removed, and within four or six weeks from the operation the cavity will 
be healed by renewed adhesion of the costal and pulinonal plcuni. Tin- 
lung will dilute to its normal extent, and the universal adhesion of ibc 
pleural surfaces will gradually give way to constant attrition, until the 
mobility of the lung and the normal state of things are re-established. 

Case. — Henry Fennel], fnrnitnrc-detiter, aged tJiirty. Enipjri'ina on left side of fonr 
weeks' tlunitioii. Ffbnmry 1, ISSU. — CtiimiuinknlJon with ii larger bronchus «p«>n- 
tanemislv estiiblHlictl, givinfj; rise to iincoiitrollable fits of coiigliinj?, which have fi- 
luiiisteil the piitii^nt. to a dan^trous defrroo, Frfirmtrff 6th. — lucisioD, drninu^c, lO^ 
irrigation with a tive-|»er-cent solution of curhulic tifid. The cough Btop|H.Hl al "ii«; 
the fever fell off. Fehruary 17 th. — riiseharge very scanty and watery; draim^fo-tniw* 
were removed. February 10th. — Sudden rise of temperature, with chill, FebruniTl 
Sffth. — Plfiiritic iterotm fJf'u/(ion un rig/ifitide, Marrhhl. — Etfuaion on right s'ulc U-S'i' 
to he ahsorhed. Left lung dilute*! to nesirly its norniiil cuui(niss. Afareh 6th, — Exm-i 
tion in right pleura hast disappeared. March LUth. — Patient was diselinrgeil rarwl. 

Lateral curvntiwe ofthf spine is a prominent symptom of long-contiun< 
empyema, and is very hard to cure. The moderate amount of lateral curt 
ture that goes along with recent emjiyema disappears with the reetontic 
of the function of the compressed lung. 

Old Eitipt/cma. — C'(fsr.<< ofiftvftfrftte empifema with or loithout trinu* tl 
nnu!h greater dilSieulties in the way of the surgeon's efforts to close the 
ity and fistula than recent cases. The retraction and consolidation of 
lung, and its envelopment in more or less thick coats of pstudo-membr 
frustrate all attempts at closure of the thoracic cavity. The unvieldt^ 
lung can not expand, while the contraction of the partially yielding wj 
of the thorax, accomplished by lateral curvature, by a close crowding 
gether of the ribs, and a corresponding fhitteniug of the affected side of 
chest, has its limits. Thus a secreting hollow space is luaintainod witl 
the chest that can not be obliterated by the unaided efforts? of nature. 
ultimately the patient's strength and life will be sapped. The injection 
irritating fluids, or the packing of the cavity with strips of lint or gai 
are of no avail, and tM onhf meani( of t'ffeding a cure is multiple exxeeti 
of f/if r<7/.v atrnrdinij In the plan of Estla»der. 

The rafimtak of this plan is to do away with the rigidity of the thoracic 
wall by removing siiitfibly long sections of as many ribs as are found to k 
corresponding to the cavity. Thus the limbered thoracic wall may W 
depressed, and cau be brought into actual contact, or nearly so, with the 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



249 



peritonaeum are easy, but in many cases may be unnecessary, hence can not 
be commended. 

The safest way is to wait till the eighth or tentli day, or until fluctua- 
tion is evident, when the pcritoiueum is well raised up, and the danger of 
ita injury very remote. 

Cask. — Jack Schlusser, fijjted ten. Had an attack of typhlitis in Novetnlier. 18S5, 
from wSiicli he proti)])tl_v ixrovered. Jn/if. 4, l^i^t!, — I*frit.ji>hliti.s Wfis tifiairi diagnnsti- 
cattnl by Dr. Koehler, «n<l, uiider tlie luluiinisitnitum of mild laxatives iitid ciR'ttiHta, tho 
coridittun of tliings seemcMl In iuipnnvd up tu the lOtlt, wliea liipiier febrile syniptotiia 
twt in, and th« area of painful inlurawsoence ia the right p?rotn beeainc ncitatily en- 
larged. June JSth. — The dijx^osifl «ii* abj^cess was made out. Jtuir l^th. — The author 
inoised and drained the cavity with the aid of Dr. Koehler, under whoB« care the case 
improved rapidly, and was oiircd June oOtli. 

I>igital exploration of the cavity is very advi.sable, fur two reasons : First, 
it will lead to easy detection aud removal of foreign bodies, as, for instance, 
kernels or stones contained in the bottom of the abscess ; and, secondly, it 
will enable the surgeon to form a just conception of the extent aud direction 
of burrowing sinuses, which may require separate drainage. 

Case. — Henry Marks, aged eeventeen, saffered from habitual consti[>ation and fre- 
quent attacks of colic. In June, July, and August, 1878, s«evere attacks of colic were 
noted and overcome l»y the u^e of purgativeK. Augvut 25th. — Dr. L. Wei**, tbe family 
attc-ndant, made out typhlitis and ordered a hixative, whidi, h(jwever, tailed to relieve 
the patient. Thereupon upiuia was nietiiodically txlnbited until September Gtli, wiien 
the patient had a spuntaneotis and copious, formed evueuntion. St^ptrmhfr 7/A, — Tlio 
temperature rose to 104° Fuhr., the external svvetlinji iu the ri{;ht proin became very 
marked. Srpffmber 10th. — The autlior saw the patient in eonsHltiition with Dr. Weiss. 
A naiform piiflFy swelling wjta found oectipying the ripht groin, and was extending 
Ixjyond tlie median line of the abdomen. Frcfpicnt urination dintressed the patient a 
If0o<l deal, who exhibited the Ui*ual Iteetic syinptonjs of lonj.'-rontinncil su|iiiiirutioa. 
l>ee[» fluctuation was made out, and evacuation of the ab^w-ess was deteruiiued upon. 
The transversalif* fascia heinp ^adunlly expoae<l, it was fr>Hn<l infiltrated and firmly 
attached to the underlyinii tissues. A probatory [nmctHre tnade iu the bottom of the 
wound, close to the Of* ilium, gave pun, whereupon tlie abscess was freely incised, and 
a large quantity of tnatter was voided. No foreign body could be found. Digital 
exploration demonstrated a long sinuosity extending toward the median tine to ft pocket 
oecupying the prevesical sjiace. A dntiniige-tube wa.*t placed into the main abscess, 
and another one wa» carried into t!ie jircvesical si>ace, and the wound was dressed with 
oarholized ganze. The patient's wretcheti condition at once commenced to improve; 
apfiotite and sleep returned, and the profuse night-sweats disajtpeared. Sfptemher 
2(Hh. — The drainagc'-tabea became disarranged, and were found slipfied out of the 
wound. IHfficolty was experienced in replacing them, and svmptoins nf retention, 
with renewed |>ain and fever, set in again, Stptrmher 2-i(l. — The aulhfir iigaiu saw the 
patient, and replaced the tubes. A considerable (quantity of pus was found in the pre- 
veoioal poeket. From this date on umnterrnpted improvement was noted, and the 
patient got up October lUth. October 20th, the tubes were withdrawn, and October 
30th the fistula was chised. 

As previously mentioned, stercoral ulceration of the intestinal mucous 
membrane is the most common cause of jierityphlitic abscess. This impac- 



250 RULES OF ASEPTIC AND ANTISEPTIC SURQERY. 

tion of faecea is ordinarily located in the ciecuin or in the vermiform appen- 
dix. But iiccji«ioi»ally, where a cancerous stricture of the ileo-caecal xalr^ 
is present, it will Ix' found located in the lowest part of the ilium, caa^ing 
great distention, ulceration, adhesive attachment, and perforation into the 
retro-colic connective-tissue space, simulating perityphlitic abscess. 

Cask. — Mr. M. G., aged sLxtv-two, had been snfferinjj: from IiAbitual and very obsti- 
iiiil* constipation for years. In May, 1880, prof ii!*e diiirrLcBn set ia, and coald out be 
controlled by any of tbe usual dietary and theraptiutic roeaaures. A grave det^rioratloo 
of thti general condition developed, and the pntieot lost very much flei^b in (tpite of 
forced feetling. August SUt. — Fever set in, and tbe presence of a painful Hweilin^ in 
tbe iliat" fo!»*ji was mwle out. Septcmher 3ti. — The author »uw tbe cm?* in con«nlt«iti^tn 
with Dr. W. Hnher and Dr. 1.. Conrad. A birjje flnr-tiiHtiiiii .Hwelling oocupie*! tbe 
ritrbt half of the pelvis, and tympanitic percns^^iion sound wu.s not^-Kl in tbe Intoktr 
re^on. Two incisions were made— one above Poupart's ligament, another in tb* 
lumbar reifion — an<l an enormous amount of gas, pus, and fecal matter was t^vaeaaU'd. 
Profuse secretion and diarrbd'a continue*!, and the patient <lie<l September '22d. P<mt' 
mortftn txuwimitiim revealed a tiglil cancerous stricture of tlie ile<>-c«C4d valve, smd aa 
enormous dilatation of tbe lower portion of the ilium, which resembled tbicJt tniU 
Uirj.'e masses of impacted fecal matter were found in this pouch. wliicJi was adherent 
to the posterior parietal peritonn^um, and was freely communicating; through a number 
of ulcerous defects with the abscess cavity. 

Flexion of the thigh upon the pelvis is a very constant symptom of jicri- 
typhlitic abscess, and is in children occasionally the cause of an erroneous 
diagnosis of liip-joint disease. But hip-joint discjise may undoubtedly Iv 
caused by the extension of a jwritvphlitic abscess aloug the ilio-i>goas muscle 
to the iliac bursa, and hence into the hi|»-jaint. 

Case.— Ernestine S., «ervant-|firl. aged nineteien, admitted March 2, 1880, to the 
Gennnn nosjiita], with the dijignosla of hiji-jtiint disease, the symptoms of vrbicb were 
indubitably present. Enwiciatiug fever, and the churacteristic tlexion an<l >i<l<lnction 
of the thigh, togetlier with swelling of the gluteal and infrapubic regions, seemed to 
admit of no doubt. Examination under ctlier, however, reveale<! a Huctunting swelling 
of the right groin, which yielded pus on puncture, and wa,s incised. A large ipiantity 
of pus and the stem of an apple t>r pear were evacnutod. Another inciisjon below 
Poupart's ligament established drainage of an abscess communicating with the ihti- 
tvpblitic gathering. The lower extremity was put into Buck'* exlen»ion. and the 
cavities were daily irrigate<l. Oponitive measures, directed agaiu^t tbe profuse dis- 
charge from the lower incision— that is. drainage or exseciion of the hip-joint — mtrt 
contemplate*!, when the girl contracted erysipelas, and died of it in May, 188o. Po*<- 
nutrtoiH examination esUibli^bed the fact of hip-joint suppuration, a communicMlion of 
tbi- perilypblilic abiioeis with the joint l»eing found, by way of the iliac bur«i. 

Of sixteen cases of perityphlitic or retro-colic abscess observed by the 
author, tiftoen were o|x'rated on. and twelve recovered. 

Three died — one of septic }K?ritonitis, due to injury and infection of the 
IK'ritonaMira at the time of the operation : one from exhaustion, due to 
cancer of the iloo-caecal valve anil nloerative enteritis : and one, complicat^tl 
by hip-joint suppuration, from erysipelas. 

One case was not operated on. and dietl of septic iieritonitia caused bv 
perforation of the absce&s into the peritoneal cavity. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



251 



Four more cases of j>erityjihlitic inflammation, not operated on, but 
treated with o])ium find lar^^e enemuht, recovered. In two of these marked 
tendency to relups^cs iind huhitual constipation persist. 

ff. Abscess of the Liver. — The diagnosis of hepatic abMjesa is based 
upon the presence uf a painful and growinor intumescence of the liver, ac- 
companied by more or less intense fever, which gradually assumes a hectic 
character. In the beginning the swelling ascends and descends at respira- 
tion ; hut later on, when tlie liver becomes attached to the abdominal wall, 
this mobility disappears. Probatory puncture with a tine aspirating needle 
can be safely made, and will generally dispel any doubt. As soon as the 
diagnosis is secured, incision has to be made. 

Where adhesion of the hepatic swelling to the abdominal wall is estab- 
lished, or. even more so, where the suppurative process has involved the 
integument, a free incision can be safely made. A large-sized drainage-tube 
should be inserted into the cavity, and frerjuent irrigation should Ije em- 
ployed. The wound is covered with an ample moist dressing. 

The incision of hepatic abscesses located in the unattached liver require 
some special precautions. The abdominal wall opposite the tumor i& incised 
under a strict observance of the rules laid doi^Ti for laparotomy, so a.s to 
expose the liver. The incision is packed with iodoformed gauze, and a dry 
dressing is applied. 

In three days firm adhesions of the liver to the abdominal wall will be 
established, when, the packing being removed, the liver is punctured, and, 
pus beiug found, is freely incised and the cavity evacuated and drained. 

A. Lumbar Abscesses. — The significance of acute lumbar abscesses de- 
pends upon their causMtion and ujion the locality from which they take 
their origin. The majority of lumbar abscesses are caused by purnlent 
atfectiims of the kidney or its pelvis — a^, for instance, by renal calculus 
or pyelitis — but in a comparatively large number of cases no utfecHon of the 
kidneys or their adnexa can be recognized, and traumatism of one or another 
kind must be iissumed as the causative agent. 

Contusion and a sudden and unexiiectcd strain of the back were stated 
to the author by patients as can.eative factor.-^. The beginnings of lumbar 
abscess are always obscure and insidious. A deep-seated unilateral pain in 
the small of the tmck is first complained of. One or more chills or a low 
form of hectic fever set in. The patient's back is bent upon the affected 
side, and is more or leas tender. Loss of vigor and emaciation become more 
and more evident, until a distinct tumor, marked by dullness on percussion, 
can be made out in the space between the crest of the ilium and the twelfth 
rib. The way of extension of thu abscess is prescribed by tbe 'luudrntus 
lumborum muscle, the onter edge of which serves as a landmark for finding 
and incising it. The presence of pyelitis or pyonephrosis, ascertained by 
examination of the urine, is very significant, and possible doubts as regards 
the nature of the trouble may be dis]ielled by one or more probatory punct- 
ure'* with a wcH-disinfected hollow needle and the aspirator. A good-sized 
caliber should be selected, as grumous or fiocculent pus is apt to clog a 




VANE LIBRARY. STANFORD UNIVERSFTV. 



RULE8 OF xVSEPTIC 







Fio. 17(3.— A, Blind fndiiisjs of ahoatliN of tlif in- 
dex, middle, and riim flnjiCTS. b, c, Shuatlis of 
thumb und little ftn^T oi^'filv ooinmunicating 
with jialmiir Itursn. (b'rom N'ogt. ) 

iii^ to these three closed sacs three poin 
nuir bursa, into which the tetidons outer 
after puj^sing through tlie sheiithless part 
of tlveir course. (Figs- 17ti liud 177.) 

Thumb and Liiile Fimjew — Upon 
this arraugcment is based tlie great im- 
port of the suppurations of the thumb 
and little finger, mentioned by tlie old- 
est medical writers, and wel! known to 
the common people. While gatherings 
of the index, the middle, and ring fin- 
gers often jiei'foraie siwntuneously near 
or on the level of the finger-balls (wheiv 
I he blind end of the cloaed tendinous 
sheath coincides with the tliinuest por- 
tion of the palmar aponenrof»is), suppu- 
rations of the thumb and little linger arc 
very apt to, and a^ a matter of fact often 
do, extend at once into the pahnar bursa. 
The knowledge of this? peculiarity is of 
the greatest practical importance. 



arrangement of the subcutaueo •^n*. 

connective tissue. (Fig. 175.) 

The manner of the extensiou ■^■i^i 
pblegmonous inflammation with 
the tendinous sheaths of the 
mar aspect oi the hand is also pr 
scribed by their special arrao^ Mi "1*1 
ment. Fig. 176 shows the sheat^^ * 
of the flexors of the (hum ft and I 
th Jiw/er in open communicati 
with the common palmar bu 
through which pii^s all the flex 
tendons of the lingers to and u 
der the ligamentum capsi transv 
sum, and hence to the forci 
The sheaths of the flexors of t 
index ^ middle^ and riny fii^yr 
represful separate and cloned 



cepfrtcff.t, which terminate on t 
level of the tuetaeari>o-phalau 
joints. For a short distance 
yond these siics the tendons ]>» 
sess no sheath jtroper, but are i 
mediately inclosed by loose co^ 
nective tissue. We see corresjKnte 
ted extensions of thecoiunion \\ 






Km. ITV.— CnmiTi' ; , 
and little finger. tFrotn Vnat.) 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



253 



■ 



Fio. I8<}.— ArTBD^ment of druLnii(rt'-(ul)«a fi>r perinephritic or any 
otber de«p-«eaU!d ai]>i Inry^v abocflBB cavity. 



a tlressing-f creeps is insinuated into the cavity, and is withdrawn while held 
wide open. Blunt dilatation of this kind can be repeatedly practiced until 
the aperture is large enough to admit the index-tinger for exploration, 

Should the abscess contain urinouB matter or stones, or should the septa 
of the calicos of the reual pelvis bo recognized by touch, the cau.<iiti(jn of 
the jH'ocess hy perforation outward from a suppurating kidney will suJfer 
no doubt. If found, atones may be then extracted, and the cavity, being 
well washed w-ith boro-salicylic lotion, is drained by the insertion of one or 
more stout ruliber tubes. 

NoTK. — A very efficient mcMle of (irAimng is the fotJowing one: A immber of fenestra nre 
cut into the siden of h large-calibcred rubber tube, whieh is plai-ed wtll willbin the cavity, An- 
other snialkT-Mlzt'il lulie of 
the saiiii" U'ngtii is [ir<>- 
vidwi with II ctiuple of 
fenetstra near ht^ tiie>'ial 
rod, and in iniiertetl Into 
the abscess alongside of 
the larger tube (FiiX. 18fi). 
A flrvam of lotion inject- 
ed into tlie smaller tube 
will enter the bottom of 
ibe ab»(x>(»!<, will vaAi out 
its reee»8e*>, and will rarry 
away .-ioeretions and fft'ftrif 

through the many fenestra <if the larper tube. Safety-pinn thrust tlirougb tlie distal ends of the 
tubes will prevent their hi.inp lowt in the abf<ceB!<, jln ample antiseptic moist dressing should 
envelop the entire lumbar region, and the patient t^Luuld be tirought to bed. 

In opening j>erinephritic abscesses, the author has met with two eases 
in which the pus had a peculiar whitish-yellow color, the consistency of 
curdled cream, and the odor of freslily-niade warm whey. In both of these 
cases death eaused by uiwniia followed some time after the incisioti, and 
post-mortem examination showed that the parenchyma of the kidney had 
been destroyed, and that the organ wa.s a pus-bag with fibrous walls, which 
were perforateti and communicating with a number of secondary abscesses 
located in the pelvis. The secretions contained tubercle bacilli. 

Oa8E. — Erriil Cohii, clerk, dRcd thirty. Pyelonephritis of iiiitiiy yearn' standing. Very 
iiuirked «na?mia snvd high I'evCT, with a large Ininhar tind pelvie swelling, that was first 
noted in Fehrtmry, 188t>. iueision^done A|>ril 28. I88fi,,'it the (rerniim II unjutal, evacu- 
ated au euorinoust ainouDt of the ahovc-uieutioued peculiar suteJHug pus. Tlie tempera- 
ture was at ouw rediioed to nearly the normal standard. As tl<e cavity contraeJed, and 
the aecretion became scanty, the hotise-snrpeon withdrew tlie tube, whereupon retention 
in the pelvic part of the abweHS with renewed lever compelled, Mhv l."ith, diliitatiun 
and refilaeerneut of the tubus. The evaeiiation i>f the rihr^eess wu-** nut followed hy au 
itnprovtMnt'iit of the qpality of the urine, which euntinned to contHJn pus and hyaUne 
cmta, showin^i^ that the other kidney was also atfected. Death from nrHSiniu, May 10th. 

Coses of surgical kidney may get cured after the extraction of stones, if 
portions of the renal parenchyma be preserved, and continue to secrete 
urine, and the ureter be unobstructed Uy calculi or cicatricial stenosis. 
84 




RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



234 



suffice ; if more, the puncture should be at once proportionately enlargi^^s^/ 
thoroughly irrigated, and covered with a nioii^t dresising. Ajs the affection 
generally extends to tlic periosteum or teudoti, the incision !:>hould alw^^i-^ 
be carried down to one or the other, and should be longitudinal to aroi'd 
injury of vessels or tendons. 

tStibfa.KCi'al phlcffmuns of the palm should be also jiromptly and su/K- 
ciently incised. The adjoining diagram (Fig. 178) will be found very iweful 

in jioirifJng out the small jirea which sliort/d 
be avoided on account of the superficial pil- 
niar arch. It is situated between the firtt 
and last strokes of the capital M that marks 
the palm. After the aponeurosis has bwi* 
cut through, any point of the palm can tpc? 
reached from the lines marked out on ¥\z~ 
178, by llilton-Hoser's method. 

Incision ia advisable even at the risk '>f 
cutting the palmar arch, as the hajmorrlm^* 
thus caused caji be easily stopped by Ugaw**" 
ing tlie ves?sel in an ainjile incision, and E*=^ 
march's band will efTeotively j>revent un»ii^*-* 
loss of blood during the operation. 

There is no region of the human bo*iy 
where senseless poulticing of phlegmonii 1»**^ 
done more harm, and timely incision can ***' 
more good, than in the palm. 

Case. — M. 51., sartiller, a^red sixtjr-five, h«<l * 
the ]att«r part of August, 1885, a boil of the f^*^^" 
which he was in t]j« habit of dreasinp hitnsclf. ■* 
the same time he iDfLH'te^l a small wratrh of ■•'' 
ripht fiirefinfjer, I'rntii whii-li ilevelfiin^*! a fehai. I'*" 
faanily nttendaut unlered pinjt(icinp, »rhUh tnu 9p^^^ 
iijt unbiterrHptedhf f»r more than fhrt-e wrekg. Kot out inci&ion had bttn m<ui4y ^^**^ 
wliCD tlie author saw tbe patient, September 28, 198.% about twenty-ftiur hoars be^*-* 
his (leatii from i*e[>tieicnna, the hjuid and entire arm presented a terrible conditio** 
plilepmonous (leHtriiction. Not one tondon, nojnint, was free from suppuration, J" 
a nuintper iif pliulanges were neerosed ; ttn- skiu was* eitenwvelv detached aud rrf>* "*■" 
seiiled u boggy biip, from whicii pus Howed I'ofiiotisly throu^rlt a naniher of sm*'*^^ 
and larger defect* duo to sloiifrliiup;. iJiphtheria of tlie thmat. toague, and moaUi t>^*^^ 
al»o devudopeil the day before the ronsidtati<tn, and the wretched general condition '^ 
tlie patient put any operative niea.si;ro out of question. The imjuiry, liow Kucb »»t**^ 
of tliiDg*^ ofiuld come alwrtit, drew tlie rt-ply tliat ''there were plenty of opening th^J^ 
si'ciiied to diseharge/rw'^// tfnJ nicely y and liierefore sargiral interference was refriio*^' 
from." 

Neglected cases, where the suppurative process has attained wide pTO* 
portions, s^houhl ho treated on genend prinei|ile.*' laid down regarding th** 
management of complicated abscesses. All receaises i^hould be found onl. 
separately incised, and drained. Where in the course of a long-continoed 




U R 

Fio. 17S.— tStmiiilil iim-a markina 
tht' phK-c'si whore mcUioiiJi van be 
wifely iiiiuIl*. The nyuwi W'X,\\vvxi 
thb Qmi and lust Htrnkcn <■!' thu 
capitAJ M, inurkiD); the palm, 
BhouUl be avoided. (From Vogt.) 



I 




DIAGNOSIS AND TREATMENT OF PHLEGMON. 



255 



■ 



bacteria. In view of iliese facts, the frequency of ulcerative and suppurative 
affections of the anal region nnii^t appear very natural. 

Anftl abscesHes are generally located in the ischio-rectal fossa. This is 
the ispace limited by the rectum on the mesial side, tlie tuberosity of the 
ischium externally, the levator ani muscle above, the fiujierficial perineal 
fascia below. It is very rare to meet with a periproctitic abscc'^s situated 
above the levator ani. if such is the case, we have to deal with graver 
affections involving the pelvic organs, or with abscei^s from ulceration due- 
to stercoral impaction caused by cancerous rectal istricture. 

Cask. — Mary Steiger, aged fifty-nine. Far-^jone cancer of rectum. Stenosis very 
tight, causing great difficulty nt defecation. A profuse purulent di?*churge from the 
antis indirated the presoiit'e «*f ulcers or nn abwi'ss above the (Stricture. Exploration 
of the reftum above the cancer was absulutely inipoesible. High teuiperaturt's were 
noted. Auffit$t 13, 1S85. — Anterior colotvmtj in ttio German Hospital. No diminution 
of fever after the operation- Augmt IGtk. — Wound hi'uled hy the Jiri»t intintion. 
Atujunt 17t/t. — PatiL'Ut ileiirioviH. Diseliargi' from mnMs very profuse. AugH»t litth. — 
Patient died with syrnptouis of »!eptti-a'Uiia. Post murteni revealed firm union of 
colotoniy wound ttirciugliont and a normal peritoneal pavity. In the sacral excavation, 
just above the massive ulcerated cancer, n very large fetid abscess was found. 

The presence of anal abscess is the source of intense suffering to the 
ivitient, and ascertaining of its precise location by the surgeon is generally 
not very difficnlt. By digital examination of the rectum a resistant, hard, 
or sometimes fluctuating swelling ean be felt protruding laterally into iJie 
put. Early incision is very urgently indicated, as upon it may depend the 
avoidance of the formation of flistula, or of a dissecting or '* horKe-shoe 
alwcess/' whieh may detjich almost the entire lower gut from the adjacent 
connective tissue. This latter form of abscess is especially to be feared, as 
its healing is extremely difficult. But, where fluctuation is absent, success- 
ful evacuation of a deep-seated jwriproctitic abscess is no easy matter. 

After a purge and enema, the patient should be anesthetized and 
brought into Hozeman's or the lithotomy position. (See Fig. l'Z2, page 154.) 
A sponge tied to a piece of stout silk is pushed well into the rectum, and 
the lower end uf the gut and the anal region are flushed with corrosive-sub- 
limate lotion. Then the index-flngcr is introduced and placed against the 
swollen side for fixation. A stout exploring needle is thrust through the 
skin into the swelling repeatedly from without until it strikes the suppurate 
iug focus. It is left in xifu for a guide, and an ample incision is gradually 
extended until the abscess is freely opened. The wound should have the 
shape of a funnel, its a|K*x being in the abscess. This w ill seeure natural 
drainage. The wound is loosely packed with iodoformed gauze, and the 
anus is inclosed in a moist dressing, which should be renewed every day. 
Daily irrigation, or in very irritable patients a sitz bath, will have to niain- 
tuin eleauliness. 

In cases where extensive detachment of the rectum or perforation into 
the gut has taken place, simple incision will be iiiBuftieient. and division of 
the intervening bridge will be necessary. 




DIAGNOSIS AND TREATMENT OF PHLEGMON. 



257 



^x 



Flu. 18H.— Ojienitiii;: ni :,_:..[.. ... .ji.,. (inxivcd din-ctnr 

ptt!^»(;<l tliToii^ii (isUllii und l>n>lJ(;ht oiil of tliu lU^u.*^, 
("mm whicli is netii (if|Xiiulinf.' a tlarewi holding »[>oiu!e 
paabed well u}i tht^ ri'otuiii. (Simon Scbulhol a com.) 



nal, that is, cutaneous, part of the wouud can be closed by silver-wire stitches. 
Free irrig^iition of the wound dariog^ the entire time of the operation is indis- 
pensable to preserve asepsis. 
Iodoform is dusted over and 
nibbed into the line of tiniou, 
and the anus is inclosed in. n 
moist dressing. 

Case. — Simon Soliulliof, labor- 
er, aged tbrty-tliree and a halt' re- 
ceive*], •luring the Austro-Prua- 
aian war of 18G6, a bajotiet wound 
neur the tmurt. Siippunition am} 
the foriiiation i>f fir*tula f<illovvf<], 
and rusiste*] tlirovi»[>eration» which 
had been jierformfd »ii\w tbtxt 
time, February 5, 18S7. — Under 
etlter, the tistiila was slit ap at 
tlie GenntiQ Iloj^pitiil. Its exttr- 
nal oritice was nearly two inches 
from thermal rniirffhi; the inter- 
nal one, one inch tmd a half up 
the rertiim. The direotion of the 
track wnii straight, and no lateral 
sinuses were jjresent. The en- 
tire riratrieial lininf; of the fistula was excised with forceps and curved soi«»or», and 
the internsd defeet won nniteil with three tierts of flue catuut sjuturuhi. Tho external 

wuuiid wrtrt hroufrht together with two silver- 
wire stiteliCii. Into the outer nn(j:le of the 
-kin-wonnil a short piece of slender rubber 
draluime-lube was pinced, A pled{i:et of iodo- 
farrued pauze was placed into the atiua, and 
the wound wa.s dressed with jraiixe and a T- 
bandtige. No reaction follow ctl. In tlie after- 
noon of February 7tb, four onncea of sweet- 
itil were injected into the Rut, and the oil- 
-I. il.iil iiiinzt' wos witlulrawn from the tmns. 
kil '^^^ An hour after this a hir;;e enema of .^oap- 

i^^^fi ^■f^^^r xvjiter was :idinini»*tered, imd bnaij^lit away a 

liiHild Ntool. Tl«e next ninminji a saline laxa- 
iive was irivou, and was enntlDuet! every day, 
>.'ach »to<d beina followed by irrigation of 
(lie anus to free it frrtrn excrementitious mat- 
ter. Fthtuiiry /"/A. — Tlie silver stitches and 
nililuT tube were renmved. The acrompany- 
iiij.!; nit .showH the condition of the wouud nn 
the tenth day after tho operation. The action 
of the sfduneter was perfect. (Fig. tf*9.> 

Regarding the managemiiut of the first and subsequent evacuation of 
the bowels, the reader is referred to the chapter on haemorrhoids {page 150). 




Flu. iMli. — Itt^Milt litter fxci.sioti ati.l .•<nliirc 
uf UhIuIu in uiKi. I Siiuun ScUulLtiro oiso. ) 



238 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

results achieved by thi« little oj>erution are very satisfactory, and the 
cediire can be warmly recommended. As a rule, a more or less moTi 

joint rcisnlts, which certainly is preferable to a stiff finger. In on* 
tlmihlf exfifcfioH ivas »uf'Cf's.Hful.iif dont' (tftfr u/elon of ihc thumb, involm 
the niHamrpn-pkalunift'al and inferphalajujcnl joinfs. To this end. h< 
ever, prcsorvation of the tendons is a nccessiiry condition. 

Oasb J. — Friuik P., litjuor deiJer, aged thirty-sii. Sttin Janaary 15, 1885, ^wr»rA 
Hr. II. IftilNor, on account of u plile^cnion uf ttie nj^Ux imlex and {>ahii, caa^ted hy og*^^ii 
injury to the nietararpo-plialftngeiil joint. The injury was Buataiued, .Tiuiaary 1, \B33. 
during h figlit hy violent couttict vvitli the antftgonlet's teetb. Tlio pi-ocess had losf Ir^ 
vlruluut fhamcter, and suliperiosteal exsection, by two lateral incisions, was doo* 
.bminiry 1 lith, T!ie i-iiro was uninternipttHi. The flexor ptrofuiidus tendon had alonglw^ 
avraj, hmwv only the liret phalanx oonld be actively bent. Patient discharged tm^ 
February 23, IH8.5, 

OAfiB II. — S. L., baker, aged twunty-nine. Seen in December, 1882, in coosalti^ 
lion with Dr. H. Kndlidi. Recent phlegmon of thumb, snpptiration of tendiuMT 
slieath of flexors and of both the jointn of the thumb. Dtee»»her I2th. — Three in- 
cisiouH roletisod t!ie tonsion. After the cessation of the acute 8tage of the rnflanini- 
tion, Ileceinher 29th, exacction of inetacarpo-ptuilangeol and int«rphalang«a] KMtt 
was done. Uninterru[>ted cure; good function preserved. 

Phhgmon af the ohrranic burxa is ehanicterized by very acute local' 
gonend distiirbunoe duo to the great tension maintaineii by the dense 
ante of tho sac. Free incision supplemented by Volkmann's punctiutioQ 
nf tlio infiltnited .skin of the vicinity is promptly followed by relief and • 
rnpitl cure. 

SupfntrniiuH of thr cubiifd or axillary lymphatic ylanda is a very com- 
mon complication of limited or extensive septic inflammatory prooesfiei; af- 
fecting tlu' hand and arm. 

Two for Hi ft if .suppuration hart' to bf dixtinguiahed: One of an tumUdun^ 
artfr, terminating in the formation of one more or less extenBive ftlnoteft, 
the result of confluence of seveml foci. A spontaneous or artifici^ ef«cai- 
riun geneniUy leads to rapid cnre. 

Anothrr more chronic and very obstinate form* in which a gn>ap 
lyinphntio glands is attacked in succession, leading to the formatioo 
series of deep-seated abscesses and a number of sinuses. Tliis form isj 
ally observed in poorly-nourished subjects. The individuality of the 
is not destroyed rapidly as in the more acute form, but tbeir slov aad 
gradual destruction is accomplished by a tedious ulcerative proceaa^ I^Mf 
before the glandnlar ulceration is terminated, cicatricial contnction of the 
sinuses leading through healthy tissues will occur, and cause retention. 
This is followed by an exacerbation of the local and general symptoms. ao4 
result3«i in the formation of a new abscess and sinus. The iuteffauadblr 
suppnrution often leads to serioas deterioration of IhegeBecal 
marked by emaciation, night-sweats, and loss of appetite. As 
reprMent an aggregation of a large number of septic foci imbedded ni 
tiane, one or even more inci^ions will not be adequate for eflbaent 
•ad in spite of them the {process will continue. 




nap 0^^ 
oo of t^H 

._ J ' 




ERYSIPELAS AND PSEUDO-ERYSIPEL^VS. 



S59 



CHAPTER Vn. 



ER YSIPELA S A XD I'SEUD O-hH YSJPELAS. 




The rules of aseptic manngeraciit described in furmer chapters are the 
best safeguard against the infection of operative wounds by the sjtoeifio eoe- 
cns of eryi=ipelas. (Fig. 131, page 109 ; Plate II, Figs. 5 an<l fj ; and Pig. 
lyu.) The autlior had observed only four eases of wound erysipelas in ten 
years both of public and private practice. In one of these, in 1879, ery- 
sipelatous infection was transnntted from a ca*« of so-called idiopathic 
erysipelas of the face to the genitals of a woniuu in childbirth by ihc author's 
hands, in spite of ordinary measures of cleanliness, llad disinfection been 
applied after the usual 
washing of the hands, the 
patient might have been 
living to this day. 

The other case of ery- 
sii"KMas was observed after 
the tirst visit of a new 
member of the house- 
statr (jf M<nint Sinai llits- 
pital, at which tlie dress- 
ing of a nearly healed 
wound was changed by 
the young physician in 
question. The eaee was 
cured. 

NoTF — Till' tiiiK' of olmii>^<.'s 
in thp house-^^tttff of the siirj.'Ual 
wanls of hospital;* is i;«'nLTany 
»ignulizoit br uiicxjH'ctiHl suiipu 
rations. The amtlior has U-ai-ncd \;m, jvu, 

to dread lIil- \Q^ii of a good iind 
well-trameil as-^t-Htant, who in 

uci'SJ^innallv rej^laccd by uii ini-fTicifiit, um-U'ttnlv, ami iritjlolent per!*oti»pe. Disasler can ha 
avortcil at Kiidi tinioB only bv iiKTciiseJ vijfilance ami rcdoubltnl diligeiKv on Ihe part of the 
vUltinf; surgeon in penfonally siitpervising ilie details* of tbe service. 

The third case w^as mentioned in the paragra]>h on perityphlitic abscess. 

The last case of erysiix-las within the author's experience was that of a 
young woman snffering from caseous cervical glands. For cosmetic reasons 
the glandular swellings were punctured with a narrt}w bistoury, and, a small 
curette being introduced into the brftken-down center of tlie gland, its ciuse- 
0U8 contents were scraped out. The small wounds were drained with cat- 
gut. Erysipelas, commencing from one of the punctures, set in, hut ended 



-Sfftioii of frv^ij'clutiius f^kio ol' bead i7'H' 
diiiitioterBf. (Kf>eli.) 



^ 



240 



EULES OF ASEPTIC AND ANTISEPTIC SURGERY 



fio. 



181, — A, Wrone wa^ of triintuing 
Uw-DttU. B, The ngbt way. 



nation. The pyogenic germs, so abundantly present in the fetid rpiirrw ^ 
masses of sweating feot, will not only come in contact with the raw sur lif^^ 
but will be rubbed into the open lyniplmtics by eaoh i>uceessive step take^»r:■ / 

the individuiil. An ulcerative \nW3Msmni 

Iniation of the parts will result. wl» mcIi 
I # % offers poor eonilitionii for natural dn« ^«- 

is 1 age, Kett'ution of the septic secretit-^ui' 

J I i loads to chronic j^uppuration, and ^" 

1 I I 1 1 the extension of the process backwa. *" 

m ll IV towtird the root of and also under t#^ "' 

~ *■ " nail, until more or less of it becom^^*^ 

undermined and detjiched. ExuberaC^^^ 
granulations, subject to frequent ulce^^^ 
ative destruction, spring up from ih ^ 
hy]>ertrophied and infiltrated overli|i^T 
ping skin, and, if unchecked, the disorder terminates in the lostts of the uaiL ^ 
Occasionally an ingrown toe-nail is the starting-point of ]ihlegmou orerj--^ 
sipelas of the dorsum of the foot. The initial stages of the mischief (M. ^ 
often be successfully met with a careful local treatment. Disinfectiug baths •* 
sprinkling of alum and sulieylie powder (alum, usti, 3 ij ; acidi salicvl., 
?8S ; bismuthi subnitr., ! ij^a) into the stockings, which should bt* daily 
changed, and the packing of salicylated or iodoformed cotton or lint under 
the edge of the nail, frequently result in alleviation, if not a cure, of the 
atfectiori. 

More inveterate or extensive cases in persons nnable to devote the neces- 
sary care and time to the treatment of this trouble will be best cured by 
operation. After careful scrubbing and disinfection, the toe is rendered 
anaemic by constriction of its root with a piece of rubber tubing. Local 
amesthesitt is produced by either an injection of a cocaine solution or the 
use of Kicbardson's ether-spray. The 
point of a bistoury is (Fig. 182) 
placed against the exuberant tisaues 
adj<>iuing the nail, and is thrust 
through the nuirgin of the toe. It 
is carried forward until the integu 
meut is separated in the shajM? of a 
longitudinal flap. Then the knife 
is reversed and carried back well be- 
ynnd the matrix of the nail, where 
the Hap {(') is cut off. 

The i)ointed blade of a straight 
pair of scissors is placed under the an- 
terior margin of the nail (Fig, 182. A, b) just l>eyond the limit of the disease. 
and, being thrust under it, cuts tli rough the nail in an autero-posterior direc- 
tion well back of the matrix. One blade of u stout pair of divssing-forceps i* 
next insinuated into the slit in the nail and under the loose segment. Thi-s 



-€J' 




Kits. IS'J. — Operation for iogrown ^•e-B•iL 
A, B, Lino of fM»otion throui^h th« nail 

and mutnx. 




DIAGNOSIS AKD TREATMENT OF PHLEGMON. 

^^^*g firmly grasped, is eralsed with an outward rotating motion. Good 
***•-"*"¥ must be tikeii not to leave behind any shreds of the cut-off matrix. 




"^"•^y granalatioiic! are scraped away with a sharp spoon, and the wound is 
^^^11 irrigated with mercuric lotion. A strip of rubber tissue well soaked 
**^ carbolic lotion, and just large enough to cover the wound, is placed next 
'^ it ; over this comes a strip of iodofornied gauze and a small ditiinfeeted 
*T^nge, the latter to exercise elastic pressure for the prevention of undue 
^ **ptnorrhage ; finally comes a light, conijiressive moinf tiri'fisinff^ fastencil 
^^" a roller bandage. While the patient's foot is held elevated, the rubber 
*^^nd is removed. The first dressing can be left on for a week or even two 
"^'eekfi. Being moist, it wil! peel etff eitsily when removed, and, according 
^*^ itj? size, the wound will be found ettiier jturtly or entirely cicatrized over. 
^J'are must be tjiken not to comjiress the toe too much, as necrosis of the 
•sltin by j>ressnre may develop and retard the healing. 

The author has treated over a hundred of these cases in the manner de- 
«*criljed with the best results, the majority being ]mtients of the Herman 
X)isij)ensary, who walked to and from the institution during the time of 
treatment. 

(A) Chronic Ulcers of tue Leo. — Neglected oxeoriatious or abrasions 
of the skin belonging to the lower third of the leg are the most common 
starting-point of ulcerous processes. Varices due to stagnation of the venous 
circulation render the progressive iiivasjon of new areas of tissue by niicro- 
cocei, ever present in the putrescent discharges, especially easy. Conne- 
quently, ulcerative destruction develops. The euceessful treatment of this 
condition must be based upon an elimination of the causal factors. Pre- 
vention or elimination of decomposition by antiseptics, and an improve- 
ment of the circulatory conditions by elevation of the limb or its ehustic 
compression, form the cardinal points of our tlierapy. 

The atfected limb is carefully cleansed with soap and a soft flannel rag 
imtil all the criLsts of inspissati'd secretion and epidermis are removed. This 
process will be greatly facilibited by packing of the ]>art8 in strips of lint 
saturated with vaseline or unsalted lard the night previous to the cleansing 
bath. Plain water should never be used on account of its irritating (juali- 
tiea and its liability to cause eczema. After the bath the soap-.suds should 
be simply wiped off with a soft towel. The ulcer is well mopped with a 
1 : l,Of)0 solution of corrosive snlflimate, or, where the stench is very intense, 
with a 4 : 1,000 solution of pernianganiite of potash. Iodoform powder is 
dusted over the ulcer, and a suitable fvateli of rubber tissue is j>htced next 
to it. The eczomatous skin in the vicinity is well anointed with vaseline 
or an astringent salve, and a regular antiseptic dressing is snugly bandaged 
on to the ulcer, the roller bandage extending from the toes to the knee-joint. 
This dressing need not be removed before two or three days, the fretiuency 
of renewal being dependent ujion the quantity of the discharge. As soon 
as cicatrization is well advanced, a simjtler dressing, consisting of a strap- 
ping of mercurial plaster covered with a pad of absorbent cotton, lield down 
by a Martin's elastic bandjige, can be substituted therefor, and the patient 




bid process — namely, of 
cellular decay canned by 
the (k'loterious influence 
of a vegotjible [larasite, 
Koch's tubercle bncillui^. 

The identity of this 
bacillus can I>e indubi- 
tably established by cer- 
taiu modes of stjiininj;. 
No otber known niiero- 
orgiiui-?m will be affect- 
ed by Koch's or Ehr- 
lich's mode of stainiu- 
like the tubercle bacil- 
lus. It appears under 
the microscojie as a blue, 
elongated t>ody of the 
length of half a red 

blood-corpuscle, and is found occupying alone or in company with other 
individuals a giant cell generally located in the center of a fresh tubercle. 
{Fig:^. 191, 192, and 193.) 

The distribution of the tubercle bacillua is very unequal. It if? found in 
largo nnmbers where the invasion of the diseage is recent, or where it is 
rapidly extending. It is very scauty in chronic aflectionii like glandular 
scrofulosis or lupue. 




i 



2G4 



RULES OF ASEPTIC AND ANTISEFHC SURGERY. 



-$ * 



Fi(». 1M2. — t'tirt. of otH* ttilHTole frnrn l<)rvjfi)i;iitf 
illuBtrutiou. Biu-illi intcrsfK'ived lx;twi>bii nu- 
clei fJOU diumc'ten*). (Kocb.) 



Tlie peculiarity of tlu- tubercle bticillus is to incorporate itself with a 
white hlood-C'orpusckv, and to iiiHncnre it in sueh a manner as to convert 
it into a lymphoid cell of soniewliat lar^e proportions. This cell IxMJomes 

sessile in some part of the body. 
After n while new lymphoid celUj 
ajipoar in the vicinity of the first] 
rell, which by this time will baTej 
i.'rawii tu the proiiortions of a mnl- 
tiijuclfitr griant coll. containing a\ 
iiumlier of bacilli (Fig. 195). As 
t!ie infection spreads along the pe- 
riphery, peculiar changes are seen 
in occur in the center of the nodule 
<■< imposed of lymphoid cells. The 
nuclei af the lymphoid and giant 
i-{']h lose their stain iii;^ ea])!icity and 
roairulate into a granular nias^. The 
ii:icilli contained within them dis- 
:ipj)ear, leaving behind, however, a 
crop of invisihk' sjiores that, trans- 
ferred f<o a suitable soil, will readily 
produce a new growth of bacilli. 
With the formation of this cn- 
ugulated raa^s of decayed cell-elements the process of caseation is estab- 
lislied. The presence of this miu^s of necrosed tissue acts as an irritant 
upon tlie ca]jillaries of the vicinity, and a wall uf new-formed gninulatioa 
tissue is tliruwn upamund the focus. Sh(uild the infection of the neighbor- 
ing tissues occur before the protecting wall oi new-fornjed granulati«tn tisane 
is com[deted, exten- 
sive rtiKemts inji/- 
traiinn will be the 
result. 

Tlie barrier <)f 
ncw-formetl granu- 
lations i^ also liabk'. 
here and there, t<i 
invasion by bacilli, 
and therefore casea- 
tion will genenilly 
extend in a rather 
irregular manner. 

An increased ex- 
udation of bluuu- 
serum and white 
blood-corpuscles will 
whirh thni rf/irfftenis 




Fio. l!»ii. — Part ot* tniliurr tubervle thttu a n«»e iil" b*i.<«ibir menin- 

gitin (7<x" 'liamoton*). fKoch,) 



finally bring about cinulsification of the cheeky fociu* 
thr bt'ijinning of a roM ahsn^sx. 



L 



ETIOLOrJY OF TUBERCULOSIS. 



2fi5 



There is no organ of tlie hiimati bodj that is exempt from the possibilit}* 
of tuberculosis. 

Thf jirt'<hj^/)onitio7t fo infcrJiun by the ubiquitous s^pores of the bacillus 
of tuberculosis is inauifostly increased by any kind of deterioration of local 
or general bodily vigor. Mal- 
nutrition, whether due tti an at- 
tack of measle-s or the whooping- 
cough, or to a chronic catarrh 
of the infantiSe gut caused by 
improper nur;^ing, or to long- 
continued suppuration from an 
osteo myelitic setiuestrum, is, as 
a matter of actual observation, 
very often followed by local and 
genersU tuberculosis. 

Thf mosf fuimmaii wrn/ of in- 
fection is UHtloubh'fih} that tty 
the lunt/ti. Catarrhal idrecii(jns 
of ihe bronchial mucous mem- 
brane, regularly accumpanied by su|ierficial denudations of the epithelium, 
serve as portals for the entrance and implantation of the s]iores of the bacil- 
lus. Ami, ax the dcffrtnratitm nf the (fenernl stnlc nf health trftrr meash's is 
finnt/im'tt with a mtttrrhnt condition nf the hrunehi, infantile tuberculosis is 

viosf nuntnonli/ acquired after this 



Fki. 194. — Ginnt cell (Hintaiiuoir hutnlU tuki'u from 
inilhiry Oilicn-lc (T'lu diiiineU'reK (Kooli.) 






rrnptive diseaat'. For unknown 
reasons tlie pulmonary tissues of 
children do rarely become involved 
in serious, tubercular trouble ; but 
the virus i« promptly transmitted 
to the /trfiurhial lymphnltc f/ funds 
(Fig. 11>5), which undergo casea- 
tion, and, on account of their close 
vieinity to the thoraek* duet and 
various vessels, serve as a depot for 
further distribution. 

We owe to I'ontick proof of the 
fact that |>crforution of a cnsenus 
focus into the thoracic duct may 
canst* !t nMoe or less general dissemination uf tuberculosis. Koch himself 
luii* demonstrated another niatmer uf distribution in tln^ involvement and 
caseation of arterial walls. Rut the mo.st common way of systemic tuK-rcu- 
lar infection was found by Wcigert in tlie decoy of the walls and pcrfomtion 
into tlie lumen of veins, which generally hold very intimate anatomical rela- 
tions to caseous glandular tumors. 

Entnince of small <piantities of tubercular virus into the general circu- 
lation by the ways above irulieuted will lead to local tubercular affections of 



^10, I'.i'i, -Ilium •rll. ^viih iMiiiul iirnin^rniC-iu 
•if Imoilli, rroin u caH«.-<niH bnjiicliiiil uliiiid 
(T"<^ 'liaiiR'tiTB). ( Kttch.) 




26<> 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



k 



various orgaus, as, for instance, the bones, testicle, or joints. MassiTe in- 
vasion, on the other Imiid, will cause fatal general miliary tuberculosis. 

Tubercular matter carried along % the circulating blood tut most apt /« 
bfi arrfisffd and to become Hcssile in the vicifnti/ of the terminal arteries. 
The views expressed in the chapter on the localization of acute infections 
osteomyelitis seem to be applicable also to tlie localization of the tubercular 
process. (Page 195.) 

Another rarer manner of tubercular infection is that by lesions of the 
skin. A Jewish circumciser suffering from pulmonary and fauciul tuber- 
culosis, communi- 
cated the disease , 
to twelve infants 
by sucking their 
preputial wounds. 
This used to be 
the accepte<l man- 
ner of stauching 
hiemorrhage after 
ritual circumcision 
in former times. 

Note.— Id 1879 tb« 
atiilnor wii.<4 the victiai of 
loc^tl hilx'rrulosis of the 
pulp of the thumb, con- 
tracted by the iofectioQ 
of a STnall cut received 
ilurinp the amputaiioo of 
a thigh for tuberculoeU 
of the knee-joint, com- 
plicated with lar^e iiibcrcular absceaeea of the thigh ami of tlie Dicdiilla of the femur. A cttsc- 
utinjr elevated ulcer of the thumb developed and persisted for six weeks. The complaint healed 
after the Uiiul detuchmeut acid e\pult»ion of two ettScouA plugs. 

The disitemination of tubercular matter during surgical operation^, done 
for the cure of the complaint, was first jiointefl out by Kueniij. 

It is well known that death Ity genera! tuberculosis is seen to follow 
exsection of the hip-joint with especial frequency. Upon this circum- 
stance is ba,=ed the rtijitistieally proved fact that the expectant or rather 
non-oi>erative treatment (if this complaint yields* better results than an 
activi" operative therapy. 

NoTB. — Thcis* facts find a ready explanatfoii in the eircunistanees under which mo«t e»rlT 
cxiiectioQS of the Iiip-joiiit are carried out. Thr depth of the disentu-d joint ; the difficulty of 
liberating; »be head of the femur, still lieM down firmly by iinde.slroyed ligatncnlfl ; the desire of 
operating pubpcrloatealiy, that is, with the employinent of a good deal of bluut force; the foro- 
bic niiinipiilatton<< in dt«tendin^ the &\^ev- of the deep wound by relractutv — all serre to propd 
any freed casetius matter into the cut orifices of veins and lymphatics. The reault is that, by 
the lime the local luberculoeis oonihated by the surgeon is healed, the patient Ruocumba lo 
meatngenl or pulmonary tubcrvuloBii>, probably chnrgeablc to ot>erativc intcrferenoe. 



Fni. ItlO. — Uiunt cfU ooutainiTifc oim baiillus from t'ij. 
(70U diumutur>). (K'jcL.) 



I Ml 



TREATMENT OP TUBERCULOSIS. 



267 



n. COMPLICATION OP TUBERCULOSIS WITH PTOGENIO OR 
SUPPURATIVE INFECTION. 

Tubercular decay of tissues by cuseatiou is a ^'enerally slow process, as 
long lis the affection remains subcutaneous— tljat h, occluded from uccess 
of air with its pyogenic orgtmisms. But let a tubercular focus of the lung 
j>erforate into a bronchus, or let a group of caseous g!fin(i.s, or a cold abscess 
communicating with a distant focus of the spine or some joint, be opened 
without asejitic precautions, and the affection will have at once entered 
opou a new and more destructive phase. The formerly thin, flocculcut dis- 
charge will assume a more purulent character, the production of pus will 
become prodigious, more or less fever will set in, and tlu; symptoms of a 
rapidly progressive local destruction of tissue accompanied by hectic, will 
become more and more pronoimced. 

A new infection was thus imphuited upon a soil already impoverished by 
ill-nutrition and preyed upon by a destructive para.><ite. To the slow decay 
of tuberculosis, the rapidly disorganizing forces of purulent infection were 
added- The seriousness of this contingency was justly comprehended by 
old-time surgeons, who abhorred meddling with a cold abscess or any covert 
strumous affection. Incision of a cold abscess then meant purulent infection 
of the cavity, extending to the often inaccessible ]jrimary focus of the dis- 
ease^ hectic fever, and rapid emaciation and decay of the jialient. 

Just appreciation of these remarks will at once impress upon the niiud 
the great necessity of aseptic measures in our operative dealings with 
tubercular affections. 



P 



HL TREATMENT OF TUBERCULOSIS. 

(if mrti i I ' It /I c iptes. 

Considering the fact tliat about; seventy j)er cent of alt deaths are directly 
or indirectly caused by tulx>rculosis of various organs, principally consump- 
tion, and that the management of the infectious sputa of coTisumptives is 
eareless in the extreme, it must he admitted that efforts at prevention offer 
no great hope of success. The sputa containing active bacilli or their spores 
are ejected on the gruund or floor, dry there, and are converted into dust, 
which will penetrate everywhere and will cover everything with it^ deadly 
burden. The tent of the Indian and the palace of the millionaire are pene- 
trated alike by dust containing dried and pulverized sputa of consumptives, 
and millions of spores of 2>yogenic cocci, derived from suppurating wounds, 
the discharges of which are carelessly thrown every day upon the ground, 
to be whirled up from there by draughts of air. 

A more promising line of iireventitm can be cultivated in the proper 
nourishment and reffime of the individual. The better tlie general con- 
dition of health, the fuller and more abundant the blood supply of this or 
that organ, the Jess the chance of its becoming the seat of tuberculosis. Or, 



268 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



if passing conditions of uiupmiii caused by illness or loss of blood hare lod 
to the establish inei>t of a tiiherculur focus, rataing of the general health bj 
proper (lift and exercise in the pure air of the sen or of higli mountains, will' 
check and often wholly eliminate the ravages of the disease. A yenerntt* 
diet, with plentif of fiCfrrisc in the open air, /.v t/te best prrvfntii'f ami syn 
temic curative of tubfrculosix. To i/n; nhst'rvnnct' of i^crupulous cleanlitirxg' 
in the hou^ifkoM and in our pt^rmnal habit. << must aim be acceded a ffrf4fi 
proieetiife, and in .some measure a ruratirt' infuence. 

Loaf! Trvaimnit of TubeTcuhm.^. 

Knowledge of tlie true nature of the various forms of surgical tubercu- 
losis has led to a clear understanding of the principles governing its suc- 
cessful treatment. Since we do not possess any therapeutic agent capable 
of destroying the bacillus of tuberculosis in situ, without interfering with 
the tissues that harbor it, chemical and mechanical influences must be 
brought to bear upon the tuberculous focus, with the object of destroying 
and removing all cell elements infested \vith the specific rims. In short, 
tite modern trmfmcnt of fnvat /ubemth.'ii,s ift ideuticnl witfi t/Ml acceptrd 
for the cure of 7/inb';/u(rnt mw (/rotvih.s- ; if ron.Hififs in a more or tf$if ctm- 
pleie removal of the ajfrcted titcaues or on/nits by caustiat, the knifvt or the 
ffoufje, under aseptic prerautiouit. 

1. Ctitaneous Tuberculosis, Lupus (Fig. HC). — Various chemical cat 
tics, the actual cautery, and excision are known to effect a cure of cati^' 

neous tuberculosis. In- 
tern it 1 medication has no, 
effect upon it. Tlie modt . 
destructive forms of lupus 
are those representing a 
conipHcatiou of tubercu- 
losis with pyogenic infec- 
tion — as, for instance, /«- 
pnx exedena. The miliary 
nodes nearest the surface 
caseate, break down, and 
perforate, and the wajTi 
is o|)en for the entrance 
of pus-generating cocci- 
Lupus of the face should 
he treated by cansliofti 
and scooping. The more 
radical treatment by ex- 
cision is not t^) be commended in facial lupus on account of the disfigure- 
ment it IS ajit to cause. Relapses are frequent. an<l should be attacked over 
and over again a? soon as they appear. Lupus of non-exposed parts of the 
skin should bo exsected. The following case demonstrates the identity of 
lupus and tuberculosis ; 



oue bacLlIa.H {'W (tiafiieUr.-*). 



I • II containing 



Lfc. 



TREATMENT OF TUBERCULOSIS. 



209 



Cask. — Otto Krim, aged five. Lupus exedens over llie left external inalleolus of the 
size of a silver dollar. The affection fXHted for nearly three years ; abuut a. year ago 
glandular swelling appeared in Scarpa's triunjjle of the left side and in the tiorrespond- 
ing groin. Extensive scrofulous idreriition of the skin followed, and raeeons glands 
lay exposed in the bottom of the inguinal wound. Frhru'tr;/ 4- i^^- — Extirjwtion of 
the lupous patrli and of tlie glandular inttssf > from Scarpa's trianglo aud above Pou- 
part's liguineDt. The iieritoniemn wsis cxposeil, and had to be strijiped up to the ex- 
ternal iliac vesj^ela to permit complete removal of the glands. Primary union of the 
wounds about Poupart's ligament. The malleolar wound healed under a Schede dress- 
ing. Febrwiry 37th. — Patient discharged cured. 

3. Tuberculosis of the Mucous Membranes. — Scrofulous rhinitis, or 
coryza. is n very rebellious affectiou of the muial miicou!* membrane. It is 
easily recognized by the clirouic swelling of the mucous covering of the 
nasal cavity, t!ie swollen upper lip, open mouth, hard heariug, utid noijiiy 
breath iug. Its surgical importauco lies in its tendency to produce an early 
affection of the cervical lyuijdiatie glands — scrofula. Ulcerative destruc- 
tion of tlie mucous covering of the uasal bones opens the way for the iugress 
of pyogenic organisms, which bring about freijuently more or less extensive 
necro.^'is. An iuten.Hply fetid odor makes tlie breath of tbcse patients in- 
tolerable. Termination of tliis condition is best accotnpliijhed by removal 
of the necrosed bones in Rose's dependent ))osition of the head. (Fig. 170, 
page 213.) Tlie sequestra are easily dislodged by the sharp sjxton. The 
ha-raorrhage is at lir^t rather profuse, but soon subsidej^ on irrigation witli 
ice-water. Daily irrigation of the nasal cavity with a mild solution of cor- 
rosive sublimate (1 : r>,OQ0) .sliould be used until discharges cea^e to appear. 

Tubfrvuhisis nf the atuiJ miicoHs mfmbrmw is a most freijuent cause of 
tuberculous /f.s7?/^f in {nitn. Simple slitting up of the.-^o listulou.s tracks, lined 
with caseouj5 granulations, and often dotted with miliary tubercle, will not 
accomidish their cnre» Every nook and rece."<s of the fiittula mui^t be carefully 
explored, and all caseous or granular matter must be removed by vigorous 
scooping and, if need be, excision. A thorough-going operation will always 
be followed by im|)rovement, and iu not too extensive cases by local cure. 

Ttihcrculnsi.-i of (Itp nri'fhra nnti hlddfhr is a most distressing comjdaint, 
and w hardly amenable to any form of treatment. Sedatives atid, in cases 
where the aflfection of the neck of tbe bladder renders life intolerable on 
account of tbe unceasing painful strangury, median perineal cystotomy, fol- 
lowed by drainage, are indicated. 

A common 8e<]uel of urethral tuberculosis is cnseouif epididymUis and 
OTchiiim. Testicular tid>erculosi!i caused by urethral di.>iease is generally 
bilateral. Single tuherculosis of the testicle, on the other hand, is gener- 
ally of embolic origin. Its sovereign remedy is castration. 

3. Tuberculosis of Lymphatio Glands, or Scrofula (Fig. 198),— Ca«eons 
chronic lymphadenitis is one of the most common niroetions of cbildhood and 
adolescence. Its foundations arc generally laid by chronic allectionsof the oral, 
nasal, and aural mucous membranes, by tubercular atfcctions of the cervical 
vertcbnK, and by lupus and eczema of the face and scalp. The incipient stages 
sa 




270 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 






of the trouble can sometimes be controlled by timely attention to the caani 
disorders, an appropriate general treatment, and the local application of 
one or another preparation containing iodine in the shajte of an ointment. 
Afi Boon as caseation has been well established, general and topical treat 
mcnt of the milder sort will be of no avail. 

Tlie modem therapy of scrofulous lymphatic gknds i« dominated by 
the idea that they are not only the cause of present discomfort and suf- 
fering to the patient, but especially that within them is contained the sefd 
for renewed infection, which by its dissemination tlirough the circulatiun' 
may cause other local affections or a fatal general malady. The close ana- 
tomical relation of must lymphatic glands tx) important venous trunks or 
their immcdiat^^ affluents renders their early attachment by inflammatory 
deposit very easy. Cheesy degeneration will ultimately reach the wall 

of the vein itself, and dissemina* 
tion of the tubercular virus through 
the circulation is the result. 

The Burgical therapy of cheeky' 
lymphadenitis will have to be varied 
according to the stage of the dis- 
ease, the chief object being always 
thorough removal or destruction of 
all infected tissues. 

Where there is central caseation 
onlff, and no Jisfula. nor an appre- 
ciable abscciis, bodily rxcision of 
the tflandukir ma^se-f is most nppn>- 
pria/f. The neck being the mosi 
fommou seat of the trouble, a few 
words may be said regarding the 
tletail of the operative treatment of 
scrofulous cervical glands. 

The incision should be ample, 
and, if the tumors be very exten* 
give, the formation of a flap is advisable. The capsule of the upi)ernio>t 
gland being split, the glandular body is shelled out of its nest. This ia 
much facilitated by an as.sistant's holding aside the detached capsule with 
a small, sharp retractor while the .-^urgeon suitably changes the position of 
the mass by turning it one way, then another, until all the looser attach- 
ments are divided. Great care must be exercised herein not to lacerate or 
crush the bri'tle substance of the gland. 

Each gland has its afferent and efferent vessels, and these form a sort of 
pedicle, which must be tied off before it is cut. 

In cases of very extensive involvement of the cervical glands eituated 
both in the vascular and intermuscular intersiJaces (see j)age 208), it is very 
advisable to rut the stertio-maatioid muacle arrows and in two. The spinal 
accessory nerve vvill Ijc found near its posterior margin, and should be saved. 



Fio. 198.— Gistiii ecll oouiamiTi); one bttcillua 
fh>ni ■ soral'ulous i;luQd ol* the neek (74)0 
diametcre). { KmcIj . ) 



TREATMENT OF TUBERCULOSIS. 



271 



The stumps of the divided sterno-mastoid inusclo are raisod from their 
mesial attachments, and one is turned up, the other is turned down, Tlie 
otherwise difficult and even dangerous dissection of the glands from the 
vicinity of the hirge veti.sels i.s made much easier hy the free exjiosure alTonhMl 
by cutting the sterno-mastoid, which sliouhl be reunited by a number nf 
catgut i<titehes after the conijiletion of the exsectiou. 

The manner of placing the drainage-tuljes, the tsuture. and dre.-ising^s, 
do not differ from the usual arrangement. Before closing the wound, a 
thorough mopping out with a strong solution (1 : 5(J0| of corrosive subli- 
mate is necessary, to make sure of destroying ail spores of tubercle bacilli 
that may have escaped with cheesy matter from accidentally injured glaiuis. 

When dealing with proyreased fentral ehecsj/ nliscetifics of the cervical 
glands, a different course must be pursued. Incision of each abscess, fol- 
lowed by a thorough scooping away of all granulations and broken-dawn 
glatjdular tissue, is the proper treatment. Tfte ."ihrtrp sjMton ran and mhnnld 
be used rather m'f/orousli/, and uo fear need be felt of injuring hu'ge vessels 
lying close hy the walls of the ubseessea, as there is a tough and thick wall of 
organized connective tissue interposed to protect them. A drainage-tube i.s 
to be inserted into each cavity. 

Casconx tibficfsfics that haw prrforntt'd .spontinimttsh/, or have been 
opened inadeijuatcly, genendly lead to tnbercular infection of the subcuta- 
neous tis.sue in the vicinity of the ajierture. More or less extensive ujidrr- 
mininfj and biuish th'sffdnrofiofi nf the skin are the consequence. The un- 
dermined, irregular edges show very little tendency to heal ; they become 
inverted, and if healed, present an ill-.>ilia]ven. uneven scar. 

To aid aud hasten the iuade(|uate elforts of IS'atnre, it is necessary to 
extirpate or gouge out the glandular bodies, to trim away all the under- 
mined portions of skin with the curved sci.*sors. yjrt///H'/ wo ra/nrd fit lln' tx- 
tent f)f thf n'xutfinf/ wnttud. However large the denudation, it will he;d 
rapjdly and kindly under Schede's dressing, and, on account of the mo- 
bility anil abundance of the cervical integument, die resnliing cicatrix will 
bo nearly linear in 8ba{>e. 

NoTB. — Glanilular, cbee!*j abscessc:- on tlic nn^kii of grown girls can Ik.* heHled, wittiout 
leaving a fonspicuoun wear, l>y re|nate«l |iunciiireH with a stout itf<piratin}i-needle. Tlit- i'onlcnt.s 
o/ the abxfi'ss bi'iug removed l>y a^jjirntioti, t-oriosivi'-i^tiljliiiiiktc hitioii is injected tlnoiigh ilio 
canntila, anil in w^a'm wUbdruwii. Tbir* <s icpeatcei until tlie lotimi returns ekar and lim[iid, 
when tlic eannntii is taltca utit. The punetnre-ln>le is pruteett'd by a drop tif iiwio formed e«dlo- 
dion. The process is repeated whenever the abscess refinn, until the Ciivity becomes cloiicd. 
The author hns enred two cnses in this rautmer. 

4. Tuberculosis of TendiEous Sbeatbs. — Weeping sinew t»r acute syno- 
vitis of the tendinous sheaths sometimes degenerates into a chronic affection 
of their synovial lining known under the name of prnliftrntinf} ht^ijromn. 
This reltelltons affection is chamcterized by an elongated, (Inctiiuting, 
irregular swelling of the carpal region. It is painless, but imi^des the free 
u.se of the fingers. The swelling is due to a gelatinous (hiekening of the 
fiheaths of the sinews. The teudou.s fitially beconu; adherent to the dogen- 



252 



RULE8 OF ASEPTIC AND ANTIBEPTIC SURGERY. 





Flo. 184, — Langc's- p^sUioii for reual mid perinMial 

OfH-Ttttious. 



small-sized needle, aud a negative result may be arrived at in the pre0encx:» 

of a large collection of matter. 

Cask. — Mr. I. A., brewer, aped twenty-two, developed Inrnhar pain and swell' 
of the right side svithout any krtown cuiise. April 17, 18S1, — High fever a*"<'oni|Mini 
ttie seizure, and, tJiough no diictiuitiun cuuld be felt, the dia^Qosis of perinephritv :• mSM 
ahst"i.'9.s was mude. April 21»t, — In the presence of Dr. Heppenheimer, the family pLy^ ^^j. 
Bician, four prolmtory puncture^n were made with an aspirator needle Mithout ptHitirs^- mn 
result, and, unfortunately, the conti^iii plated incssian was deferred until the next d air- . ^mv, 
wheti perforatiou into the ]»leura and rajjidly fatal pyothoras deYe!o|>«d. 

Mud a larger-sized needHT Jlf 

been u.'Jed, pus would \\n\ ^ Tr 
been found, and the fat^ae-*' 
termination might hare bee "-S^n 
averted by timely incision. 
Early incision eau nevi 
do any harm where periiK 
]>]iritic abscess is sQgpecte(^^==^ 
and will be of some use eve """^ 
if pus be not found at il^^cae 
first attempt. On accoaTi*:"^^ 
of the deep situation of th^^*^® 
abscess, and the necessity 
exploring its interior for sinuosities, wliich may require separate drain 
an ample incision is advisable. It sliould be done in anae'^thesia nnde 
strict antiseptic preoautions, and by gradual dissection. 

The patient is brought into the position rccomniendod by Dr. F. I^njp^ 
for nephrotomy. A roll made of a blanket is slipped under the lumbar re-^ 
gifui, and the body is placed semi-proue 
upon the affected side, as shown in the 
accompanying cut (Fig. 184). The vicin- 
ity of t!ie swelling is carefully cleansed and 
disinfected, and the surrounding part- of 
the body are protected with rubber cloths 
and towels in the usual manner. A lon- 
gitudinal incisitm two or three inclMv- in 
length is made, commencing about an inch 
below the last rib. and extending to near 
the crest of the ilium, and is gradually 
deepened until the abihjminal muscles are 
all divided. Frequently pus will be readied 
before the edge of the (juadratus lumboruni 
muscle is exposed. Should this not be the 
case, a grooved direetcu" may !x' inserted un- 
derneath the external margin of this muscle, 

and, being pushed downward aud toward the median line, will soon enterdif 
abscess. As soon as pus is seen to appear in the groove of the iustrument, 






DIAGNOSIS AND TREATMENT OP PHLEGMON. 253 

^ clmssing-forceps is insinuated into the cavity, and is withdrawn while held 
'^i^e open. Blnnt dilatation of this kind can be repeatedly practiced until 
*''^e apertnre is large enongh to admit the index-finger for exploration. 

Should the abscess contain nrinons matter or stones, or should the septa 
^^ the calices of the renal pelvis be recognized by tonch, the causation of 
^«^^ process by perforation outward from a suppurating kidney will suffer 
^^^ donbt If found, stones may be then extracted, and the cavity, being 
^^c»ll washed with boro-salicylic lotion, is drained by the insertion of one or 
**^«ie stont rubber tubes. 

Note. — ^A rerj efficient mode of disiniiig Ib the foUowing one : A number of fenestra are 

^^t into the sides of a luge-«alibered nibber tube, whidi is placed well within the oaTitj. An- 

^''(iier analler-sised tube of 

^tte same length is pro- 

'^'^ded with a ooaple of 

'fenestra near its mesial 

<bndf and is inserted Into 

tthe abscess alongside of 

-ftbe laiger tabe (Ilg. 18«)l 
JL stream of lotion inject- 
ed into the smaller tabe 
win enter Uie bottom of 

the abscess, wfll wash out p,^ 186.— Anangement of dnunage-tubes for perinephritic or any 

Its recesses, and will carry other docp-«ested and Urge abeceiw cavity. 

awsiy secretions and dli6m 

throng^ the many fenestra of the larger tube. Safety-pins thrust through the distal ends of the 

tubes will prerent tbdr being lost in the abacesa. An ample antiseptic moist dressing should 

envelop the mtire Inmbar region, and the patient should be brought to bed. 

In Opening perinephritic abscesses, the author has met with two cases 
in which the pus had a peculiar whitish-yellow color, the consistency of 
curdled eream, and the odor of freshly-made warm whey. lu both of these 
OMM death caused by uraemia followed some time after the incision, and 
pogt-mortom examination showed that the parenchyma of the kidney had 
been dflltroyed, and that the organ was a pns-bag with fibrous walls, which 
wen peiioiated and communicating with a number of secondary abscesses 
looafted m the pelvis. The secretions contained tubercle bacilli. 

OaOi — EmilCohiifOlerk, aged thirty. PyeloDepbritisof many yearn' standing. Vory 
marlised aiUBmia and Ugh fever, with a large Inmbar and pelvic swelling, that was l!ri^t 
noted la B^bmaiy, 1886. Incbion, done April 28, 1886, at the German IIoH[>ital, evncii- 
•tfld an enormons amoont of the above-mentioned peculiar smelling pus. The tcinpera- 
tare was at onoe redaoed to nearly the normal standard. As the cavity contracted, and 
the seereti(Hi became sosnty, the honae-surgeon withdrew the tube, whereupon retention 
in the pelvio.psrt of the abscess with renewed fever compelled, May IHth, dilatutiou 
and replacement of the tabes. The evacuation of the abncess wan not followed I»y an 
improTomrat of the quality of the urine, which continued to contain pus and hyaline 
casts, showing that the other kidney was also affected. Death from urnjmia, May lUth. 

Cases of surgical kidney may get cured after the extraction of stones, if 
portions of the renal parenchyma be preserved, and continue to secrete 
urine, and the ureter be unobstructed by calculi or cicatricial stenosis. 
84 



*254: 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 





i>reM«iii^: Tor liinitiiir ur lie|>iiti«- iihMvr.s. 



Should the latter conditions prevail, a urine fistula will persist, and rerao' 

of the kidney niuy come in question. 

In cases where the kidney has lost its identity, but no complicated 

unfavorable topographical conditions of the ubscess cavity are present, 

cure may also follow incisi 
und drainage. 

Where the relations of tt-*^ 
abseess are unfavorable — th-*^' 
is, the kidney consists of • 
number of communicating c-*'" 
t^epMrate ubscesscfr — debilitaticm j^ 
e;u]>purutiou may baffle the e ^^ 
forts of the surgeon for a lors.^^^ 
time. It is best in these cn**-^'' 
to await the contraction of tl^-^ 

walls of the main abscess (►! the kidney before proceeding to the extiri«i-^ " 

tion of the organ. 

Lumbar abscesses, the relation of which to purulent affections of tt^^^ 

kidneys is unlikely or iloubtlessly absent, iidniit of a much better progno-ir=? 

They are fre<pient[y referre«l by the patients to traumatisms, and, properL 

incised, heal very prom{)tly, 

Cahe. — A. F., piovnlirnkiT, ajred twenty-fi'iir, .siistainpfl, in Mny, 1HS6, in jiiiup: 
and sljp|>injr, a severe stmiii uf the left aide i»f tlie stnalt uf tlie bark, which was* i 
lowed by sharp jmti and stiffness for a few days. It subsided spontaneously, but I 
beliiiul a soretiesH ot viirvinp; intensity. J/tfy 2f>, WS6. — Fever set in with intense !n 
bjjr pain, hut sxveliinjr i-iniie on very slowly. Thuujcjli looked tor, it conid nt»l l*e xww"^ 
out initil July Kitb. when Dr. E. tSi-hwedler iiscerluiiied its* jiresence. The kiduei 
(flit, and spiniil I'uhiiiiii were foniid nortiid. JhIij I^th, — Incision by ^udual disM.t'ii« 
wii« praelioed luider ether. The ubdoniiual muscles helnj; divided, the v*\^' »>f tt 
(iuudratiis luinhnriini was exposed. I'robatary puncture in the bottoiu of the woni 
bad to be dime five times before pus was fonnd hi}j;h np close to tf»e edge of the twel 
rilf, beneath the <inadratiis naisde. This was drawn aside, and the cavity v 
by Ililttin-l'o.<er's method. About an ounce and a half ul' udorless pus , 
dijLfital e.vphtration showed that it bud been cimtatned in a snmll, Nnmoth-walied ' 
Drainatre and antise[iti<> dressinfts hfiiig ji|i](lii'd. tlie wound was irrifraled and «!; 
daily; biter on, at Ioniser intorvids. The patient was dischargeil cure<l Septemt'. 

L Anal Abscess. Fistula in Ano. — The anus, tlie final strait thruu; 
which all uxcretueutitioue matter must pass, is subject to a great number 
traumatisms from within and without. Foreign bodies, such as pit* ai 
kernels, chicken- and lish-bones, are frequently caught by. and imbedded 
tiie mucous lining uf the sjihinetL-r muscle. The rough introduction 
syriugc-points for the application of enemata, scratching and mani]>ulatii_:^'** 
of itching and bleediug piles, the surgeon's digital exploration. 8<Kloni,^'- 
aud the forcible expulsion cil massive firces, lead ti) superiicial injuries of t^«<" 
mucous membrane and outer .«ikin of the atud region. Persons whose han«;i^ 
and faces are habitually unclean do not scrujilc much about the untidy coti- 
•dition of their breech. And the fa?ces of even the most cleanly swarm witA 





d 




TREATMENT OF TUBERCULOSIS. 



275 



trouble, free incision and exposure by chisel and mallet mnst be practiced, 
fallowed by ii painstaking: reninvnl of al! decfenomted tissues. se^iuesiTa, atid 
cheesy dejtosits. The subsequent treatmeut of tliese wounds is identical 
with that advispfl after necrotomy for osteomytditic eeipiestra. 
6. Tuberculosis of Joiots. White Swelling : 

General Part. 

Typical tuberculous arthritis, caused by perforation of an epiphyseal 
cheesy foctis into the joint, or by an indejiendent infection of the synovial 
membrane from a di,«;tant focus (bronchial glands) by way of the general 
circulation, is popularly kni>wn as white swelling. Mild cases of children, 

treated by an invigorating regimen ^ 

and proper orthopedic measures, |r ^^ '^ ' * 1 

will yield very good results with- 
out serious operative interference. 

Even when "starting pains" 
indicate loss of the cartilaginous 
covering and caries of the joint 
surfaces, a cure by cnchylosis or 
with the preservation of more or 
less mobility is possible. Small or 
great {leriartieular abscesses, in- 
cised and drained un<h'r aseptic 
cauteltP, will heal kijidly, and the 
ingrafting of the more intense [>u- 
rulent infection upon tissues whose 
power of resistance has been low- 
ered by tuberculosis aud disuse, 
will be avoided. A careless incis- 
ion, or a spontaneous perforation, on the other hand, is generally the start- 
ing-point of widespread destruction, caused hy suppunitive infection from 
without. Then, to con.serve the limb or life of the patient, the diseased 
joint must oft*'n be sacrificed. 

ff. Te«*hniqi'k of Joint ExHKOTroN. — The technical rules to Ix' o!> 
eerved in excising joints are governed by the following reipiirements : 

(a) Septie infection from without must Itp t'lrrlmied l)y strict adherence 
to the rules of jiseptioism. If a local se)>tic condition, due to ]>nrulent 
infection by uncleanly management of a cold abscess or sinus, be present, 
this has to be first eliminated by free incision and drainage of burrowing 
phlegmonous collections and by frequent irrigation. Only after the return 
of the tem|K'rature to nearly the normal standard is exsection permissible. 

NoTX. — Pblegmonotta iuSamraation of a tuberoulous joint i» a much more seriouH trouble 
than tlu( of a previous bealtJjy joint, Tlie cavities and sinuses prefonned by tlie tulierciiloaa 
prooOM serve to dispense the oew poison mucti more rapidly and widely tliao would otherwise 
be the case. Hence tlie furiirntiou of pprforations itnd biirrt>H-» u]* am! ifonrnward between the 
miucles of the citremily occurs much »ooncr iti tuberculopiis thnn liappeii:* w ith a previously 




Kk*. *ji*1. -iTiunl ecU cnnt-uiniu^r two hin.-illi 
trorn furnfoid (/ninululitiiiH of tlm CMpsulo 
of ttio hip-joint iu morbus coxoriun (7<.K) 
tUanicter!'). (K<X'h. ) 



256 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



By spontaneous evacuation outwartl, extenud incomplete fijstula will S^ •^e 
established. Some of these eiises Ciiii still be cured by a free bloody diUl 
tioD of their orifice, and a careful antiseptic treatment as above indi 
But most of them are complete fislulw, the inner openingtt of whirh can 
be found on accaunt of their ininuffnens. 

Cases of incomplete internal and of complete fistula should be cut. 

In incomplete inner fisfula a Sims' vaginal speculum is used for exp«>sir "^ ^ 
the entrance to the sinus. A bent probe and alongside of thie a be^r^ * * 
grooved director is introduced into it, and is pushed well outward town 
the skin, which is incised over the point of the instrnmcnt. After this t 
intervening bridge is divided. 

Cotiip/t'fc anttl Jiftfufu, especially where several sinuses exist, sbou 
always be carefully explored before the incision is made, as otherw 
pockets and braucfiiug sinuses may be overlooked, A silver probe shou! 
be introduced into each sinus and left in situ until its turn for cutti 
should come. A grooved director is cairied into the gut along one of tl 
probes, is caught up by the tip of the left indei-tiuger, and turned out 
the anus. The bridge of tissue taken up by it is then divided. The ed 
of the cut are well drawn apart by four-pronged sharp hooks, in order i 
fucililate securing and tying of sjnirting vessels. The next sinus is take 
up after the first, and every nook and recess is carefully examine^l and spli 
oj^en until natnral drainage is secured everywhere. Free irrigation of th 
wound should be employed during the whole process. When hsmorrha^ 
is projierly attended to, all the old granulations should be forcibly scrapec^^^^^^^^" 
away with the sharp spoon, and the wound should bo packed with narro 
stri|)s of iodofornied gauze. xVftor this the s])onge is withdrawn from thi 

rectum, and a moist dressing is applied and held in place by a T-bandage> 

(Fig. 12«, page 157.) 

NoTK. — When the internal orifice cnti not be found, or a burrow extends upward bcjcaC"^^^ 
it, tilt- (rraovfd director ehuulil bti inscrU'd an btgh up us the cavity or siniu permlUt, and tbttto^^^ 

should bo tliriist through the mucous nuMubrani.' into the gut. 

The length of time rerpiirod fur the cure of fistula iu ano will depent^^- 
on the extent and form of the wound made by the surgeon. Iu simplc^^ 
cases a fortnight or three weeks will autlice : complicated ones may neeti^S- 
months. In favorable eases, that is, where the fistula is straight and single,.-' 

cure ffin be vn'tf muck hanfened by exer.non tind .•iufitrr of the euiirf fi.*f¥ 

louM intcA\ The restitution of the parts to their normal condition will aC:^ 
the same time insure against incontinence. The callous lining of the ninti^^^^ 
is carefully excised with forcejjs and curved scissors, and the remainin:^ 
wound is united by several tiers of buried cutgut suture;*, the ends of whicl-» 
should be clipped otT short. The up|}crmost tier of sutures should no»- 
inclose the mucous membrane, but the curved needle should be introducet^ 
close to its edge on one side, and brought out in the same manner on tli^ 
other side. Thus inversion of the mucous lining will l>e avoided, and th<? 
stitches, being buried under the overlapping edges of the mucous mem^ 
brane, will be protected from infection by intestinal contents. The extor- 




TREATMENT OF TUBERCULOSIS. 



27T 



ostcnm can be stnp|»ed off easily with au elevator or Sayre'g "oyster-knife." 
except at the sitt* of the insertion of mupcles, where the aid of the scaljiel 
or a shaq> ni.^|iat<jrT mast be accepted. The re-formation of the normal 
contour and function of the prospective joint depends in a great mciisnre 
upon the preservation of the periosteum. 

With draina£;e by rubber tubes, an exact suture of the external wound, 
and Schede's modification of the a^ieptic dry dressing, the ojK'ration is com- 
pleted. Where E.-?march'e; constricting band was left in fittt until the conj- 
pletion of the dressings, these must be made rather amjde, and a good deal 
of elastic pressure by snug bandaging must be brought to bear ujkhi the 
wound to control oozing and siiiling of the dressings. The dressed limb 
must be susiK-nded or otherwise elevated in a vertical position until the 
hypertemia due to vascular paresis disappears. Care must be taken to ascer- 
taiu, by the lo<ik of the tips of the toe* or fingers, that circulation is not 
wholly cut off by strangulating compression of the bandage. 

Should the oozings penetrate the dressing in the coui-se of a few hours, 
the soiled surface of the bandage must be thickly dusted with icxloform pow- 
der to favor ex>iccation. A few compresses of sublimated gauze are plact'<l 
over the bloody siMjts. and are (^ecured by a few turns of a roller bandage. 

In case of continued o<»zing, further loss of blood can Ite checked by the 
temporary application of a Martin'.** elastic bandage over the dressings. If 
the soiling is too extensive to admit the use of such partial measures as 
those just indicated, the external compresses con){K)siug the dressing must 
bo removed and replaced by clean ones. Tke deepest part of the dressimfy 
however, should nut hf disturbed. 

b. Aftek-Tkeatmext.— Where, as for instance, in the elbow, mobility 
of the joint is aimed at, abaolnte fixation by splint should continue only so 
long as the drainage-tubes are withdrawn and the incisions jire firmly 
healed. Pasxive^ but esj>ecially eitrfi/ jHUa^ivr mntiontf, .so warmly recom- 
mended by older authors, are hartn/ul, and not to be compared at regards 
their value with arfive ezerdne*. 

The disadvantages of early passive motions can be summed up in this : 
Before the re-establishment of the normal condition of the tissues pcrtiiirt- 
ing to an exsected joint — that is, before the disap[X!araMce of the sjvflling 
and rigidity of the soft part.s — all motions, active and jja^sive, will hv [uiiti- 
ful. Active motions will l>e limited to a harmless compass by the pain for- 
bidding extensive movements ; but ]>as8ive motions, done without, regard to 
the pain and struggles of the resisting patient, will be, and as a matter of 
fact often are, carried far beyond the limit of harmlessness. The f<»rcil)le 
stretching and crushing together of the newly united parts and of the young 
connective tissue are inevitahly followed by minute ruptures and lacerations. 
Renewed exudation and a diffuse state of adhesive inflammation are .si*t up, 
which will cause the persisteuce or even an increa-se of the j)ainful swelling 
and induration jirimarily found about the exsectcd joint. The greater tho 
surgeon's energy the worse the re-suIt, and in many cases unuhylosig i' 
brought on bv the very measures intended to prevent it. 
37' 




278 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



If the surgeon, on the other hand, patiently aw»iits the time of sponUmi 
ons detinnef^cence, which, with antiseptic metisures and proper fixation, will 
occur at about the fourth or tiflh week after the operation, gentle motions 
will cause no pain, and will encourage the patient to uctive exercise of the 
joint. The pain felt on excessive movement will serve as a wholesome 
check against undue zeal ; the improvement of nutrition due to active exer- 
cise will hasten the definitive involution of the inflammatory products. 
Thu.<. day by day will the strength and amplitude of the active movements 
be incrcfuiei], and by dint of painless attritio!) new articular surfaces will bo 
ground and polished into shape. The psychological and nionil part of the 
after-treatment is of the greatest importance here. The conviction that 
active move lit f (it )( of (he exsccfed joinf arv posHbh without pain wilt inxpirr 
the patient with eottntgc. Unceasing active exertion will work wonders, 
based upou tJie iiatieui's conlident expectation of a good final result. 

The acute pain [)roduced by frequent and merciless passive motion, an 
the subsequent tetiderness cngendL-red by it, will convert the after-treattncn 
to a source of constant terror and moral depression to the patient. Llls 
courage will be shattered, and no amount of persuasion or coercion will in 
dace him to inilict piiin upon liiinself by active movenietits. And it will, 
l)e a lucky eircunistance if the physician's illy conceived attempts at estab- 
lishing a normal function are frustrated at an early date by the patient'^ 
resistance. Subsecitieutly, rest and the disappearance of local pain will 
naturally elicit first timid, laler bolder, attempts at active movement, and 
after all, an unexpectedly good function may thus residt. 

The aid afforded to Nature should be very discreet indeed, here as well 
as in other branches of surgery. 

Aside from active movements, niassaye and farndlsm are powerful aids 

in re-establishing normal 
circulation and lost mns- 
eular power. 

Special Part, 

a. Shoildeu - Joint. 
— The application of arti- 
ficial anemia in exsection 
of the shoulder-joint is td- 
Wijys ditticult and some- 
times entirely impracti- 
cable. After due cleaus- 
iug and disinfection of 
the field of operation, the 
hand and forearm of the 
affected limb are envel- 
oped in a clean lowel wrung out of mercuric lotion (Fig. 202). and. the 
rest of the body being well jirotected by rubber sheets and clean towels, an 
ample anterior incision is carried from midway between the acromion aiid< 





I 



Fio. !«0S.— Exwsctuii 



I -li'iililer-jolut, Ilcud of humerus 
■ut ot trlfiioid cuvity. 





TREATMENT OF TUBERCULOSIS. 



279 



the curacoid procoj^a down to the limit cif the uj>ju'r third <»f the humerus. 

The tendon of tho Uing liuiid (}f tlie biepjjs is lield usidv hv a hUnit huuk. 

The cajisuhii* ngraiiiont and periostL'iim are raised 

from the bont' by muana of an elevator, or, where 

the insertions of the innscleji otfer greater resistance, 

by a sharp raspatory. Tliis step will be very mueli 

facilitated by gradual inward and later by outward 

rotation of the hnnierus, to he done by an assistant 

holding tlie hand and btnit elbow. Affer ih-capiia' 

lion of the humerus^ 



^:^' 






Fii}. 203. — Evftmtioii of shouWer-j"!! 



iMoii <ir <lni'Liiab;o on 



lliL' fK>Hti;ri<>r Ui«|>cfl t,j tlif *h'ju!.kr. 



the captitde. U to he 
exmrted by forcfipft 
and blunt sciss&rM. 
This, the most ditti- 
cult part of the op- 
eration, will be very 
ea^y if the primary 
incision is amjjle. If 
found diseased, the 
glenoid fossa is thor- 
oughly scraped, and, 
a counter-incision being made at tiie posterior aspect of the joint, ii drain- 
age-tube is inserted there. (Fig. 203.) The tirst incision is closed by several 
tiers of catgnt sutures, and, the wound being dressed, the limb is bandaged 
to the thorax in a flexed position. Later on, an arm-sling will serve as an 
adetiuate 8U])j*ort, (Figs. 204 and 2<t5.) 

The dressings are changed on the tenth day, when the drainage-tube 
can also be removed. In grown subjects the ojieration will generally rescdt 
in a somewhat loose joint, hiekiug especially the jtower of active abduction. 

Oase L — Anna Iluupt, aged sixty. Large Hdltddtoid cold abscess; no fi.stula. 
Mai/ Sr>, 1H7:>. — ExjitM-tion of rifilit sljimlckr-jaiiiit at llie (iorumu llotijjital. lloml 
of hnnieriis biirt' ol" eartilfiKi* and carii»iis ; rarifs 
of glenoid cavity. Awfrnt ,iif. — Disfdarged L-urt'd, j 

Cask II. — Willie Kuuz, iiged four. 
Januarif 25, ISS.^. — ExstH-tion of left 
nhoijlder-jiiint fi>rclieesyr»*tillis(jf tlu^ 
liciid <»f liiiitK'ru"* ut l\w iivrnnui [i\H- 
ponsary. Murili Wth. — I'ls-lctrned 
cured. 

Cask III.— August Arnold, aged 
three and fi half years. April 17, 
188S, — Exseclion of kfll slioaldyr- 
joint for caseous tw\ in tlie hciul uf 
the iniineru.s at tlie (lerman Hos- 
pital. May 30th. — DiscihargLMJ c iiriMl. 

Cask IV. — Harry Gross, aged two. Si-fifti»hrr SO, I8S4. — Exsectiuu t>f right 
shoulder-juiut for caeeous ostoitis at Mount Sinai Hospital. Several relapses rectnired 




-First dreeslug after exueclion of 
nhouldiT- joint. 



260 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

in cure. Undoubtedly either the bistoury or, more likely, the sharp spoon 
was the carrier of the virus. 

There is not one among the many topical remedies recommended by the 
writers for erysipelas that is pre-eminent in limiting or stopping the affec- 
tion. The author's local treatment consists in moist antiseptic dressings 
inclosing the affected parts, with a general supporting treatment by proper 
nourishment and stimulants. The much-praised specific effect of the tinet^ 
ure of iron is, to say the least, very problematic. 

NoTS. — ^Lately Kraske has published a series of cases in which muUipU aearifieation ^,^^1 
puncture of the affected parity especially along the line of the spread of the disease, has led xa 
prompt cure. The little operation is followed by the application of a moist antiseptic drw^ S^ ^""g 
As the principle of this mode of therapy is rational, consisting in depletion and disinfectioc^^, ii 
would deserve extended trial. 

An unmixed infection by the coccus of erysipelas will never cause ^at*!)- 
scesses. Whenever abscesses form with erysipelas, we have to deal witk — » * 
mixed infection, namely, by the coccus of erysipelas, and by one or anotlMfc* ^f 
of the pus-generating cocci. 

Phlegmon and erysipelas also represent a mixed form of infection, ■n^tnt 
this combination is rare. What is generally called phlegmonous erysip^"^^-^* 
is commonly no erysipelas at all. It is a phlegmon produced by the I^J?^^ 
genie chain-coccus, the spread of which along the lymphatics resembles t '^:» «t 
of true erysipelas. 

Pseudo-erysipelas is an erysipelatoid skin affection of the fingers £iK.x3d 
hand that resembles true erysipelas in most of its morphological feata'X"'^^ 
But it presents this important clinical difference, that it never is acconm. x=*^~ 
nied by fever. The affection is very tractable, as the application of a th jl c*c 
per-cent carbolic lotion for a few hours will generally consummate a c^ 
Its cause is a specific coccus described by Rosenbach. 




Fiistenor Inujfitinliiiul mcbiioii of tllxnv -joint. 



I 



and ]>ut np at 
the Stttue angle. 

As !:oon as the drainage-bok'S are healed, passive, '>»t fspi'tiftlft/ ririivf, excr- 
cii^r.s- should commence, aided by niassii^e and faradisni uiiplied to the imisclcs. 
After partial exseetion of the joint, little lateral mobility will be observed. 
In the.<e ca-ses no special apparatui* will be required. But where much lateral 
mobility, due to extensive removal of bouorf, is! present, the nse of an appa- 
ratus con lining the movements of 
the joint to tlcxion and extension 
will be retjujred. (Fi^rs 'i\i, 'IVi.) 




Fiii. 2(*S. — Finishpcl divBsinj^ und ctpvu- 
t'um alter i-itifotiiin of ellKiw-joint. 




Ki'- -I'l'. — Tciiriii;; into i~l)jij>i- kI' |':ihti'l> .ahl splint. 



NoTJi. — The appnrmiifi tiui be luadi.' by ihc hiirjii*jn wifboitt the aiti of tlie itiiitnimcnt-niaker 
in ll»e followin-r manner: Two ulripB of very light hoop-irnn or i^hect rinc. nbout one imh wide 




1 



2H2 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY, 



r 



and from four t» ms inchfH long, arc looaelj riveted tti l'uuIi otiier at tlieir voda, so i&a to form • 
hinge. Twci imirs of such liin<res are iiecessarv. The patient's mm beinjc protected by a few 
tiiniM of a flannel ba.Ddftgi.', h lij;lit f*[lkate-of-fto<]a wristlet and arrii-liand (Fig. 212) «re appUi^ 
To t1ie.*c are titted thf lviu!:es, one externally, the '►ther internally, bv giving their middle a t>tiiui*jle 
bend to allow for tho cxpausiou of the soft tLsatien on tlexitiii of the joint (isw front view;. Rj 



Fi<-.. 'JlO.— Paftorn t r 



11- |. 



lH..!fl ^|ili(lt. ( L 



a few more tnrtin of the silicate bainlaf^c. the hinpes will become immured in the wrlutJet aniJ 
ami-band. Ah hood (is the splint i.-* dry, it is split lonfiitadiually on its anterior aspect, to por- 
niit its removal and further fittin(». Sh^K* eyelets aw put in alonp ilie edges of the loogititditial 
cuts for Inciup;. Twn pairs of j*tHull-tiized brnss aerew-eyes are let in <»m each side of the wri*llr< 
and arm-band, to 8crve for the iittaelitneiit of Kotid niblwr biind.H, which are to aid the cffon« of 
thu flexor umtfclcs in bending the ellKiw. To prerent slipping down of the apparatus, a c^ ta 
made of a piece of sole-leather, softenDd in hot water, which is 
niulded to the shoulder. It is left on till dry, A button is let 
into it to [(erve for ffusjiondin^; frotn it tln< appnratus by a short 
strap. Another strap .'^lipped over ihiji button i.* pai»s«l around the 
thorax of the patient, and is buckled iu the oppOHte axilla. (Fig. 218.) 
Flcsion and extension are to fa* dune by the patient at regular 
iulei"vaU from six to ei;;bt timett a day, by ruisiii;^ lirst an erajjty pail 
from thf? ground twenty or tiitrty timcH. The elbow flexed by the 
rubber band-^ is extended by the weight of the pail. As the strength 



V 



Fin. SIL — Angular pastebourdi xplial iu m'tu. ( Enniarelu) 

of the flezor« improve!*, active Dexion is to be tried, and the weight of the pail i» to bcgrado- 
ally increaacd by putting more and more !?and or gravel into it. The apparatus is to be daily 
remo^red, for clean-'ing and the ajiplioUion ol inn.^saf^e and farndism to the ami. The »J«c of 
the apparatU!* can be abandoned with the dianpiR^aranee uf lateral mobility. 

The first of the nine cases of exsection of the elbow-joint performed by 
the author was done without aseptic precautions. Study of the history of 
this case and comparison with the oilier cases is earnestly recommended to 
the reader. 



TREATMENT OF TUBERCULOSIS. 



d8S 



I 



Cask I. — .I(>!*epli Kerk, sllk-weavor, ugetl thirty-niuc. Synovis'l tuberculosis of 
rijrlit elbow, with c<»ld almi'edjs situated beneath the supintitors ; nu ti!>tiilu. Pceember 
Kk L'^77. — lotal exsL'ftkm <if tlie j<iint at tlio itmrns itf the patient 
withimt any t^"^^Jptil" (trccaxitiunM. Trochlea, iilnji, and radius cn- 
riiiiis, Drainu^'u, suture, and }tuH[jensiif>n in an interrupted wire 
spliDt. Wound was dressed with a com press, to be kept moist by 
iiniiiermon in tepid water. TIim thermometer indiaited 103° Fahr. 
iiij the evenJjijr of t!ie same dny, and nvver desceoded below this 
fifliire until I>eceniber 24th. Frequently the temperaturui rose to 
lo5° Fahr. Dfcembtr Idth. — Wound fetid, iuHumed, suppurating; 
ptitfhes were removed, whereupon the wound paj»e(^ open, and was 
seen to be covered with a thick, adherent coating. Decemher 15th. 
— ^tireat swelling and dusky ap[ienrani'e of cubital region. Incision 
of ab!«"ess near trieep;; tendon. iJecfuilifr 17th. — Ri<;or, elbow still 
more swollen. Ikecinber 18th. — llijfor. Deeemher lUth. — lii^ror 
and jrrwit debility. Dtxeiuhfr 22J. — Rigor. Ikcemhir 24ift. — 
Evaluation of another ahacesis from the upper angle of the wound, 
whereupon tlie temperature fell to 99° Fahr., and the dusky Bwell- 
ing of the limb moderated. Apparently the fever wa-* due to osteo- 
unyelitiH of the lower end of the humerus. Dteemhrr SHth. — Ery- 
isipelas set in, conituenein<: from itn abnision caused by the splint. 
Temperature, lo.'j^ Fahr. Ihfetuhi r Ulith. — Erysipehis extended tn 
»thoulder-joint, where it disappeared, iftireh 10th. — Indued tliree 
abscesses of the forearm,^ wmind granulutiajjr and contriicting; re- 
moval nf sequestrum of hmnerus. June 14th. — Removal of six 
small sequestra from hntiients. Active and pa-'sive movements coro- 
lueiK-ed. Jitlt/ 12th. — Flexioa to IHi''; extension normal. Sinuses 

were scraped in ana-stheaia. 
Lateral mobility dimini.-^hing. 
SepternhfT 2Uth. — Application 
of artieulating apparatus, (k- 
t^ibfr sulk. — Patient was dis- 
charged cured with nurmul 
tlexiftn and extem^iou, with 
limited ifromttinn uiui stqiina- 
tiou, and slight lateral mobil- 
ity. May., 1887. — Arm sound 
and quite useful, in spite of slight lateral mo- 
bility. 

Case II. — Ilerniann I'rieg, laborer, aged thir- 
ry-eighl. Nnrtmhrr h\ IHSO. — Total ex-section 
of eUioM'-joint at the German Hospital for syn- 
ovial fungous disease nith tistula, under onti- 
sejitic precautions. Feverless course, primary 
union. Fihrmini S7tL — lite patient was dia- 
cliarged cured, with limited motion nnd no lat- 
eral ninbility. 

Cask III.— Lena Boia, a(w?fl twelve. Mnr(h 
IJ^, 18fi2. — rartial exsectiim of elbow-joint for caseous ostitis of the olecranon, from 
which a seipiestrum was removed at tlie Uerman Hospital. April 30th, — DiscliargeU 
cured with limited motion. 




Fiti. 212.— Appara- 
tits r«)rntU-r-tn-«t- 
mirn <>r exMotum 
oJ' L'lbow-joinL 



Flo. Silt. 



-ElUiw-jiiim appjiruius in 
pc»ition. 



1 



264 



RULES OF ASEPTIC AND ANTLSEPTIC SURGERY. 





• "^^ 


1 




f 


( 




^ 


■k^"- 








>^., ' 


^^ 




V-^' 
t 


'•-*^ 


-■ 





Kin. r.i2.— Purr 
illustration. U " 
clti (700 diuniwturs). 



■Uitr 



. K.„yh 



The peculiarity of the tubercle bacillus i.s to iiicorj>orate itself witli 
whit^ blood-corpuscle, and to influence it in such a maimer as to conrQ 
it into !i lymptioiij cell of somewhat large proportions. This cell becoi 

sessile in some part of the Ixx^^^ 
•Vfter a while new lymphoid c^i^ 
appear in the vicinity of the P^ ^ 
cell, whieli by this time will Ik ^^.^ 
•rrowii to the ]>ro]iortions of a ix:i rri 
tiouelcar giant cell, containing j, 
number of bacilli (Fig. 195), ^^ 
(lie infection spreads along the pe- 
ripliery, peculiar changes are seea 
to occur in the center of the nodaJe 
t'oni posed of lymphoid cells. Tl 
nuclei of the lymphoid and jeiinl 
rrlls lost' their staining ea])Q(.'itr unJ 
coagulate into agranular mas?* The 
biKtUi contained within theiu die- 
;j]ipear, leaving l>ehind. however, i 
crop of invifiible spores that, tnin^ 
f erred to a suitable soil, will rp«dily 
produce a new growth of bacilli. 
With the formation of this co-j 
agulated mass of decayed cell-elements the process of rnxration is 
lislied. The presence of tliis muj^a of necroiscd tissue acts as an irritan 
upon the capillaries of tl;e vicinity, and a wull of new-formed grauuliitifl 
tissue is thrown up uround the focus. Sfiould the infection of the neighli 
ing tissues occur before the protecting wall of new-formed granulation tisftiP' 
is completed, exten- 
give cfismus injil- 
traiioH will be the 
result. 

The bitrrier of 
iicw-formed granu- 
lations is tilso liable, 
here and there, to 
invasion by bacilli. 
and thercfo]-e caseu- 
tiou will generally 
extend in a rather 
irregular manner. 

An increased ex- 
udation of bloou- 
eerum and white 

blood-corpuscles will finally bring about etnulsififatinn of the ehff^y 
u'hk'h fht'u irprcjiPnts thf bfijinning of a eald abxrrss. 




VSA. 



-I'art of milisiry ml)en»)e fn>ni a cjiws of boMIar naiil»- 
),'itis (7'Hj"»IiameUTHi. <Koc}i.) 




TREATMENT OF TUBERCULOSIS. 



285 



I 



arul teudineal anchylosis will he avoided. The active muve merits, feeble and 
hurdty pLTCcptihlc at firsts will become visibly stronger us tlic hcrtling pro- 
grc'sjses, and thus :i 




Pio, 214.— Xiiitigetjbcck'B dotsfll incision for ex<tH'tinij of wrji*t. 
Primtirv union. Septe.tnh«i SOth. — 



very uceeptable degree 
<if u-L'fuliu'ss (if the 
hand niity be regiiiiied. 

Case I. — Bertnttti IJn- 
KtiiRfirilexj, clerk, ajicd 
Iliinty-funr. Jun<f7, 18S^\ 
— Tiitiil essectitm uf wrist, 
at Muunt Siniii llo^ipi- 
tal for aynoviiU tubercu- 
hm»* with sc'verftl fistulto. 
Priuiury union. Atigu»t 
7 til. — l»jsfliar>:ed curfd. 
Wuen leaving, liy plaji'd 
on tin uCL-oniion. 

Oase II.— a woiiiiiQ, 
Aged tbirty-eipht, Au- 

t SB, JW5.— Totftl ex- 

lon of li'Jt wrist at the (k'nnan l!(»s[>ital 
Disc'Ii urged euro*!, with iiinderati* fiinctiim. 

Cask III.— Mnttiiew Deiafisey, hdiurer, af,'t.'d twenty. JuneS3, lS85.— 1<ii&i v\svv- 
tion of wrist for oBseal tnhenalosis uf cnrp.il hones »t Mount SiD»i Ilot^pitaK Primary 
nnion and very fair function were sefurtHl. Tlie discliarfre of the jiatient waa dela^' ed 
til! the end of the year hy several [lulniouary hajmorrhapes. 

Case IV. — Pniil Klein, lahorer, aped forty-one. Fehruartf 25, 1SS6. — Total exsec- 
tioa uf wri*it for (wseal ttibcrcnlosts with Heveral tishdjt* at the (iernain Hotipital. The 
putient was* ^nlfennii from far-j;one pulmonary [>hthisis. Pritrjury nnion, hut speedy 
rclaptM? of tuberouhtsis hi the interior of the wound and the cictitrix. April 11th. — 
Piseiiariied not eared. 

C'Asg V'. — Max Frie<]mann, ape<l ten. April ^fh. — Partial exoifiion <if wrist joint 
on aecoiint of c^:9eoU!< OHteitis of Htyloitl i»roeej<i< of ulrta, witlt involvement of the radio- 
ulnar and nidio-etirpal joints. Priiaary union. April 20th. — Discharged cured, with 
goo<l funetiiin. 

Cask VI.— Ferdinrtnd (Hde, aiurcd live and a half, ^ftirrh 22(1. — Tntnl cxseetion ot 
left wrist at the German lloy|iital for osteal tviherciilosia. Woaud healed hy primary 
oaioQ. PutieDt rumaiued in ho8|)ital for treatment of simulttineoaH tnheroular diiteaKC 

of the knee-jfiint. 

(L IIip-JiUNT. — The aitUior'g 
very limited experienco iti the op- 
erative treatment of hip-joint dis- 
ease, extent! in^ over 
tlirec eases only, does 
nut afford suflieient 
material tu base any 
t rust worthy conelu- 
.■iion upon. Moreover, 
two of the three ejises 




Fin. 'j15. — K'x^icli'ii 
38 




i:|'-l>iMt. Po^-iti'-n of p.'itli lit 



26ti 



KULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



Tarioua organs, as, far instance, the bones, testicle, or joints. MfuseJTe io- -^ 

vasion, on the other baud, will cause fatal getienil miliary tuberculosis. 

Tubercular matter carried aJong btf the rircuhtintj blood ii< most apt tc^^ 

be arresfcd and fo btrome ncsgile in the viriuiiif of the terminal artrrir*. 

The views expressed in the chapter on the localization of iwnte infectio 

osteomyelitis ficem to be applicable also to the localization of the tubercu, 

process. (Page 195.) 

Another rarer manner of tubercular infection is that by lesions of t 

skin. A Jewish circumeiscr sutferiiif: fmm pulmonary and faucial tu 

culosis, comniu 
cated the dise^ 
to twelve infaa 
by sncking th 
preputial woun< 
This used to 
the accepted ma»K»- 
ner of stanchm za^ 
hsemorrhage ar^t^' 
ritual circnmcisa*:^^ 
in former tirnc^ 




«»e 



Fi't. l'J6. — O'mnt cfll cmitiilninif on\! bacUln» Iront Fiji, istl 
("tio iliuiHOturs). (Koch.) 




NoTK.— In 187» 
aiitliur was the victicKS ** 
locul tuberculosis of 
pulp of the thumb, 
tracted by tbc infe 
of n atnall cut r«op«^''*** 
during the &mputaiicB«> •» 
a thigh for tubt>rcu1 
of the kBee-jcnnt, 
plicated with large tubercular abpcessefi of the tliigli and of ilie nicditlta of the femur. A 
atin;; elevated iilecr of the thumb duTeluped and |>orsii>ted for six weekd. The complaiot h 
after the final dctnchment and expulHion of two caseous plugs. 

The dissemination of tubercular matter during aurgiml operations* done 

for the cure of the complaint, was first pointL-d out by Koeniij. 

It is well known that death by general tuberculosis id seen to follow 
exsection of ihe hip-joint with especial frequency. Uj)on this circnin- 
stancc is based the statistically proved fact that the expectant or rather 
non-operative treatment of this eomi>laint yields better re»ultj< than an 
active operative therapy. 

NoTK. — These fucts find a ready explanation in the eircumstances* under which mort e*''? 
exscctions of the hip- joint are earried out. The dt'ptli of tin' diseased joint; the difficuUjo' 
libcrnlin.!? the head of the femur, still held down tirtnlv by unde.*lroyerf ligaments; ihedwiTfof 
operating subpcrio9t«ully, thot If, with the employment of a jzood deal of blunt force; the /"fa- 
ble manipulationB in dii^lcnding the e<lget> of the deep wound by ■'Ctractors — all serve to pro^' 
any frettl easeouH matter into the cut orifiees of veiniii mid lymphatics. The reauh is tJut, bj 
the time the loeal tuherculo.'iiB combated by the surgi-on is healed, the patient sueeual* •• 
meningeal or pulmonary tuberculofti^i, probably chargeable to operative int«rfercace. 



TREATMENT OF TUBERCULOSIS. 



287 



it with shortening of linib, tlie result of hip dii^easo contrftct«d in childliood, 

wliidi was trcati.Ml (jrtlio[<edicully. No listulii. Tuborculuus (.istitis of iliiitii iiiiid udj'»in- 

inj: part of o^ pubis, J/«/r/i 17, ISST. — At the German lltispitiii, exsectlun of trrfai 

trochnnter ami retnnAiit of neck of thigli as a means to jfain access to the diaeaned 

fntiis. An abiicesR was opined in front of the joint, and; beiiij; followed up, led to m. 

iniitibtT of seiiuentni located at (ho jtiucnire of iliiiin iiud ns [mbis-, which wt^re remov(^d. 

The ttofteued ami broken-down walls of the eavity eoutaiuiii;.' the sen^tiostra were serajied 

and ^oii}ie<l. ]>raitin^'e and siUiire uf the wound. Uneventful eonrse of healinfr. lu 

^■Angiist thei pntient wjis still ntidcr treatment. A sirms persisted at the site of the 

^BoperutioD. The dischnrjxo was very s^eanty and seriMis, however, promisiD)^ early clos- 

^■bre. Anchylosis Hrui again. Putieut wtdkiug witbout support. Cured October 1. 

^P e. Knee-joint. — Wbite swelliug of the kueG-joint iu adults of the 
laboring ehiss can. for various external roasons, rarely lu; trraled by ortbo- 
potlic measures. In ehiljren, a rational mcchauiea] and geiitral treatment 
will often reward the patience aud skill of the pbysiciuti by excellent results. 
Exsection of the infantile knee-joint is to be avoided a.s long as possible, on 
aeeount of the great sborteniiig Unit is caused by tbe rennjvii] of the epi- 
physes adjoining the knee, on which depends the growth of the thigh and 
tibia. In adults exsectiou is tlie shortest and safest way of eliminating the 
tedious morbid process, and substituting firm ancliylo.sis for a useless joint. 
Aiiknetfiniif, or exsection of the capsular ligament alone, as sugge.sted by 
Volkmann, ha.s not been attended with good success in the experience of 
be autlior. Two caj^es — one in an adult, the other in a child — resulted in 
(Ttdajtse of the tubercular alTeetiou, although great care was taken in remov- 
ing the entire capsule. A third case was pcrmauenlly cured. 

C-AflK F. — .S. Lindholm, metal-worker, aged twenty-&even. Fehrtutry S8, 1882. — 
rfhreftoniy and removal of the patella were done for funfjoiis artliritia of the kuee- 
int. Primary union of wunnd followed. Mmrh ii:3ii. — A relapse occurred in the 
catrix, which gradually involved tlic articular as]tectrt of the femur 
d tibia. AnipuUtlJaii of the tbigli was performed by Dr. I. Adler. 
Ca«e II. — Fretl. (tide, ajjed tive and a half. Tiihercalar arthritis 
©f the knee-joint. Janmtn/ JUJ, 1^87. — Arthreetomy was perfitrmeil 
Bt the German Hospital. March 22tL — Revision tmd scrajtiug of the 
entire cavity on nccnniit of tubercular relapse. In May the boy wa^i 
«lUl nnder treatment. 

Case III. — George Kulm, butcher, aged twenty-six. ,/m/;/ i}, 1S82. 
Arlhrectoioy and removal of curious patella was performed at the 
ennan Hospild. Xuvtmhrr 5th. — Discharfjed cured with slight luo- 
bility of joint. 

In children, exsection should be strictly limited to the re- 
moval of acttially diseased parts of tlie bone.s. By Sebede's 
|)lan of dressing the wound, the hollow space remaining be- 
tween tlie ineongment joint-snrface.«. will be tilled ujr by an 
organizing blood-clot, and firm union may bo attained. 

Ca«k IV. — Eva Greenhurg, aged eight. Osseal tiibercnioais of the 
knee-joint witli se<piestnim in the external condyle; j!:ranular oatitis of the interiial 
condyle; niiiltiple choo.sy deposits in the thickened capsule; subluxation backward of 



|^»ti 



Fiii. 2i.'0. 
IhiliiiV Hiiprn- 
jtuU-llar incis- 
ion Jt»r exsec- 
tion of knei- 
joiiit. 



238 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



the tibiuvvUli rectaiigulnr coutriiclion. Attgitnt 13, ISSG. — Purtinl exsectlon of knee- 
joint iit Miiunt Sinai lliis|jitiil, AlU-r the rt'tnoviil of tht* scqiiestrutii, n deep ^eoe^»4 

wa.s left bL'himl in tlio intoreondv. 



\ 



u 



^ 



r fef 



.^! 



\\^ 



s:, 



fio, «21.— Exsevtiori of kiiou- 
jiittit. ExpuflUrc of urtieulHr 
pUues. 



liir notfh. Patella and entire vn\t- 
f^ule were removed; tiie hani-«jtriiig 
toni1<ind were divide<l to prevent 
reeoutraction. The tihia wa.* &»- 
Ijoitieially pared, and the Itones 
were held in ai>position by a nail 
driven dia^irunallv ihrMUgli lemur und 

■\^J^» I [wrj tihia. I'laster-tif- Paris epliul over 
a Schede's dressing. Several re- 
lapses in the i)0[>liteal ^pace tt- 
qiiirci rcpeiit«d ^erapiogs. Tlie pi 
rii-iit haJ i>no litttick of crr8i|>cl 
i>y reason of thes<> Cumplictttionis 
i-nre was dehtyed. Fcbrwiry ^, 
Ii-iy?. — F'atient was discharged cuprd 

with lirni :ini-li>-lusis. 

Total exsection of the knee-joint is U!>uiillv 
(lone by the author in tln^ foUovvirig msHincr : 
AfttT cnruful shuving;, scrubbing, and dijJDfw- 
tiun of the region of tlie kiiw, the foot and Je« 
and the tliigh of the diseased 
limb are wrapiK'd in elca 
towels wrung out of corrosivt 

sublimate lotiou. The limb is held elevated in the vt* 

tieal position for live minutes to deplete Us vessels, an 

the constricting elastic band is applied well up near tl: 

root of the thigh. The knee is flexed, und an iiicisiot 

eommeneing at the mid<lle of one comiyle of tbefemu; 

and extending in a semicircular 

/he paffJln to the middle of the 

dvio, is carried into the joint. (I 

NoTK. — The transiverse indaiou 
tltove the patt'ltn, inupostd by EiiL:<n< 
llahn, of HiM'lin, hns uiunj ailvant.iLji ~ 
over ihe ineisjon mailc below the kmi'- 
pan. The ebief one i* the free ftcee^M 
it affords to the bursa of the fpinJri. 
cep.i, which mu^it \h- i-an-fuIlT uiiiected 
along with the cap^Jule. 

The crucial ligaments are 
cut close to their attachment 
to the femur, and the patella, 
semilunar cartilages, and entire capsule. loi^vLlin wiib the bursa of the 
quadriee|)s, are exscett-d with mouse-tooth forceps and curved sci*>ors. 
Care must be taken uot to overlook tsome small bursae situated behiad 



.\ 



Flo. 3XL 
ExMction 4>l 

knee - joint- 
A view of 
the MKWod 

»unjie«'v 




wonnd. it shuuld be sufticieiitly lengthound. The iiuR-r cuds of tbc tuborf 
sh<Jiild reaeli iuto the popliteal space just behind the sawed surfaces, and the 
tubes must not Ih* compressed and oceliided hy ilic tension of tlie soft parts 
surrounding them. 

The limb is placed upon a lont^ euiihi 
covered with si eh^an towel wrunt; out 
corrosive-suhlimate iotion, imd, wiiile ( 
sawed surfaces are !ield in exaet appositi* 
two or four lon<^ steel nails, previoufily w 
disinfectetl by heating in an alcohol flar 
are driven diagonally 
through femur and 
tibia, so as to firmly 
lock the bones in 
the desired ])o.'^ition. 
(.Sec Fig. T9. piige 
84.) The cutaneous 
incision is united by 
a siuRlcient number 
of catgut .stitebei!. 
The limb Ih raised 
by tlie foot from the 
cushion, which 

then removed. Strips of disinfected rubber tissue are slipped under the 
eafety-pins; seeurin*,' the ends of the trimmed drainai^e-tubes, and an oblong 
compress of iodoformed gauze is laid over the entire line of union. A suit- 



270 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



of the trouble can gometimes be controlled by timely atteotion to the caus 
disorders, an appropriate general tTeatment, aud the local application < 
one or another preparation containing iodine in the shape of an ointment. 
As soon ii8 ca.<'ation has been well established, general and topical trea. 
ment of the milder sort will be of no avail. 

The modern therapy of scrofulous lymphatic glands i^s doniioated 
the idea that they are not only the cause of present discomfort and si 
fering to the patient, but especially that within them is contained the 
for renewed infection, which by its dissemination through the circuLit: 
may cause other local affections or a fatal general malady. The close av:^^. 
tomical relation of most lymphatic glands to important Tenous trunks, or 
their immediate affluents renders their early attachment by inflammatorjr 
deposit very easy. Cheesy degeneration will ultimately reach the vraji 

of the vein itself, and dissemina- 
tion of the tubercular virus ihroogh 
the circulation is the reaulL 

The surgical therapy of cho*«jf 
lymphadenitis will have to be varied 
;iccordiug to the stage of the *li>^ 
ease, the chief object being al^^aj:* 
ihurough removal or destruction"^ 
all infected tissues. 

Where there is central caseir^i'"^ 
onli/, and no fistula, nor an upl"^ 
ciable abscess, bodily rxciniomr "J 
ike glnndular ma^fiefi i>< mo.*t af^^''"' 
priaff. The neck being the r«^«' 
eommon seat of the trouble, a 'f*^ 
words may be said regarding ^^^ 
detail of the operative treatmer* * t>f 
scrofulous cervical glands. 

The incision should be an»r'^' 
and, if the tumors be very ex; ten- 
sive, the formation of a Hap is advisable. The capsule of the upperrno-t 
gland being split, the glandular body is shelled out of it« nest. Tht* '* 
much facilitated by an assistant's holding aside the detached capsule "W'f^ 
a small, sharp retractor while the surgeon suitably changes the position* "^ 
the mass by turning it one way, then another, until all the looser att-*«c'i' 
ments are divided^ Great earo must be exercised herein not to lacerate*'" 
crush the brittle substance of the glatuL 

Each gland has its afferent and efferent vessels, and these form a eortoi 
pedicle, which must be tied off before it is cut. 

In eases of very extensive involvement of the cervical glands sitiuf^' 
both in the vascular and intermuscular interspaces (see page 208), it w w? 
advisable to rnf the sierno-mafttoid muscle acro-ss ami in two. The sj'io*' 
accessory nerve will be found near its posterior margin, and should besuvrd. 




I'i'i. hiS, — GiLiui cell L'ODlaiiiuii.' oni; l>injilhia 
t'roTn n wrolulouri ^lund of tlie ncfk (700 
dioint't-cre). (Kneii.J 



TREATMENT OF TUBERCULOSIS. 



20 1 



til 



Fio. 328. — Ertcmal kiujr ktcral pHBtel>onrd splint'* after cxaec- 
tinn of kriL'c-joint, ap|>lifd ovtr loiiiiili/tu lirc^iing. 



Irnee. April S.^d.—^e\uiratum of epiphysis of tiU'itL Separated epi[>liy8i? firmly 
miiled to feitnir. In April Hyniptoms of meninpi-al tiibercalosis developed, to which 

liutk'Dt suceuinbed May 31xt. 

Ill one of the remainiiin: eleveu cases anipu- 
taf ion of the thigh became tiecossary on account 
of suppuration. 

Cahk 11. — 11. Deaniond, profe.tsional atlilett.', aged 
lirtv. Kvtcnstve destnietton of right kiit'o-Joirit liy 
tui»ercnli>.,)?i, cotnpliftiteil with pyii|Tenir 
iuloftioii. Thu knee, lea, and thigh ron- 
tairj u luTjxe number of ubscesses. Phj- 
fus© secretion froui seven 
fistiiln?. The caae wa.s not 
suitubk' for exsection, and 
uinpiittttioti was adx'isoil. 
But, nt tlie patient's ur- 
gent rei^nest to make !iii 
attiMiipt to save his litnb, 
February 14, 1884, total 
exsei'tion was done at tlie 
Gernran Hospital. As stip- 
pin*nti(in was cvjict'ted, i\iv 
extremity was fixed to un iiiterriipted dorsal stifipeni^ion splint made of hoo]>-iron oiid 
planter bondages. Profust* suppuration followfil with evident prostration, aud, April 
19tb. amputation of tho thigh was performed. Tiie wound henled by grnnulution, and 
in Juno patient was dist-liarfited cured. 

Ten cases were cured with preservation of tlie liinb. In nine of these, 
firm bony anchyh>si.s was secured. One cflso terminated in the formutiou 
of ligamentous iinion. 

Case I. — Niclas Gies, cttq»eDter, aged fitly -four. Synovial tnboroiln.sisi with high 
teniperatares and emuoiation ftdlovving a sligJit truiunatiam. Contraction of knee at 
an ■•inile aUfrle, witli c-nnstunt violent pain. Fffnturnf lt\ l.'^SG. — At the (ierman llotf- 
pitfd, piinctnro yieldeit a snndl rpiantity of turbid bloody sernm. In niiaesttiesia the 
limb wns straightened, and tlie joint was incised, irrigated, nud drainrd. The fever at 
oace dimippearud, but floctHdeiit pun comiiienccd to exude from tho tubes, conlinnini; 
the nasumption of tuboreulosis. In view of the patient's age, his wretched general 
fOnditiuri, due partly ti» ilisense and to rhronie alfoliolism, amjmtation wn-* tbuii^rht to 
bo advi.sablo. The plan nf o]ieration was cJumged at the itpenitin^r-table, imd total 
exsection of the knee-juint wiw done. Ila'iiiorrliagic synoviti.'< antli a largo cheeky 
deposit in the Imrsa of the quadriceps were found. Five nails were employed, with 
an aseptic dressing niid pasteboard splint.'i. Temporary comi)reiwiiin by itartin's elas- 
tic bandage was applied to (?imtroI secondary oozing. Esniarch's oonstrletor wns 
removed after the eoniplotion of the bandage. A feverless course of heiding fol- 
lowed. Change of dre.smngs was done un the twenty-woond day. Fcmr njiils were 
found lfK)3e, and were withdrawn. Afny Sffi, — Scraping of d rain age- 1 ruck i* and 
removal of liftli nail. Ligamentous union was found and a jdaster spJint np[died. 
«/u7M> 12th. — The »inuse.H were healed, and the patient wu.s walking without ilie aid 
of stick or crutches in a light nilicate-of-soda splint, though union of the bones was 
not perfect. 





Flo. 199. — Group Illustrating ad ex^«ction of tubercukr tendinous (^honthis of the (mIid. 

Topical applications make no impression upon thig disorder, which c?««^n 
be cured only by free incision and methodical removal of the fibrinoujf 
bodies and tlie gclatitiouri slicaths by careful dissection in artiticial ansetrm i^sA 
If tiic new growth extend underneath tlietrausver.se carpal lii^ument, a.r^<i 
can not be ^ot :xt ntherwise, the lif^ament must be divided to percKS it 

thorougli removal. The cariml ligamer* t, 
fascia, and skin arc uiiiited by several tiers of 
cutfrut sutures, a slit is left o|>en at each c?«i<l 
of the incision, and a compressive Sche<3^'* 
flres.<infr is applied to tlie arm and ha.n«^. 
which should be placed on a volar splint »?3t- 
tendiut; to the line of the metacarjio-phal***^* 
^eal joints. Thf pnticnf is dinrfffi to acti*^*" 
}fj i/iovi' hi.1 Jitifjers from the Hrcnwl day *'>'*- 
and thus to fashion grooves id the blood-ol^^ 
filling the interior of the wound, which 4^** 
to become new tendinous sheaths after t.l>* 
3ubHtitution of the clot by new-formed co^' 
nective tissue. (Figs. I99and2(K). ) 

Cask I. — Samuel H., medical student, a^*** 
twonty-tive. Tnberciilnr gelatinous synontis of "* 

t'ltensors of right hiiiid uihI of flexors of left b»0"' 

JJeccmher 30, 1886. — Extirpation of disea.'*c(l sheJtb* 

of extensor tendouH of riglit hand ander EsruarclJ ** 
Mount Siuiii Hospital. Jantcarif l^th. — First cli»nf 
of dressinga ; primary union. By January 20, \9SfT, 




rimr timl ilitrsu) tiMpt-ot- nf'llii' hwi'l 
for liTKliincal tulH-Tciilosia. (llnse 
of Snmuol IL) 




TREATMENT OF TUBERCULOSIS. 



293 



Flu, 



aay. — ^iiraafrenQeut of paticBt for 
Mikulicz's operation. 



anchylosis. Tubes und three aailB were removed ; a fourth naO could not be found, 
but was removed by incmion on June 2d. Patient was discharj^ed cured, with firm 
anchylosis, July 1st. 

NoTB. — To preTent the disagreeable neceaslty of 
cmttiog down for searcbing out a nail buried in the 
tissues, Dr. F. Langc's sugge:*tToti of fastening a ailk 
ligature to the bi-ud of eacli nail before dridng it id, 
Boetns to be very appropriate. 

/. Ankle and Foot. — Tuberculous 
affectioDs of tlic anklQ-joint, or of the 
joints formed by tlie tarsal and metatar- 
sal bones, require, in case of the presence 
of one or more sinuses, exsection of t!ie 
diseased parts. The long-continued dis- 
charges and lack of active exercise are 
very apt to reduce the 

general condition of tiie patient to serious anfemia and 
marasni, and, the disease extending to most of the eom- 
jrlicated Btructurea of the foot, may finally require am- 
pu tation. 

Early operations, especially in chil- 
dren, yield good functional results, a^ 
tbe extent of the removal can be lim- 
ited to the parts actually involved. 

Exscctions 
of the ankle or 
of other joints 
of the foot are 
not followed 
by good results 
in grown sub- 
jocts. on ac- 
count of the tcolinical difficulty of a complete removal 
of the synovial membrane. Kelapse of the tubercu- 
lar process often supervenes, making amputation a 
noce.*sity, 

In tuberculosis of the calcancum or the astragalo- 
calcanual joint, Mt'htltcz\'< ostnti/dafi/ic exarrtion of the 
(arsus fiesf'rtfe.1 emphynwnf. The lower ends of the 
tibia and fibula are sawed off iia in Syme's amputation, 
and the articular surfaces of the cuboid and «'ap!ioid 
bones are also sawed off, so as to Jit the section of the 
tibia antl tibula. (Fig. 230.) Nutrition of the ante- 
rior part of the foot is maintained by the dorsalis pefih artery, and the 
patient soon Icarus to walk on the balls of the toes, as in pes equinus. 
(Fig. 231.) 




Fio. "jao.— DiatfTiim illuntrutinjr the plan of 
Mikulicz' !« •ipcratioii. ( lii*mareh. ) 



^> 



"C^ 



Fio. 231.— Sbnpe of fnot 
aA^T Mikulk'ic's upcr- 
ation. (£timarcb.) 



294 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



Oase, — Hermann Mehle, barber, aged thirtjf-foiir. Synovial tuberotilosis of the 
•stragttlo-caloaneal joint, with several firtnln^ HJCimted to the right and loft of Ui*J 
tendo Acbillis. Augnat. 20, 1885. — Ostoo]tlaHti(' eisection of tarsus nt the Germi 
Hospital. Primary union of the deep parts, of thc^ wound and of tlje bones, 
pinal sloughing of limited extent of the upper edge of the wound delayed the cnr 
somewhat. Oetober 10th, — Patient was diBoharged cured. 

Note. — This operation waa employed by the author succesBfully in two more cases. In 
an epithelicvma of the caleancal region ; in the ntlier, extensive chronic ulceration, due to fr 
bite of the heel, «aa the iadication to ita performance. 

The preparation of the foot to be openited on is of very great importance, 
anil thorough removnl of effete epidermis and rlirt is a necessary condi- 
tion of asepticism (see page <j1). In exsection of the ankle, the bilateral 
incision gives very good access tn the ankle-joint, though excision of the 
capsule will be fonnd, at best, ditficult to accomplish. 

It being desirable to produce a movable joint, subperiosteal dissection 
is to be aimed at, as in exsection of the elbow. As soon as the sinuses are 
healed, active use of the foot on crutches, aided by a shoe and brace, or 
siJicate-of-soda splint, should be encouraged. The tendency to posterior or 
lateral deviation of the foot will be best met by the long-continued use of a 
supporting apparatus of one kind or another. 

Case I. — Caeeilia Raab, aged twenty-two. .Synovial tiibcrc»lo!»is of ankle-joint 
with several ainuaes. Nocember 9, 1882. — Exsection of ankle-joint at the Genuan 
IJo9i>itul. Healing of the wound proff^es!^©d favorably, when, November 30th, tl 
patient contracted ucuto lobar pneutuonia, iu consequence of which she died Decem- 
ber 3, 1882. 

Caab II. — Georffe Eitt, aged six. TtibereuInBiH nf ankle- joint caoBed by a chee«y 
forua in the astragaUis. January 11, 18SS. — Partial ex»eeticin of ankle-joint, part of 
the astragalus and the inalteoM being removed, iftrch J.*?M. — Sorapini? of the sinu»etj 
on account of relap:*in^ tuberculosis. Sinuses persiHted until the summer of 18ft4, when 
Dt. F. Lange, then on duty at the (ierninn Hofipitat, performed total exsection, which 
resulted in a cure of the tubercidosi!*, but with [jsciidarthmsis. Jultf 20, 1885. — The 
HUtli«>r exsected the li^^anientoui^ mas.s interposed between the lower aspect of the tibia 
and fibula and the calcaneura, and fixed the latter to the tibia by a steel nail driven 
throQgh from the pjanta pedis. Primary adhesion followed, with the formation of a 
slightly movable union of the tibia and oalcaneum. Septetaber 5th, — The boy was dis- 
charged cured. In January, 1886, the brace worn until then was dispensed with. 

Case HI. — Henry Holzfaller, siged four. Osseal tuberculosis of ankle-joint. March 
SO^ 1883, — Total exsection at the German Hospital. J/ay ;?5<iA, — Patient discharged] 
cured, with nerviceable joint. 

Cask IV. — Frida Schmoltz, aged three and a half. Osseal tuberculosis of ankle- 
joint with fistula. Heptemhrr 19, 1883. — Removal of external malleohia and part of 
astritgahH, which contained a oaseons deposit. October 15th, — Wound completely 
healed. Plaster-of-Pari."* splint applied. OrtohrrSUt. — Silieate-of-soda splint applied, 
and patient directed to use the foot. August 4. 1885. — Normal poisition of foot; func- 
tion perfectly re-er*tabli.«hed. 

Cask V. — L S., aged eight. Osseal tnbercnlosia of ankle-joint with tlirce sinuses. 
September SG, 1883. — Partial eiseetron of ankle-joint; astragal us and inner malleolus 
were removed. Notemher 15th. — Patient discharge*! cured, witli improving fonctioo 
and normal position of the foot. 



TREATMENT OP TUBERCULOSIS. 295 

Oase VI. — Jacob Deibel, farmer, aged twenty-three. Synovial tuberculosis of 
ankle and of astragalo-caloaneal joints. March 12, 1886. — Removal of both malleoli 
and of entire astragalus at the German Hospital. April 20th. — Patient discharged 
cured, with fair function of the foot, walking with the aid of a stick. 

Cask VII. — Abraham Moses Goldenberg, aged four. Osseal tuberculosis of ankle- 
joint with sinuses. November 8, 1886. — Total ezsection. Several relapses required 
repeated scraping with the sharp spoon. June 3, 1887. — The patient was discharged 
cured. 



276 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




nonual capaute. The typical mode of inciaion and drainage of Ihc knee-joint, for instanoe, viD bt 
found influflictent in tliis ifinltnfrency, and multipk' ^wrforaljon into the popliteal epuce will mi 
ilj occur. Exi^octiun of a kiice-juiut i^ubject to tlie ravan;c8 of Ixjth tnlMMtnilosii and isAeatt 
phlegmon will offer verj slender obancefs of Huccess, and amputation will bare to be decided on. 

The preservation of asepticism is greatly [jromoted by almost oontinnoiw* 
irrigiitiun of the wound during the time of operation. Corrot<ive rfubliiiiata , 
(1 : 1,000) can he fearlessly used for any length of time wf/ilt' E/finarch'Hton- 
sfn'ctor is in xiftt, as no absorption is thus possible (Woolfler). In emc- 
tioHii done wiilumi (irtijivial anwmia, iwry ivfak .snlu/iotitt of atrmirf 
sublijiuifv {1 : fi,f)00) or Thiersch's lotion should he eviplniu'd. At tbi* con- 
clusion of tlie o[>eration, however, the wound ehould be well tlu.^hed with 
stronger (1 : 1,000) corrosivo-tiublimate solution, 

{b) Rfimnval of all part><, mft or osxcoun. that are manifeHthj di»enif<i. 
whether curiou-s cheesy, gelatinous, or granulating, is a most iniporun 
condition of success. On the other hand, no apparently healthy parts ot 
to ho needlessly snerifieed. 

NoTK. — Without antiHepticfl partial ezri/iv»ui of joints were much more donperoun thao 
ones. The reas'iin nf tln;< w na t!ie fact that after totii) csd^ion tlic coiidition*^ for fffcctirc 
were much hctter than after partial pxscctions. Suppuration of resection wound* WM theruli 
then, and is* now the cxt'cptiou, hence partial excisions are }ui*t us safe at present as total om* 

To prevent further dissemination of the fuhernthir inrus from the fit* 
of the opfntfion, ample inriKifmtt musf he made. They will enable rbe sur- 
geon tn reacli every jiart of the diseased joint without the employmt'tit *>i 
undue force by retractors. 

Diseased bones are removed by the saw in julultj* ; in children, thevcftfl 
be pared oiT Avith a strrmg seaipeh Pockets tilled with casoouai inatti'rafB 
scooped out with the sharp spoon. Tht> entire aipmile must l>e removfd H 
dissect ion with curved scissors and it tnovse- tooth forceps, 

(r) To cnufrol hti'mttrrhnrjey artificial anaemia should he ust>d during '''* 
operation wherever possible. Where, as in the shoulder- and hij>-joint*i. 
Esnnirch's band can not be well applied, each vessel must be t^x-ured «"* 
tied as soon as it is ex|>osed or cut. 

Artificial anmmia may be kept up till the dressings are completed ', ^w 
care must be taken to search out and tie every cut vessel before closing t 
wound. How to do this is described in the paragraph on artificial anffi*'* 
in amputations (page 06). 

{d) rrescrimtion of Hie usefulness of the limh, or of the function of 
exsected Joint, is the last, but not least, requirement to be fulfilled. 

The knee- and occasionally the hip-joint will, as a rule, be more use: 
if firmly anchylosed than otherwise. Mobility of the other joints, howe 
limited, is more desirable tlian anchylosis. 

To favor anchylosis, the sawed surfaces of the bones to bo united m 
be brought and kept in firm a])position by posture, suture or uails, uud 
contentive dressing. 

Where preservation of mobility is aimed at^ the periosteal coeeriru] 
the exsected bones must be preserved by subperiosteal dissection. The p<^i 



1 



M 



PART IV. 

GONORRHCE A : 
ITS ANTISEPTIC TKEATMENT. 



J 




In examining the pumlenfc secretion produced by a virulent ease of are- 
thral gonorrhoea, the observer will detect with the microsco{>e a number of 
dark, round objects resembling grains of fine gunpowder, that are vividly 
oscillating, and can be clearly distinguished from the adja- 
cent pus-corpusdes. The use of a stronger lens will reveal 
the fact that each individual coccus is divided in two un- 
equal halves. If staining is employed, the body of the coc- 
cus will appear colored, and the dividing-line will become 
very consjiicuous in the shape of a light, colorless streak. 
(Fig. 233.) 

Frequently an indication of incipient secondary division of each half of 
the coccus can be seen. Thus four cocci will bo united to a seemingly single 
body, which can be aptly compared with four coherent biscuits, divided into 

equal quarters by two cross -shaped 

grooves. 

The faimritf locaiion of the gono- 

coccL found in the urethral secretions 

in within the pus-corputicks. This 

peculiarity belongs exclusively to the 

cocctif! of gonorrhcea detected by Neis- 
ser in 1879, and represents its most important charac- 
teristic. (Fig. 334.) 

frotiovort-i are to be found in the secretion of every 
cam of gonorrhaa, provided that no germicidal injec- 
tions were used. 

Infection of the urethra with pas containing gono- 
cocci alwayH prmlnres ffonorrhwaf and secretions that do 
not coutain gonococci are invariably non-infectious if 
brought upon the urethral mucous membrane. 

Gonococci have a peculiarly immsivc faculfif, by which they penetrate 
first the superficial layers of the epithelial membrane, and gradually by 
further proliferation the submucous layer. (Fig. 23G). The route of their 



Flo. 233. 
DevolopciwHit and 
ftsMon of (<ono- 
coocufl. (From 
Bumm.) 






Fiu 
evil 



284. - Kj isli 
Btuitdeil with 
^.'onociKx-t 1 ]«ufi oM, 
itK i>rotc[iIiiAm dlk-d 
witli jforiocoLfi ; an- 
othf r jHi.': wll -rnr^rd 
with ):■■' II 

jrroui- i 

al(in;fH'nJ^, 1 „ :- M'- 
iiml pun -cull i7<«> 
diiunt'tfrej. (From 
Bumm.) 



I 



I 



300 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



.(^:' 



Fio. 236. — Vertii'ul irt'otiou through mu- 
cjoiii!* inctubriinL% showing first ooloui- 
zatjon of gonooooci (700 diamotens). 
(From Buimn.) 



inroada is along the intercellular substance. An intense liiypera?mia of the 
capillariGs and other blood-vessels wdjoining the seat uf the primary infeo-i 
tion leads to a niariiiive emigration of white blood-corpuscles into the affected 
epithelium. This and the growth of the gonococcal colonies lead to a rapid 

disintegration of tlie epithelium, which is 
washed away by the lymph-serum in the 
shape of single cells or in coherent epi- 
thelial flakes. Loss of the epithelial in- 
vestment is often followed by the exuda- 
tion of a croupous membrane, beneath 
which clumps of gonococci are to be seen 
in process of active proliferatiun. Gono- 
cocci can be found occupying at this 
stage the interstices of the subepithelial tissues, their columns extend- 
ing inward along the lymphatics, whence, according to various authors 
(Knmmerer), they may be transported to the endocardium, the joints, and 
the synovial sheaths of tendt>n8. 

With the deeper invav<ion by the gonococci goes pari pasnu the denae] 
infiltration of the in- 
fected tissues with 
leucocytes, the ex- 
tent of which serves 
as a gauge of the in- 
tensity of the infec- 
tious process. 

At the acme of 
the process, general- 
ly reached about the 
end of the second or third week, a regeneration of the lost epithelial layer 
commences. Complete restitution of the epithelium signalizes the termina- 
tion of tlie malady, which, however, is attained only in favorable cases under 
favorable conditions. Generally primarily unaffected parts of the mucous 
membrane become involved by spontaneous extension of the infective pro- 
cess, or by the improper use 
of instruments ; or portions 
^^ which have recovered snc- 
cnnib anew to gonococcal de- 
struction. 

The regeneration of the 
epithelium i?; always accom- 
panied by hyperplasia, which 
somewhat resembles by its 
tubular formations epitheliomatous mucous membrane (Bumm). These foci 
of epithelial hyperplasia are often coincident Avith the seat of the most intense 
primary affection. They also correspond with those parts of the submucous 
layer at which the most intense inflammatory infiltration was present. 




Fio. 2."J« 



% 

-Invwion oF c>pitltelium \>y gouooocd (700 diMueteffty. 
(From Buinru.) 









Fio. 237. — ProlilcTuliou of l^>nococ■l•i in the e]>it helium 
(JOO diunnjlt'im). (From Bumiu.) 



L^ 




TREATMENT OF GONORRHCEA. 



301 



As regeneration progresses, the hyperplasia of the mucous memhrane 
and the infiltration of the Kubmucous coniiuctive tissue disitppear by abaorp- 
tion. In some cases, however, ru-atrieial intnafarmatinn of the nrw-formed 
connrriivp finmie of the stuhmufous' faif/'r fakes plart inab'tui of absorpfiou, 
and organic stricture dcvrhtpx. 

The transient hyperplastic conditions existimj inuntdiatelti after the 
termiiuttion of the gonorrfimdl process, and which generally give rise to a 
Kcanty secretion called gleet, are mistakenly called strictures by various 
authors. 

In contradistinction to stricture, which is a perimmcnf condition, they 
muj^t be declared to be transient stenoses of the urethral caliber, which in 
most cases do disappear without or with the methodical introduction of a 
full-sized bougie or soutui. The salutary effect of dilatation upon these 
coarctations of the epithehal and aiibmucous layers is explained by the 
hastening of the absorption of the cellular infiUration by pressure. 

It is true that, if neglected, some of these coarctations will not he ab- 
sorbed, but will become veritable cicatricial strictures. Nevertheless, if is 
an error to dfcfare each and eccry narrowing of the nrethraf caliber observed 
shortly after a <jimorrha>al attach a " strict a rf if wide caliber." The term 
of ''incipient stricture" is less objectionable, thougli often incorrect, as 
many of these '* strictures " disappear spontaneously, 

Smu. — The presence of various mkro-orgftiiis^mw, asidi' from the gotioooccus, iu n-t-ent and 
chronic urethral discharges, seems to point to the fact that mofit aixrn of urethrith rejtrfiwnl a 
mited form tf hadcriol infrclion. There is no doubt that the inoculation of pt/oijaiic mirrobn 
into a gonorrlupiilly iifTcctcd muwms incinbranr forins an inipnrtntit cletncnt detcnitining the 
intt-nsity and pemicioutrifsa of eouie very bad cases. This assmnptirm is id»o mure in accord- 
ance with the theory of the development of metastases, notably of ;;onorrho?al rbeumatiiiim. 
Bumm 19 very re»erved in rofrard to the actejitancc of KammercrV iuvc?tigatious, who fouml 
gonococci in recent cfTusitmg produced during an attack of j?<>norrhical rhcutuaiism. On the 
other hand, we liuow thiit rheumatic attackii arc occii^ionally ]»riivokcd Ity nn in^trutucntal 
examinalion of the urethra of a patient afflict'Cd with "simple"' or "catarrhal " itr "traumatic" 
urethritis, iu which (he absence of gunoeowi i^ iudieiputoble. Finally, the frapient prc^Hsnce of 
iiimple pyogenic organisms in rheumatic effuBiona is generally accepted. It seema, then, that 
pu»-j;eneratin,g organism? play an important part in cases of {»onorrha"ic and non Rfinorrhteic 
urethritit>, and that the metastatic processes complicating urethral inflammation!< arc mostly 
chargeable to thtiy <m<i nut to tfu prexmct of ^vnotocci. Hence the name "unrthral rlieuma- 
tiam" wouhl he preferable to "gonorrhu-al rheiunati^ni." 

n. TRliATMBNT OP GONORBHCEA. 

1- Acute Gonorrhoea. Clap. — For [mictieal reaf^ons it will be found 
most conveuifut to divide the maiu urethra into two easily distinguished 
parts. 

The first part cmtiprlscs the anferinr pnrfion of the urethra, extending 
from the meatus to tlie "cut-otT n\\X'Av\Q,'' iyr compressor urethrtP, which is 
situated in the niembratiouH portion. All secretions originating in this 
anterior portion rjf the urethra will readily escape by the nieatns into the 
linen of tlie patient. 
40 



L 



302 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



The arcond or deep portion of the urethra consists of a fraction of the 
membranous purt, together with the prostatic portion — in short, of all that 
is Kitmited behind the " eut-otf muscle." 

This posterior portion of the urethra ia correctly called the neck of the 
bladder, as it forms one cavity with the bladder whencYer this becometi 
di-steiulc'd witli urine. The internal sphincter alone, unable to resist long/ 
yields readily to the pressure of the urine. The voluntary contraction of 
the compressor urethras becomes, then, tlie only barrier to the escape of the 
urine, and water is voided immediately after the reluxatiini of this muscle. 

Discharges secreted in the posterior part of the urethra can not esca] 
outward past the compressor muscle^ and do not appear at the meatus 
the ahape of an external discharge, as those of the anterior urethra. Thej 
accumulate in tlie neck of the bladder, and are voided only with the arine, 
which is rendered somewhat turbid by this admixture. 

A very useful practical lest for determining the seat of urethral inflam- 
mation is thai su(/f/ested by Ultzmann. 

Tlie patient is made to pass his water consecutively into two tumblers, 
80 that the amount voided should be about evenly distributed in the two 
vessels. Whenever the anterior urethra alone ig the seat of inflammation, 
oufif the first half of the urine will be turbidy or ut least will be found cou-»1 
taining flukes and threads ; the second portion will appear perfectly char. 

In cases of deep-seated urethritis — that is, when the neck of the bladder] 
is affected — tlie first tumbler will receive Jiaky and turbid urine, and tM' 
water held by the second glass will appear cUmo iurbidy but somewhat 1«h» to 
than the first portion. 

An additional and most important symptom of the aflEection of the neck 
of tlie bladder h frequent micturition^ in acute ca^^^es accompanied by severe 
spasm and the escape of a small quantity of blood at the end of the act. 
^Simultaneously with the severe contraction of the vesical muscles, anal 
tenesmus is observed. 

In every case of recent gonorrhoea the infections process is confined to 
the anterior urethra, and first to its foremost portion alone. It extends 
from the meatus backward to the compressor urethra?, where it generally 
stops. In exceptional cases only does it j^euetnite to the deep urethra, as 
the " cut-off muscle '* seems to serve as an effective barrier to its extension 
backward. 

NoTK. — Forcible urethral injectioiu) made from a sjringe contaialng too l&rge a quantity of 
liuiil, or the premature introduction of a sonnd, are frequent cauaea of the infection of the nedt 
of the bladder. 

The seat of the most intense inflammation of the urethra is in its natu- 
rally widest parts — that is, in the fossa navtcularis and the sinus bnlbi. llere 
we lind located the majority of all strictures. 

rt, Antekior Goxorkhceal Uhethkitis. — ^The treatment of anterior 
gonorrhoBal urethritis should be very discreet in the first invasive stage of, 
the disease. It should consist of rest and appropriate general sedative man- 
agement. Locally, cold applications will be found very grateful and effective. 




TREATMENT OF GONORRHCEA. 



303 



As soon as the turbulent first onaet has abated, local treatment by dis- 
infectaota should commeiice, Sineo the oedematous swelling of the ])art8 
is still prominent, introduction of any instrument for the purpose of irri- 
gation will luive to be done with some force. It will cause abrasions of the 
tumid epithelium, and thu.s will open new portab to gonococcal and pyo- 
genic invasion. Hence irrigation ut tlii.s period is to be condemned. 

Urethral injections, on the other hand, done with a properly shaped 
syringe of moderute capacity, are very useful. Sigmund's syringe, hav- 
ing a blunt conical nozzle, is an appropriate metrument. It holds three 
eighths of an ounce 
of fluid, which quan- 
tity is sufficient. 
(Fig. 238.) 

The strength of fio. 238.— Sigmund's urethra] ayringc. 

the solutions em- 
ployed should also be determined by the iutensity of the local symptoms. 
Strong aolutions will cause intense smarting, and on that account the injec- 
tions will not be made frerpiently cnotigh by tlie patient. In very sensitive 
cases an entirely uuirritant tepid solution of salt water (<j: 1,000, or a tea- 
spoonful to a quart) can be emjiloyed with uiueh benefit. As the symjitoms 
abate, sulpboearbolate of zinc (fifteen grains to six ounces), or permanganate 
of pot-ish (one grain to six ounces), can he sulistituted for the saline solution. 

The main object of these tirst injections is the cleansing of the urethra ; 
hence the injections mnd he made frequenUif, at least six times in a dny, or 
oftener. Each injection should be preceded by urmalion, and should be 
a double one — the lirst syringeful to wash ont the pus ; the second syringe- 
ful to jict upon the mucous membrane. Tliis second injection should bc^ 
retained in the urethra for two minutes. The strength of the injections 
should bo increased pari puHHU- witli the abatement in the acuity of the local 
symptoms^ but tliR solutions should never be made corrosive. 

Every patient shaidd receive practical instrurfion from t/tr plii/siriati 
regardini/ the pruper manner of injecliuij. 

NoTK. — The author «aw a case of chronic goni>tThcea lliat had successively pacsec! through 
the hands of throo i-ollcagupi), none of wbuni convinci-d himself whether the patient was making 
ttie injcctionH projveriv or not. i'liiniosis v.ut< presout, inui the piilieni was in the belief thnt 
the injections had to be made under the prepuce. No wundcr hi.s clap had remaineit iininflu- 
enced hy this treatment. 

In the later stages of acute gonorrhoea irrigation of the anterior nrethra 
will be found a very satisfactory and elTective mode of treatment. It should 
bt^ dowQ by the physician himself at least once daily, or as often as possible, 
in the following manner : 

A pint bowl is filled with tepid water. To this is added enough con- 
centrated solution of permanganate of potash to color the water to the hue 
of light claret. A straight or slightly l>eaked female catheter of metal { V\g. 
239), five inches in length (No. 8 English caliber), is lubricated witli f/tifc- 
&rin, and is introduced as far as the coniprcssor-urethrae muscle. When- 



304 



EULES OF ASEPTIC AND ANTLSEPTIC SURGERY. 



ever the beak of the instrument comes in contact with the mascle this will 
contract, and will resist further introduction. The patient stands in front 
of the sitting physician, and is made to hold a pus-basin or tin pan under' 

his scrotum and penis. The 



jd. 



Fi<i 



'l&Q, — Short metallic cathotor Ibr irrigation of 
uDteriur urethra. 



physician fills with the solution 
a hand-syriiige holding four or 
five ounces, and injects the fluid 
through the catheter into the 
urethra, wliencc it will readily 
escape by the meatus into the pus-bnsin. This is repeated until the sola- 
tion is exhausted. Irrigation should be preceded by micturition. 

With proper diet and regime, ordinary cases of gonorrbu?a will be cured 
by this treatment in from three to six weeks. 

Note. — To prcrcnt soilm;^ of tlic pnticnt'n linen by profuse urctlirtil diecharpe*, the follow-. 
inf; simpln Hrrnnpeiuciit will he found i;ffefti%-o Hnii L-onvenienl. A cliilil's sock i>* fastened wit 
a safety-pin to the interior of the ekirt of tin- jiatii'DtV nmkTiililrt. In tlie toe of the Pock 
thrust a Hniall hall of (!oUon, which is then dran'n over the peiiitt, and is httld thcrp by ttic mk-Jl' 
Wlieciever occuioD perwits, the soiled cotton in rcplaeed bj clean material, and thus no ted- 
tale blotches will be made on shirt and drawers, 

b. Deep-seated Gonorrftceal Urethritis. — Spontaneous extension 
of gonorrhceal infection beyond the cut-ofT muscle to the jKisterior part of 
the urethra is a comparatively rare (►ccurrence. More frequently infection 
is carried to the deep urethra by too large injections or t!u' jiremature inser- 
tion of sonnds. As long as in a case of antirior gonurrhwa ihv (/isc/mrgf" 
arc profuse and crmmy, and the moufk of the urethra (edematoui* and reJ, 
no Jfoujui should ever be passed. 

Infection of the deep urethra invariably provokes an unmistakable com- 
plex of symjitoms — uanitvly, frequent urination, which is followed at it* 
termination by a violent spasmodic pain and the escape of some bloody 
urine ur a few drojis of jmre blood. 

Ordinary injections, or even irrigations of the urethra as above described, 
are utterly unable to reach and to influence the course of deep-seated , gon- 
orrho-a. To cleanse and disinfect the diseased part, an efficient germicidal 
sohition must be brought exactly in contact with the morbid mucous mem- 
brane of iha po.tterior itrethra. If we inject a solution into the bladder, ita 
chemical properties will bt' at once destroyed by the admixture of urine, 
hence means must be found by which wc can make the unchanged solution 
come in contact witli the seat of the disease. For this purpose Ultzttmnn't 
method of irrigating Ike twck of the bladder will be found very effective. 

As soon as the most acute invasive stage of the affection shall have be- 
come mitigated by rest, sedative^, balsamies, aud proper diet — that is, in about] 
the third or fourth week — a quart of a mild, tepid soUitJon of ]>ermauganate 
of potasli (1 : 'i.OflO) is prepared. A not too small-sized soft gum (Nelaton's) 
catheter (Fig. 240) is lubricated with glycerin, and is introduced as far aSi 
the cora]>re8sor-urethrfie muscle. A hand-syringe holding about fouronnoei^ 
of fluid is filled with the solution, which is then injected into the catheter. 



L 




TREATMENT OF GONORRHCEA. 



305 



and will be seen escaping from the meatus alongside of the instrument. 
After this preliminary washing of the anterior urethra, the patient is di- 
rected to assume the recumbent posture. The soft catheter is again lubri- 
cated, and is passed gently into the bladder. This process will be very 
much facilitated by the iujeeticni of a small quantity of glycerin through 
the catheter when it is about to pasi? the cut-off muscle. A small anumnt 
of pre&sure will overcome the tension of tlie compressor, and the arrival of 
the point of the instrument in the desired locality can bi' tested by injecting 
an ounce or two of the prepared lotion. Should it escape from tlie urethra, 
this would be a fiign that the eye of the catheter has not passed the com- 



I 



Fk*. 'im, — N^latou'« Boft gunv taitlit'tt-r. 

pressor muscle. If, on removal of the syringe, the lotion is seen to e.scape 
at once from the bladder through the catheter, then it may be concluded 
tluit the eye of the catheter is in tlie cavity of the bladder, and tliat Jt hjis 
been introduced too far, and needs to be withdrawn an inch or a little more 
or less. ShouM^ an renewed ii/jfctiun^ the lotion all rnhr the hlndder, hut 
fail to eftmpe fhrom/k the rafhfffr, this is a ponitive sign that the heuk af 
the inxtrnmt'ni it just l/ct/onfl the rnl-fiff musrlf — thai is, in the pnsffrior 
part of t/w titctnl/raiious portion. Fluids injected into this place will readdy 
enter the bladder, us their pressure can easily overcome the internal sphinc- 
ter; but recontraetion of tliis muscle will prevent their escape until the 
beak of the instrument is pushed into the vesical cavity. According to the 
irritability of the patient, from one to four ounces of the lotion are slowly 
injected while the point of the catheter is located in the space between the 
cut-off and internal splitncter muscles. As soon a> the patient com]tlains 
of pressure, injection sliould cease, and the catheter should be gently pushed 
within the vesical cavity, whence it will at once conduct the injected iluid 
into a vessel placed between the thighs of the patient. It is better not to 
inject too large a quantity at '^'s is liable to bring on 

vesical spasm, resulting in a sion both of lotion 

and catheter. 





ntnj^'uincnt of [iro- ^^^^^Bj boalcd bv auchvlosis, as far as the affec- 
teotiire cloths. H^^H^isSI ■,/,.* 

tion 01 the joint proper was conccniw. 

They ca«ue under the autlun-'s care on aceoimt of tubercular jirocc?st'S 

located on the pelvic bones, re*[uiring o])crative treatineut. 

Cass I. — Albert Gaupp, a^ed thirteen. Anchylosed hip-joint: t-u^eous (Kititi»iif 
us iliuru with roui|>licat«t] sinuses and pelvic absee-i*. 
Aufjnut !«', 18MJ. — Int-isitm and drainage of variuas «na^ 
>-s iind i>f tlic fu'lvic absreas; remoTAl of a t'on!»idenil»le 
jiijrtit.ui of the iUniii and 09 pubis with niMlK-t jmd chb-'l 
at tlie Gertuiiu fTospita!. Jan. 21, 
l8S:i. — Diwhurf:^! nnich iniprovt'd. 

Oahe II, — wSftnincl Aiiisttvr, atred 
ten. Tiibcrcidar cositts, with sinus, 
of two years' duration. Drcrm- 
her S, 18S5. — Eisection of hip- joint 
nbnve the trochanters at Mumit Si- 
nai Hospital. Iteraova! of tliL> ace- 
tiibuhnn, which was fuimd perfi>- 
rated. After-treatmeDt with wei^'ht 
extension. Jautiarii IS and 20, 
188(j. — IJovisiona of wound, on ai^- 
I'Oimt of tlio presence of exnberaiil 
pranuliitious in the dminape-l racks. 
Mutf 10th. — Dischurfji'd cured. In 
November the patient wa.s readmit- 
ted oil account of peh'ic di.seuse. A 
listuhi liiid been eHtfiblisbeil la-lnw 
the anterior-superior spine, lesidinp 
to the inner aspect of the iliiinu 
DdecmhiT Ljih. — Three soqiiotr.i 
were removed by an incision made 
nlons the crest of the ilium. In 
Jime, 1887, tbci patient was dis- 
charged cured. 

Cabk ni. — Jolm Realc, aeed 
thirty-nine. Anchylosis of right 




Fill. 21s.— Ksseotioa of hip- 
joiut. Fiuiil rcHutt. .Vnte- 
rior view. (I>r. V. haa.avi'A 

CftKO.) 




lin-joJrT' 



TREATMENT OF GONORRHCEA. 



307 



* 



I 
I 



urethra. Intense smarting and spasm of the neck of the bladder follow the 
injection, but soon disappear if the patient ret-ain the reclining posture for 
a short while. 

These deep injections of nitrate of silver are a very eifective though 
painful mean^s of checking a gonorrhoial inflammation of the deep urethni, 
and deserve more frequent employment than they receive at present. The 
procedure does not entail any danger, and is rather a preventive than a 
cause of epididymitip or cystitip. 

2. C]iromc Gonorrhoea. Gleet : 

a. Inflammatory Stenosis (Incipient Stricture) and 
Permanent or Cicatricial Stricture of the Urethra : 

(a) Anivrior Urvihru. — ^The termination of acute gonor- 
rhoea is never abrupt. It is always inaugurated by a period 
characterized by the escape of a scanty amount of purulent 
discharge. During this jieriod sulnicute attacks or relapses 
of the affection may be precipitated by any cause inducing 
hyperemia of the urethral mucous membrane. Sexual irrita- 
tion, alcoholic indulgence, severe bodily exercise, offer mainly 
occasions for this occurrence. 

When an acute gonorrhcea has reached this stage, the prog- 
ress of the recovery often seems to sutler a halt, due princi- 
pally to secondary hyperplastic changes of the mucous and 
submucous tissues. The daily introduction of a full-sized 
sound or Ijougie for a week or two is generally sufficient to 
produce rapid absorption of the interstitial exudation and a 
permanent cure. 

A contracted meatus is an effective impediment to the 
ap]>licuition of the sound, and requires an adequate division 
of the narrow urethral orifice. Menlulomy, however, tthould 
never be carrml too far, its only object being the eaay admis- 
sion of a full-sized steel sound. It is made with a blunt- 
pointed tenotomy knife, and tlie hsemorrhage caused by it 
can be easily checked by the introduction of a small pledget 
of iodoformed gauze into the slit. 

Should the patient positively decline moatotomy, blunt 
dilatation of the part of the urethra, which is the seat of the 
inflaramatciry swelling and contraction, can be done by 0/i.'<'.s 
urvUirottiffer. (Fig, 243.) The closed instrument is intro- 
duced beyond the coarctation, then it is opened until the dial 
indicates that the bulb has been dilated to full caliber, and 
then it is drawn with some force through the narrowed portion of the 
urethra. The author baa seen very good results follow this use of Otis'a 
instrument, though the procedure does not deserve preference over mea- 
totomy and dilatation by the steel sound. 

The absorption and (lisapjioarance of these '* incipient strictures " is very 
much hastenefl by the local application of a strong (tive-per-cent) solution 



H 




308 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



of nitrate of silver. To enable an exact application of the caustic under the 

gvidance of the fjfe, the mdosropfl must be used. 

The (.aidoscope it; a cyliiulrical silver tube of from four to six inches in 
lenrfth, and of various calibers. (Fig, 244.) An obturator facilitates it> 
painless introduction, and a flantje or shiekl matk^ of hard rubber, having a, 
**dead finish,'' permits an easy handling of tire instrument. Strong arti- 
ficial light or sunlight is needed for endoscopy. The patient reclinee on a 
tall chair, or sits on the edge of a table, liis back supported by a suitabU' 
rest, the examiner occupying the space between the ]iatient's legs. To pro- 
tect the patient's clothing against soiling with blood or chemicals, a pieo6| 
of rubber cloth (eighteen inches square), provided with a e-iduII central frjitj 
just long enough to permit the slipj>ing thraugh of the penis?, is sprc^ on' 
the pubic region. Thus the only object exposed to view will be the pationt'a 



(i.TlEMAN 



Fio. 244. — Klotz'H iirethnil i-ml'-'i«>.'ope. 

penis. Over the rubber cloth a clean towel is laid for wijting off fingers, 

etc. A baain containing a nnmlwr of slender match-aticks, their ends 
armed with tufts of absorbent cotton, is at hand, and a pus-basin is next to 
it, to receive the soiled sticks. On a little table adjoining the operating- 
chair are a small, wide-mouthed bottle of glycerin and a few glass salt- 
cellars or hour-glasses for the reception of such solutions a'^ may be required. 
Of these the author usch tvvci — a five-per-cent solution of nitrate of silver 
and a tcn-per-cent solution of the same substance, both in dark bottler. 

An endoHCopjc tube of suitable she beiug selected, it is lubricated with 
a little glycerin, and is introduced well into the bnlbous portion of the ure- 
thra. The obturator ia withdrawn, and the surgeon by his lieatl-rairror 
dirt^cts a ray of sun- or laraji-light into the bottom of the tube, where the 
mucous membrane of the urethra is visible in the shape of a typical image, 
consisting of several concentric folds uniting to a central, funnel-shaped 
depression. 

In sunlight ihr normal tntimjis membranf is pale, of about the same hue 
as the normal buccal lining, and on it are visible a tnimber of delicate trac- 
ings, produced by minute vessek«. It is very smooth and glossy, and the 
folds of the image are flexible and rather delicate, and present po change of 
color nn da^/icr introduction nr wilhdrttwal of Ihr lah'. 

Infiamed urethne show an entirely different aa|)ect The mo^t delicate 
manner of introducing the in.strument is aj>t to cause slight ha'morrhage, 
which sometimes is very trouble^nnie, as the lilood fills up the lul)e fjistcf^ 
than it can be moj^ped away, frustrating for the time being all further 
manipulation. When the mucous membrane, exposed in the l>ottom of the 
endoscope, is dried off with a pledget of cotton, it ha^ a dull, dead glosii. 



TREATMENT OF GONORRHCEA. 



309 






N 



Fio. 245. — McUlUo bulbous bou^o. 



or velvety appearance ; it shows a more or less intense, uniform shade of 
red, scarlet, or purple. The folds of the endoscopic image are few and 
coarse, and not ro Hexible as those of the normal urethra. 

Gradually withdrawing^ the tube with short stops, the entire length of 
the urethra can bo thus inspected. 

In chronic gonorrliceal urethritis the inflammation will be found limited 
to more or less well-circumscrihed portions of the urethra. These parts, 
ixamiiied by urethrometor or bulbous bougie, quite frcfjuentty slunv a wfll- 
marked tliougli mftderiite contraction, which can also be demonstrated to 
the eye through the endoscope. 

In withdrawing the tube, new parts of either normal or uniformly red, 
inflamed muc<Mis membrane will present themselves to the examiner's eye. 
Suddenly, however, the field of vision will become pale, perfectJy anamiCj 
and ivory-colored. This change of color is 
due to de])letion of blood and the anaemia of 
the constricted part of the urethra, caused 
by the distention produced by the dilating 
instrument. As soon as the end of the tube 
is withdrawn from the atenosed part, the formerly bloodless tissues are seen 
to gwhlrnlff fiiiidi up and become of ezartly the name color ax the resi of (lie 
inflamed munms memhrnne. Examination by the bulbous bougie (Fig. 245) 
will show that the seat of this ]ihenomenon corresponds exactly with the 
locality of the narrowing of the urethral caliber. 

In cases where gleet has persisted for several months, these constricted 
places appear in the endoscope of a pearly color, which is due to the con- 
siderable thickening of the epithelial layer. 

The application of the nitrate-<jf-silver solution to those *' incipient strict- 
ures '* will be found to materially hasten their absorjition, if it bo supple- 
mented by the introduction of a full-sized sound. The applications are 
made through the endoscope every other day with a camel's-hair brush or a 
wad of absorbent cotton fa.stened to the end of a long mateb-stick. They 
cause a slight smarting, which does not persist very long. Occasionally 
they are followed by slight hjemorrhage on the day subsequent to the appli- 
cation, which, however, is without any significance. 

Most of these "incipient strictures" get well under the treatment just 
described, and do not require urethroiomy. 

But, when the embryonic connective tissue of these stenoses of inflam- 
matory character becomes detinitely transformed into iibrillar connective 
tissue — that is, a fully devehiped cicatrix — it represents a permanrnf — ihnt 
is, organic — stricture that can not be cured by simple dilatation and toi>ical 
applications. True, it may be gradually dilated to the normal caliber, but 
the dilatation will be evanescent, and speedy recontraction will follow the 
ceaaation of the treatment. 

The appearance of a cicatricial or permanent stricture in the endoscopic 

field of vision ditfers in many ways from that of an inflammatory stenosis. 

This diagnostic distinction is all the more valuable, as an examii 

41 




310 RULES OF ASEiTlC AND ANTISEPTIC SURGERY. 

the bulbous bougie, although capable of demonstrating the presence of a 
narrowing of the urethral caliber, docs not divulge anything regarding the 
nature of the stenosis. 

The most characteristic feature of permanent strictures is the nncbang- 
ing ana-mie, pale condition of the mucous niemhrane about the strictuR' 
in the endoscopic field of vision. The i^ndden Jlushimj up on withdrawal 
of the endoscopic tube, seen in the contractions of recent date, i» abstnt. 
The ttecond characteristic is the pfcttUar rttjidiitf uf ihe urethral wall at 
the site of the stricture. On withdrawing the endoscope, the rigid walU 
of the urethra show a tendency to remain patulous, so that, instead of u 
small and rapidly changing image of soft, pliable mucous membrane, a 
comparatively long stretch of the urethra can be looked over at a glance, 
resembling somewhat the walls of a short tunnel. 

Absorption and disap|>e!irance of a cicatricial stricture are a very excep^^^H 
tional occurrence, whether it be subjected to treatment or not. To ^K/Ji^^^H 
cie fitly widPH a strictured tireihra, urethrotomy, followed by methodieal 
dilatation-f is required. 

Such n cure as is not infrequently observed to come from treatment of 
an inflammatoi'y (stenosis — that is, a perfect restitution of the normal state 
of atTuirs — i.s never to be expected after the treatment of a cicatricial stricture. 
be thtjt trentment dilatation nlone, or eutfiny eombtned with nubsequcnt dila- 
tafinu. The cicatricial ring will become wider than before, but its rigidity 
and unnatural appearance will remain unchanged. 

The cases in which the cicatricial bauds can be divided in their entirety 
yield the comparatively best results. But the worst strictures involve the 
entire tliickness of the spungy part of the urethra., and to effect complete 
division in these cases the entire thickness of the urethra would have to be 
cut through, which is an impracticable and sometimes dangerous procedure. 



Case. — M. P., aped forty-two, liud a series of old cieatriciul stricturos involving thct 
entire anterior portitm of ihf uretlira. One seated in the fossu nuvicularis was r 
tipbt, another one at the bulbo-motnbranous junction was very niasriite, so that it 
could be felt tbrouph the |>erinrt?iin]. RInnt (iilfttation xvitli steel sounds, up to No. 84 
of the French scale, always prodiu-ed cessation of the profuse di'<rbarge, buU, recontrac- 
tioii to the old vondttiou uhvuy^ followiug within forty-oight hours, internal urf- 
iJirotomy was decided on. Attgu^it 20, 1885. — The operation was perfornjed with Otis'* 
urethrotome. The iirethra was <lilated to No. 30, and then two parallel inciisions wero 
made along the entire length of the roof of t!ie pendulous portion. Some heiiitation 
of the bulbous bougie was noted at the Imlbti-raeiubranons junction, therefore Otis'* 
ini*trunieut was reintroduced, dilated to No, '62, and the still narrow part of the urethra 
once more cut. Smart hremorrhago was observed, but not more than the length of 
the iaciaion jastificd, and after some compression it eea.Hed. On returning to the pa- 
tient after the lapse of two hours, the writ^'r found him lying on hiri hlood-soaketl 
mattress in a pool of blood, in a most deplorable stale of prostratiou and anxiety. Tlic 
scrottun and penia were swollen out of proportion, and had as.snmed a blue-black color, 
and blood was issuing from the nieara.-* at varying intervals. A large English web- 
catheter was introduced and tied into the bladder, and only persistent digital pressuro 
exerted over the bulbous portion for more than two hours succeeded in arresting tlM 






J 



TREATMENT OF GONORRHCEA. 



311 



^ 



I 



h 
^ 



^ 



lora of blood, and cliCK^ked furtbor bloody intlltration of the penile and scrotal tissues. 
Fortunately, infection uf tlR* wmitid was* avoided by careful asepsis, and thut*, no fever 
nnd inflnmnirttiiin following, the entire enonncins extrflvasation vfm readily ubflorbed. 
Introduction of large sound* waa rommenxed on the twelfth dny, and after a eonie- 
what prolonged convalescence the patient recovered. With the regular use of the full- 
aized steel sound, and an occaeionid irrigation 
of th« neck of the bladder, tbe patient suc- 
ceeds 3D nmintaiuiiig a very cotnfortable state 
of health. 

In the case just related, complete di- 
vision of the posterior stricture, situated 
at the biilbo-membranoua Junction, led to 
the injury of the bulbar artery, imbedded 
in the cicatrieiwl xtui^a constituting the 
Btricture. Had the wounrl been infected 
by the u^e of uncleanly ingtruments, sup- 
pitmtion and decomposition of the large 
bloody infiltration might have brought 
the patient into very great danger. 

A seriou8 objection to tie's otherwise 
excellent urethrotome (Fig. 24(1) is tlie 
great difficnUy of thoroughly cleanging 
the complicated insf rnment, 

Tlte author rvniminfmh the foUmritui 
simplijit'd manner of pcr/ormiuf/ inter- 
nal urethrotomy of the anterior urethra 
for strictures of wide caliber. A long 
and etout-ehanked, rather muTow-bluded, 
blunt-pointed tenotomy-knife is first in- 
troduced well beyond the ascertained 
depth of the stricture. Alongside of 
this, Otis'ri urethrometer is inserted to 
the same depth. The bulb of the latter 
instrument, being well dilated, is ilrawri 
forward until it is arret^ted by the strict- 
ure. While the bulb of the urethrome- 
ter '\& held close to the mesial entrance 
of the stricture, t!ie tenotomy-knife is 
grasped and its sharp edge is applied to 
the tense cicatricial bands. It is drawn 
forward until the blade is past the con- 
striction. Should the bulb of the ure- 
thrometer follow without a halt, the stricture can be considered as suffi- 
ciently divided ; should the divisitni bo insufficient, the bulb of the ure- 
thrometer is closed, and the tenotomy-knife ia slipped back past the stricture 
to repeat the process of cutting. Thus the surgeon is sure of dividing only 





312 



RULES OF ASEPTIC AND ANTLSEPTIC SURGERY. 



the stricture, and not cutting deeper than necessary to permit the passage 
of the dilated bulb. The method is both simple and exact, and eeems wpU 
deserving of trial. 

For very tight atrictures Maisonneuve'a instrument is most proper. 
(Fig. 247.) 

Careful disinfection of the surgeon's hands and instruments, and irri- 
gation of the urethra with a watery tepid solution of permanganate of pot- 
ash (1 : 3, 000), should precede every step or oper- 
fation that may lead to wounding of the uretbml 
mucous membrane. As a lubricant, iodoformized 
1m vaseline (1 : 30) should be used. The operation 

should terminate with a reucM'ed irrigation of the 
urethra. 

Wlienever strictures are cut that have their scat 
near the bulbo-membranous junction, a new, large- 
sized, English elastic catheter should be tied into 
the bladder for twelve hours, and the patient should 
be kept in bed for a day or two. These precautions 
are rarely necessary in cutting strictures located in 
the pendulous portion, as it is not difficult to pre- 
vent hsemorrhage by the application of a compre*- 
sory bandage to tlie penis. A gutter of light pasto-^ 
board ia applied to the under side of the penis, 
which is first enveloped in a layer of cotton, and 
the splint is firmly secured by a few turns of a rcdler 
bandage. The penis and scrotum arc held up to 
the belly by a snugly fitting T-baudage. Thi:< pre- 
ventive appliance can bo abandoned on the second 
day after the operation. 
M - If ammoniacal urine be present, its condition 

ifi should be influenced before o])eration by the in- 

Ml I ternal admiuis-tration of boracic acid, benzoate of 

soda, lactic acid, or turpentine, so as to become at 
least of neutral, or what is still better of acid, re- 
action. 

A fuU-sixed steel sound is to be introduced twice, 
weekly, the Jirst application tint io rommenct bffor$ 
the ffth or seventh day after the operation. Much 
pain to the patient will be avoided by first intro- 
ducing a copiously anointed smaller-sized sound. 
which will carry a good deal of the lubricant into 
the urethra, and will render the subsequent use of a futl-sixed instrument 
compuratively painless and easy. 

With the precautions above described, the author has not observed a 
of urethral fever following either internal uretlirotomy (^r the use of dilat- 
ing instruments in the urethra. Ilis cxiierieuce extends over twenty-one 




TREATMENT OF G0N0RRH*:EA. 



313 

No febrile or 



cases, in which strictures were cut successfully from within, 
inflammatory cumplications were ever observed. 

(i) Dvt'p Vnihral Strirturea. — Strictures of the deep urethra are located 
in the membnuiuus portion. Their development is preceded by a stage 
of epithelial and submueou,'^, hyperplasia, identical with the jirocess observed 
in the anterior urethra. This hyix'rplastir contlition is amenable to suc- 
cessful treatment by dilatation and caustics, but unheeded, will develop 
into permanent stricture. 

Internal urethrotomy of a deep-seated stricture is a much more grave 
undertaking than the cutting of a stricture of the anterior urethra. Both 
the danger of hiBmorrhage and the difficulty of controlling it, should it 
occur, render the operation serious, iltemorrhage from the posterior part 
of the urethra, lying behind the "cut-off" muscle, may long remain un- 
recognized on account of the absence of free bleeding from the meatus, as 
the escaping blood wilt ^\jvf back into the bladder, and can be ex]-»elled only 
with the urine. For these reasons treatment by gradual dilatation should 
be carried on whenever possible, and uretlirotomy should be reserved for 
cases only that do not yield to dilatation after patient trial, or will not 
brook delay. When an ojieration is decided on as necessary, external nre- 
fhrotomij deaerrex the preference aver the infernal nprrntinn, especiaUtf in 
cases complicated by ammmiiaeal rysfitis. Ilfiemorrhage will l>e easy to 
control. The good drainage resulting from the external incision will pre- 
vent urine infiltration, and ready access to the bladder will facilitate anti- 
septic irrigations of the organ. 

Exii'rnal Urethraiamy. — The auffisthetized patient is brought in the 
lithotomy position, his hands being bandaged to the feet, which iu:e then 
wmpped in clean towels, wrung out of corrosive-sublimate lotion. The 
perinaeum and anal region being shaved (uul rubbed off with the same 
lotion, the operation begins. Irrigation of the wound by I'hiersch's solu- 
tion is carried on during the entire operation. When a stutf or even a tili- 
form bougie win be carried into the bladder to serve as a guide, the opera- 
tion will offer no difficulty whatever. As soon as the urethra is ojiened and 
the stricture exposed, its division can be accomplished by the use of a blunt- 
fiointed tenotomy knife. External urethrotomy without a guide is not as 
easy, but its dirticulties can be overcome by patience and circumsttection. 

While an assistant exerts gentle pressure over the distended bladder, the 
bottom of the uretlmil wound being well exposed by small, shartt retractors 
or lillets of silk drawn through the lips of the urethral incision, one or two 
ilrops of urine will be seen exuding from one or another point of the strict- 
ure. A tine probe is inserted into the point in ipiestion, and will »>ften 
penetrate the stricture. A narrow, grooved director is insinuated along the 
probe, and serves to guide a sliar(»-pointed tenotomy knife through the con- 
traction, w^hich then can be divided without ditliculty. 

Should this exiwdiont fail, on account of inflammatory swelling of the 
tight part of the urethra, suprapubic aspiration of the bladrler may serve to 
tide over the difficultv. Ilelief of the distention of the bladder is often fob 



HU RULE8 OF ASEPTIC AND ANTISEPTIC SURGERY. 

lowed by decrease of the swelling, and a few hours after the operation nrine 
will be found escaping through the urethra, when the true cbanDel can bo 
searched out aud dilated. 

Case. — N. J^., laborer, agod 42, impermeable strictare of the meitibranons portioo 
ol" tlio tirotlira. March 11, IJ^SS. — ^External urethmtoTuy witliout guide. The strictare 
Lein>r ox|M>i*ed, ttumt diligent search tailed to ast'urtaia tliw direction of the chAODcsl, 
whicli was obscured by tJie intBraciwence and gresit vascularity of the parts. The di»*- 
lended bladder was fiaaHj^ ejnptitfd by snprahubic aspiration, and the patient wjis 
htLHight to bwl. Six hours later the bla<Ider hud refilled, and urine wa.s seen to trickle 
from the wouud whenever the patient strained. Renewed search was rewarded bj 
the finding of the right track, which wjis divided on the grooved director withoat 
much trouble or pain to the patient. May fO/A.— Patient was discharged cured. 

A modifieation of another ex{>edicnt. propossed by the venerable Petit, 
was also successfully eiuiiloyed by the writer. 

Ca6e. — •Inbn Smith, negro hostler, aged 31, suffered from impermeable strictorv 
of the deep urethra with daugerun^ distenaion of the bladder. The usual expedieoti 
for entering the bladder having failed, external urethrotomy was determined upon, 
and was carried out Decenxlyer 2, 1876. The distal part of the stricture being 0i])O!*eiI, 
mi entrance could be effected. As there was nu aspirating needle on hand, « slender 
trocar was in!«erted into the middle of the Btricturat mtuss, and wan pushed forward in 
the direction of the urethra, toward the center of the prostate, under the guidance of 
the left index-finger placed in the reetuui. The point ui' the instrument was several 
time» caught in the mass of the pro^itatic gland, hut finally entered the median C4UMil 
and the blftihier, this being uttoi^ted by the escape of urine. A grooved director wat 
put?hed in along the cannula, which was withdrawn, and the stricture was divided 
with a tenotoniy knife. A sharp attack of fever and cystitis followed, but the patient 
fully re»-uvered and was discharged cnre<l March 5, 1877. 

strictures located in the anterior urethra can be siinnltaneou5»ly dinded 
by Otis's urethrotome or the tenotomy knife before tlie patient recovers 
from the ana>.sthetie. The bladder is then washed out with Thiersch's 
Bolutttvn, and the wound is drcHsed with a pad of iodofornied and a compress 
of sublimated gauxe, held in place by a T-bandagc. In the presence of 
fetid urine, the use of a drainage-tube is advisable. Before applying the 
dressings the wound sboold be rubbed out with a stnall sponge di]»{>ed in 
iodoform powder. .Vnoiriting of the pcrinwum and buttocks with vagelinc 
isi necessary to prevent eczema. The extenial dressings ought to be changed 
whenever soaked ; the iodofornied pads, liowever. should not be disturljed 
without necessity as long as they are adherent. Daily sitz-baths in a weak 
(1 : 10,000) corrosive-sublimate solution will tend to increase the comfort 
of the patient, and will aid the healing of the wound. 

The daily introduction of a full-sized steel sound need not be commenced 
before the seventh day, and .^ihould be continued at increasing intervals for 
at least a year after the operation. 

Altogether, tlie author performed external urethrotomy seventeen times. 
Fifteen patients recovered, two died. The fatal cases were as follows : 

Cask I. — Mr. S. O., tailor, fifty-four years old. suffering fr(»Mi tight, deep-sealed 
stricture of the urethra, complicated with purulent and fetid pyelo-nephritis. The 




TREATMENT OF GONORRHflEA. 



315 



nriDe remained atntnoniacd, and the fi^tiilji never closed. He died, August 5, 188ti, of 
iirfBTiiifi, live fiiontlifi nfter the operation, <l(iiie M«rfli 25, 1886. 

Case II. — Abruliiim (tuIJIisIi, aged sevetit-y-suven, fufieriug from deep-seated ure- 
tliral stricture, fetid cystitis, and extensive urine intiltratiun of tlie perinmuni, due to a 
fake pa&saicre made by ii physician. Exlernal urethrotomy wat performed, November 
I, 188H, lit Moimt Sinai Hospital, with niui-h relief of the subiyctive svtnptowiB, but 
tlie patient succumbed to septicsQiuia uud septic uephriti.4 on Noremlter IB, 1886. 

Of the remaining cases, one descrvus speciiil inoution oti account of its 
rarity : 

Case. — S. E., shopkeeper, aged wixty- three, snatainod, in 1875, a compound fraeture 
of the It^f't h»rhovtal ramn« of the os puhiti, from whirdi be recovered iifter a long term 
of illness. In the springr of t883 Jni-'reaning ditticulty of micturition became notireable, 
and linally led to retention of urine. June 25, li^S2. — Tlje ainhor saw the cftso In eon- 
siiltntion with Dr. 1. Schnetter. A metrdlic sound eould he i)flHsed easily as far ns the 
inembrnnous portion, but wita there arrested by a grating, hard body, thought to be a 
sequestrum or a stone. Estenuil uretlirotoniy wa.s flone June 27th, juid an irregularly 
shaped sequestrum, one ineh long and one sixth of an inrli thick, was witlidrawn with 
some difficulty. Patient reci>vered witliout fistula, and was cured in about six woeket. 

b. Vegetations of the Urethra. — Venereal Tpo^etations, such as are 
frequently observed under the jireiuiee of men tiuffering from gleet, ueea- 
sionally occur in the urethra, principally in the fossa nuvicularifi and in 
the sinus l>ulbi. They maintain a rehellious urethral dit^chargc tliat can he 
stopped only hy their removal. Their diagnosi.s can be made by the aid of 
the endoscope, which al.-^o atfords the best means of access for their treat- 
ment. The use of the curette, or a small wire Buare, or of chromic acid iu 
crystaK will readily destroy them, and will terminate the urethral di.«cliarge 
depending on their presetice- 

c. Granular Urethritis. — One of the most tedious affections of the 
urethra is a chronic inflammation of the mucous membrane following an 
attack of acute gonnrrlicea, charactcriiied by an irregularly distributed hyper- 
semia and scanty discharge. The velvety mucous membrane Vileeds at the 
slightest touch, and the condition resists every form of local treatment for 
a disproportionately long time. It seems that the intractability of this 
affection dei>ends hi a great measure upon eongtitutioual dissorders; at least 
the author observed it most frequently in aua?mic individuals of a scrofuloua 
habit. Measures directed to the improvement of the general condition, and 
supplemented hy the local apiilicatioti of a five-per-cent solution of nitrate 
of silver by the endosco]je, seem to have been more efficient than anything 
else, though it must be admitted that a few ease's, resisted every kind of 
treatment, and ha<l to be given up as entirely unmanageable. 

d. Chronic (".itarhh op the Posterior Paut of the Urethra, 
and Chronic Cystitis. — Chronic cataiTh of the membranous and prostatic 
part of the urethra is frequently observed following an acute attjick of gon- 
orrhoea, in subjects formerly addicted to masturbation, or those indulging 
in general, and especially m sexual, excesses. In these cases no external 
urethral discharge is visible, but frequent micturition is present, and both 




TREATMENT OF aONORRHCEA. 



317 



until the returning fluid ceases to be discolored. By aud by, aa the hhidder 
becomes more tolerant, the injection should be made more forcible, as a 
thorough stirring up and dislodgment of the ropy sediment by tlie jet of 
lotion is very essential to its comj»]ete evacuation. The strength of the 
medicinal lotion should also be gradually increased (to 1 : 1,000). 

In cases of paresis, or when a tendency to vesical haemorrhages be pres- 
ent, cold, instead of tttpid, injections will be apprupriatc. 

In obstinate catarrh tlie strength of the permanganate-of-potash lotion 
c^n be increased to 3 ; 1,000, Alum (from 1 : 100 to 5 : iOO), sulphate of 
zinc (from 1 : 100 to % : 100), and nitrate of silver (from J : 100 to 2 : 100), 
will also be found very effective, Deodorization of fetid urine is readily 
effected by injections of a 3 : H<0 aolntion of resorcine, which should be 
followed up by the employment of one or another of the medicinal solutions 
above mentioned (ITltKuiann). 

If the capacity of the bladder be very much diminished by long-con- 
tinued spastic contraction accompanying gonorrhceal or calculous cystitis, 
gentle and gradual distention of the organ by salt water or nieilicinal in- 
jections of increasing volume will bo followed by increasing tolerance. 
Thus micturition will gradually become less frequent, and the normal con- 
dition of things may be re-established. 

N'oTK. — iiradiial dbtoiitioii nt the ahruuken bladder of elderly persoos i» daiigerouB, as it 
may lead to rupture of diverticula. 




CHAPTER IX. 



NATURAL HISTORY AN^D TREATME^TT OF OONORRHO'IA. 
L ETIOLOaT OF QONORRHOIA. OONOCOCOUB. 



Ftci. 232. 

Pure ciilfuro of 

>fonmT>ecuii(7<K) 

(From Bumtn.) 



9 



In examining the pnralent secretion produced by a virulent case of ure- 
"€hral gonorrhtea, the observer will detect with the microscope a nnmbGr of 
^ark, round objects rescmblino; gniins of tine gunpowder, that are vividly 
oscillating, and can be clearly distinguished from tlie adja- 
cent pus-corpusclep. The u^o of a stronger lens will revejd 
tJie fact that each individual coccus is divided in two uu- 
e(]ual halves. If staining is employed, tlio body of the coc- 
cus will appear colored, and the dividing-line will become 
rery conspicuous in the shape of a light, colorless streak. 
(Fig. 233.) 

Frequently an indication of incipient secondary division of each half of 
the coccus can be seen. Thus four cocci will be united to a seemingly single 
body, which can be aptly compared with four coherent biscuits, divided into 
equal quarters by two cross! - shaped 
grooves. 

The. favorite location of the gono- 
coeei found in the urethral secretions 
t* tvitkin the pus-corpusdes. This 
pecuharity belongs exclusively to the 
coccus of gonorrhoea detected by Neis- 
rer in 1879, and represents its most important charac- 
teristic (Fig. 234.) 

Gonovocci are to be found iti the secreiion of everif 
ease of gonorrhmt, provided that no germicidal injec- 
tiona were used. 

Infection of the urethra with pus containing gono- 
cocci always produces gonorrhma, and secretions that do 
Hot contain gonococci are invariably non-infections if 
brought upon the urethral mucous membrane. 

Oonococci have a peculiarly itnfaftive faadftf, by which they penetrate 
first the superficial layers of the epithelial membrane, and gradually by 
further proliferation the submucous layer. (Fig, 23C). The route of their 



Fif,. 233. 
Devt-lopment mmI 
fission of frono- 
co«;a<(. (From 
Bumui. } 




Fio. 884. — Epithuluil 
ogII studded with 
jTonoctHX-i : puB Ofll, 
iL'' rirotoplafim filled, 
with ^^noLvieci ; all- 
ot licr piLi it'll K'orgetl 
with jfiiiiococci ; a 
proup itf free cooci 
uliingside nl' K nor- 
mal puH - cell (700 
diiimc'iers). (From 
Bumm.) 




300 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



^#5^ 







Fio. 2S5. — Vertii'ul «!L"tion thmugh mu- 
oous mcmbnoe, Btiowiu^ ittt coIoili- 
xation of ^noooooi (700 diamotcra}. 
(From Bumm.) 



inroads is along the intercellular substance. An intense h\7>era?mia of t 
capillaries and other blood-vessels adjoining the scat of the primary inf( 
tion leads to a massive emigration of white blood -corpuscles into the affect^^=d 

epithelium. Tliiij and the growth of the gonococcal colonies lead to a mp id 

^^ disintegration of the epithelium, which is 

washed away by the lymph-serum in t^Hie 
shape of single cells or in coherent c^^ni- 
thelial flakes. Loss of the epithelial it di- 
vestment ifi often followed by the esn(^ a- 
tion of a croupous membrane, benea. "•h 
which clumj>s of gonococci are to Ix? se^^" 
in process of active proliferation. Goim ^>' 
cocci can be found occupying at tb» i* 
stage the interstices of the subepithelial tissues, their columns exteu. ^■' 
ing inward along the lymphatics, whence, according to variouB uuthc^ ^'^ 
(Kammerer), they may be tmnsported to the endocardium, the joints, Mr:»" 
the synovial sheaths of tendons. 

With the deeper invasion by the gonococci goes pari passu the dei»- 
infiltration of the in- 
fected tisaues with 
leucocytes, the ex- 
tent of which serves 
as a gauge of the in- 
tensity of the infec- 
tious process. 

At the acme of 
the process, general- 
ly reached about the 

end of the second or third week, a regeneration of the lost epithelial la 
commences. Com]tlete restitution of the epithelium eignalizos the termi 
tion of the malady, which, however, is attained only in favorable cases uncn^ivf 
favorable conditions. Generally primarily unaffected part;? f>f the mucc-^^^'** 
membrane become involved by spontaneous extension of the infective p — ro- 

ce&s, or by the improper ^^■iw 
of instruments ; or porti 
which have recovered : 
cunib anew to gonococcal 
struction. 

The regeneration of 
epithelium is always ace 
panied by liyjterplasia, wl» 
.somewhat resembles by 
tubular formations epitheliomatous mucous membrane (Bumm). These "0 
of epithelial hyperplasia are often coincident with the seat of the most int^*«' 
primary affection. They also correspond with tliose parts of the subma(y*'0* 
layer at which the most intense inflammatory intiltratiou waj* present. 




Fia. 



2.36. — luvwioD of epithelium by (^nococci f700 diaawtan] 
(From Bmiini. > 



er 




^^ >t;^ ^ 






Fio. at7. — I'rolitemliou of gonococci in the optthoHum 
(700 diumeters). (From Biimrn.) 






CflAPTEF! X. 



ASEPTICS AXD 



AXTISEPTfCS APPLIED TO KXTERXAL RYI'iilUTIC 
LESIONS. 



L Aseptic Treatment of Primary Induration.— The nature of the specific 
virus of gyphilis is not known. In most canes its local and general mani- 
festations are amenable to appropriate system in and topical remedies. 

It is not intended here to dwell upon lire nature and treatment of 
syphilis as a general diseiise ; only in!ii>niuch as some of its more eommon 
local phenomena require surgical treatment will their consideration be 
deemed within the limits of this chapter. 

The anatomical structure of the primary induration, of tuberous syphi- 
lides, and of gummy swellings, resembles cloi?ely that of recent tuberculous 
deposits; and their course of development and termination in central 
coagulation necrosis, fatty changes, or caseation, also bears much genera) 
resemblance to the aflfections caused by the bacillus of tuberculosis. But 
there is a third point of parallelism. 

As long as softened tuberculous or syphilitic foci remain subcutaneous. 
and are not exposed to the ititlufnceof the air and its pus-geuemting germs, 
their coarse is bland and slow, and their tendency is to fatty degeneration, 
encapsulation, and final absorption. But, as soon aasuch a softening deposit 
comes under the influence of the pyogenic elements contained in tlie at- 
mospheric air, its slow and bland character is changed to a most destructive 
one. Thus syphilitic nodes of the internal organs, being protected from 
contact with the outer air, rarely, if ever, termiuaie in nlcerative destruc- 
tion : they generally tend to fatty involution, absorption, and cicatrization. 
Specific deposits of the outer skin, the mncons memhrancB — as, for example, 
of the nasal and oral bones — on the other hand, are all noted for their pro- 
nounced tendency to rapid ulteration or gangrenous destruction. 

As an illustraMon of a parallel behavior of tuberculous foci, cold ab- 
scesses and articular tubereulosis may bo mentioned. Before perforation, 
their course is mild and slow : but after the establishment of one or more 
sinuses they become the source of profuse secretion* and their course is 
characterized by rapid local destruction with general emaciation. 

The explanation of this peculiar difference in tlic behavior of syphilitic 
indurations or tumors, essentially identical in morbid character, is to be 
found in the fact that the poor nutrition and low vitality of the cellular 





302 RULES OF ASEFHC AND ANTISEPTIC SURGERY. 

The second or deep portion of the urethra eongista of a fraction of CMt^ic 
membninoiis jmrt, together with the prostatic portion — in short, of all tbt-^-sAt 
is situated behind the " eut-otf muscle." 

This posterior portion of the urethra is correctly called the neck of r.^^ 
Mmidfr^ as it forms one cavity with the bhidder whenever this becoa^M^A 
disteiuied with urine. The internal sphincter alone, unable to resist ioife.jK» 
yields readily to tfie pressure of the urine. The voluntary contraction ^^f 
the corapre-*sor nrethrae becomes, tlien, the only barrier to the escape of t'B^^ 
urine, and water is voided immediately after the relaxation of this muscle^ — 

Di.'^chargea secreted in the posterior part of the urethra can not esca 3K** 
outward past the compressor muscle, and do not appear at the meatus i«^ 
the shape of an external discharge, as those of the anterior urethra. TIl-^^3 
accumulate in the neck of the bladder, and are voided only with the urin^^^^ 
which is rendered somewhat turbid by this admixture. 

A very useful practical test for determining the Beat of urethral iol 
mation is that sugfjested hy Ultzmann. 

The patient is made to pass his water consecutively iuto two tumble 
so that the amount voided should be about evenly distributed in the 1' 
vessels. Whenever the anterior urethra atom is the seat of inflainmaiit 
only the first half of the urine will be turbid^ or at least will be found c« 
taining flakes and threads ; the. second portion will appear perfectly clear 

In cases of fleep-seated urffhritis — that is, whf.n the neck of the bladt 
is affected — the firtit ItimMer will receim flaky and turbid urin*', and i^At 
water held by the second ylas» will appear aUo turbid, but somewhat le»r -^ 
than thejirsf portion. 

An additional and most important symptom of the affection of the n^s^^lt 
of the bladder infrequent mictvrition, in acute cases accompanied by sev^?^'* 
spasm and the escape of a small quantity of blood at the end of the a-*:?*^ 
Simultaneously with the severe contraction of the vesical muscles, &«:■» 
tenesmus is observed. 

In every case of recent gonorrhoea the infectious process is confined *^ 
the anterior urethra, and first to its foremost portion alone. It eitec»"* 
from tlie meatus backward to the compressor urothraj, where it generak^^-? 
stops. In exceptional cases only does it jKinetrate to the deep urethra, ** 
the "cut-off muscle" seems to serve as an effective barrier to its ertensi*^" 
backward. 

NoTB, — Forcible urethral injecdonei made from a syringe containing too lurge a quantit;^ 
fluid, or the premalurc [ntrocluction of a sound, ure frequent causes of the infection of the x»^'^^ 
of the tiladdcT. 

The seat of the most intense inflammation of the urethra is in its na^^-**' 
rally widest parts — that is, in the fossa navicularis and the sinus bulbi. H^** 
we find h:)cated the majority of all strictures. 

tf, Antekiok Gonokkikeal Ukethkitis. — The treatment of anter»<^'' 
gonorrhoa^il urethritis should be very discreet in the first invasive stage *' 
the disease. It should consist of rest and appropriate general sedative ra***'* 
agemeut. Locally, cold applications will be found very grateful and effective- 




I 



ASEPTICS AND ANTISEPTICS IN SYPHILITIC LESIONS. 323 

adjoining noii-infiltrated parta of the skiu, and the formation of sujtpurat- 
ive buboes and other complications, will be obviated. The following case 
may serve as an illustration : 

Case. — 11. B., aged twenty-five^ preaented hiinaelf Januarj 2, 188T, with a hard, 
elevated node, the size of a nickel, occupying tlie dorsum penis, and another i^raaller 
ioduration near the freniilnni. Suspicious cohabitation had been indulfred in for some 
thfic iiiitil within a few ilnya of the visit. Bilateral indolent inguinal lyiriphadeuitis 
was noted, and the presence of Bpecific infettion wa;' Jissmned. The patient was kejit 
under daily observation, and was directed not to meddle with any blister that niii^iilit 
appear on tlie indarated «[K>ts. Jan tin ry 8th. — X yellowiah di.seolonttitjn was observed 
occupying thu apex of the larger mxle, and was looked upon an an indication that a 
pustale waa forming. The entire peuis was earefuliy cleansed with green soap and 
warm water, and was disinfected with o 1 : 1,000 .solution of corrosive sublimate, good 
care being taken not to break the transparent layer of epidermis covering the dis- 
colored spot. A thick layer of iodof«irm powder was sprinkled over bntli indurated 
noiJes, and a small put<-'h of iodofortuized gauze was placed over them — this being held 
down by a narrow, oblong cuniprcss of eorroRive-subliinale gauze, snugly liaudaged on 
with a muslin roller. The meatus was left exposed for mietiirition, and the patient 
was directed not to interfere with the dressings arui to report daily. The first dress- 
ing remained undisturbed until January 17lh, when its external part, getting disar- 
ranged, was reioijved. The strip of iodoform gauze was found tirmly .ittaehed to the 
nmierlying indurated nodes, and had the appearance of a hard, Hat cake, that had been 
evidently noaked through hj lymph or serum some time since its application. Evap- 
oration of its aqueous contents had converted it to the shape just described. It was 
left in »jf «, and a. freah outer dressing was applied. 

At the sjinie date (lanuary 17th > the girl with whont the patient had held com- 
rneice, |>resented hei-sclf for examination at the author's reiiuest, and was found to bo 
covered with a small, papulous, specific rash. The appearance of her throat, the uni- 
verajtl adenitis, and twu freshly-cieatriKed wpots on t[i« labia ininctru, left no doubt of 
her being subject to florid sypliilis. She remained nmler prolonged specific treat- 
ment, and in July, 1887. stilt exhibited pharyngeal ulcorationa. 

,fanuttry 25th, — The dressings ufijilicd to the [Hitient's penis became again disar- 
ranged, and liad to l>e nmewcd. The immediate citvering of tlie nodes, consisting of 
iodofi»rin gfiuze, was still tirmly adherent, uml was left inichanged. 

Fehrnarn Irith. — A general maculous rash appeared on the patient's body, and sys- 
temic troattnent by mercurial inunctions was eomnieneed. 

Februttrii 30th. — The entire dressings came off — the strip of iodoform gauze in the 
flbape of a perfectly dry scab, to the inner side of which was found nttached a patch 
ot shiny 8<.'ales, consisting of effete epidermis. The not'es, which were formerly promi- 
nent, had receded to the it*vi-l of the surrounding skin, and the induration, which still 
could be felt, was marked by a coat of fresh-looking yonng epidermis. The patient 
received titty inunctions of blue ointment^ which freed him frotu all cutaneous symp- 
toms of the disease. In May, pharyngeal ulconitions appearing, the inunctions were 
rasanied. Size and hardness of the initial sclerosis were nsibly diminished by this time. 

It seems in the fori'goinjj cai?e that the ulcerative destruction of the pri- 
mary indnrntion was forestalled by disinfection aud subsequent aseptic 
management. Without them the irnmiuetit formation of an initial sore wouhl 
have inevitably occurred. The treatment of the fully-developed chancre 
would certainly have been a much more disagreeable, painful, and filthy ex- 



1 



324 



RULES OF A>SEPTIC AND ANTISEPTIC SURGERY. 



perience than the simple manipnhition of once cleansing and protecting the 
initial induration. The sit43 of tlie morbid process thus protected against "ex- 
ternal irritation'" — that is» pyogeutc infection — r;in, as it were, a eabcuta- 
neous and bland course of slow involution, the aggregate of discharge during 
forty-three days not exceeding the tiuiall rjuautity re<[uired to permeate a 
strip of four layers of iodoformizod gauze, covering an area of abont two 
thirds of a square inch. 

2. Antiseptic Treatmeot of tlie Primary Syphilitic Ulcer.— The result* 
obtained by the various time-honored and well-eHtablished forms of local 
treatment of the primary syphilitic ulcer all bear out the assumption that 
the specific alteration of the aifected tissues only serves as a predisposing- 
condition to the subsequent ulcerative destruction of the initial sclerosig. 
The ulceration is directly produced by the ingrafting of purulent infection 
on a soil, devitalized by the dense cellular infiltration, characteristic of 
initial sclerosis. The rapid destruction observed in chancre is always sig- 
nalized by the detacliment of the epidermis raised in the shape of a pustule, 
under wiiicJi we tind a yellowish, brittle necrobiotic nucleus, which is the 
first to succumb to the onslaught of the pyogenic organisms, depossitA^ni on 
it by the manipulations of the patient or otherwise. 

The variaus forms of local Ireaiment auccesgfully employed for the cure 
of rhancre are all aniiaejdir in vhararter. 

Their aim is either the promjit removal of the infections discharge by 
prolonged baths and frequent moist dressings, or disinfection by weak or 
concentrated caustics, or a combination of measures directed toward a rapid 
mechanical removal of the deleterious secretions, with chemical disinfectiou. 
As the most powerful and most elTective arrester of the destructive course 
of phagedenic chancre, the actual cautery is to be mentioned — the sover- 
eign destroyer of all microbial parasites. 

a. Chemical Stekilization and Surface Draixaue hy Medicated 
Moist Dressin(J8. — The energy to be applied to the loeal treatment of an 
ulcerating initial sclerosis sliould be proportionate to the virulence and de- 
structiveness of the morbid process. In most cases the resistance of the 
vital forces combating the morbid pnicess will be sufticient to check the 
damage. This is attested by the numerous cases of neglected chancre that 
end ultimately in spontaneous cure. Hence, in most instances, a mild 
treatment by local antiseptic baths, combined with moist antiseptic dreaft* 
ings, will answer the purpose. 

Frequent removal of ike soiled dressings forma the moat essential part 
of this plan of therapy. The patient is directed to provide himself with a 
wide-mouthed, one-ounce vial, which is filled with suitably proportioned 
small, flquare pieces of lint or gauze, over which is poured a moderate quan* 
tity of a one-per-cent solution of carbolic acid, or a 1 : .l/XK) solution of 
corrosive sublimate. The cork-stoppered vial cau be easily carried by the 
patient, who is enjoined to dress the sore or sores at least once every hour, 
and oftener if the discharge be very jirofuse. In the morning and evening 
a prolonged local bath in the same solution is advisable. In many cases 



ASEPTICS AND ANTISEI^TICS IN SYPHILITIC LESIONS. 325 



this plan will be sufficient to check the extension of the ulcer, ami to bring 
about cleansing of it.s bottom. 

Another mild form of antiseptic treatment consists of the uitplication of 
iodoform powder to the ulcerating surface. Tbe objectionable odor of the 
drug can be excellently nuksked by the admixture of equal parts of freshly 
roasted and ground cotfee. As soon as the ajypearance of a cicatricial bonier 
ia apparent, these modes of treatment sliould be abandoned in favor of the 
application of strips of meeurial plustor, which sibonld be renewed in jiro- 

' portion to the amount of discharge. Cicatrization will be very much has- 

B tened by this change. 

" b. Chemical Sterilization' by Stkoxo Cavstics.— Ca^jcs of greater 
virulence which do not yield within a fnrtniglit or so to the mild plan of 

P treatment by scrupulous cleansing and disinfection, or in which rapid ex- 
tension of the ulcer doen not justify temporizing, require the ajiplication of 
escharotics. The author iias found a Jiftif-prr-vent dilution of rhhn'idf of 
^B zinc the most convenient and most effective of al! chemicals recommended 
for tfre cauterization of chancre. Its ajiplication is to I»e done as follows: 
The ulcer and its vicinity are subjected to a careful cleansing by a nmp of 
^^ cotton dipped in a 1 : l,()Of> solution of corrosive sublimate. Crusts and 
^" scabs overlafiping the edge of the sore must l>e gently removed. A small 
piece of clean blotting-paper is applied to the ulcer and its vicinity with 
gentle pressure to remove all moisture. A moderate quantity of the caustic 
solution is applied to the sore with a glass rod or match-stick, care being 
taken not to corrode unnecessarily the surrounding healthy akin. Previous 
thorough drying of the integument with blotting-paper will Ik'sI prevent 
I overtlowing of the eau.stic. All the nooks and indentutionM of the margin 
^b- of the ulcer must be carefully covered by the solution. As soon as the base 
of the sore assumes the color of parchment, which will occur in fronj three 
to five minutes, cauterisation is completed, whereupon the surplus of caustic 
should be removed by the application of another piece of blotting-paper. 
The eschar is dusted with a little iodoform and coffee-powder, and is pro- 
tected from injury by a strip of moist lint or gauze. 

If the cauterization was suftieient, further extension of the ulcerative 

process will be arrested thereby. In from two to six days, according to the 

depth of the eschar, a narrow line of demarkation will appear, and, the 

eschar being detached, a healthy granulating snrfacc will become visible. 

'^m This should t>e dressed with strips of mercurial plaster unti! cicatrization is 

H completed. 

^1 Insufticient chemical cauterization will not check the ulcerative decay 
™ of the tissues. In proportion to the incumpleteness of the application, par- 
tial or total extension of the ulcer will be observed. In some cjuses only u 
t^jngue of renewed ulceration will be seen extending outward from the mar- 
^ gin of the eschar. In others, the ulceration will spread all around the 
■ cauterized patch, thus demonstrating the entire inadequacy of the ajiplica- 
tion. The surgeon's error should be in favor of too much rather than too 
little of the caustic. 




326 



RULES OF ASEPnC AND ANTISEPTIC SURaERY. 



Whi'Ti the process is found to be extending mure or lose in 8pit4? of a pre- 
vious cauterization, the deficiency should he corrected without delay by a 
renewed application. 

c. 8TER1LIZAT10N BY THE AcTfAL Cautery. — Phagedenic forms of 
chancre, occurrincr on the penis, lips, or tinkers, tmd t-haracterized by du5ky 
swelling aud a rapid ly-spreadiug, more or less gangrenous decay of the tissuer, 
can be mrely arrested by anything short of the energetic application of the 
actual cautery. In .some cases renewed seuring will he repaired to check tlje 
trouble brought under control in one portion uf the ulcer, but extondiiig 
further in another direction from n limited jiart of the lesion. It is espe- 
cially important to search out all recesses overlapped by the undermined 
margin of integument, a« they are the chief nidus of active infection. The 
thermo-cautery, or red-hot iron, should be well inserted in all of these re- 
cesses and sinusen, otherwise the result will be incontplete or entirely iin-« 
satisfactory. The wound should Ik' packed with very narrow .'^tripg of iod< 
form gauze while the patient is gtill under the influence of the indisjwn sable 
ana'^thetic, and care should Ix? taken to line all nook)* and crevices of the 
irregtdar vvonnd with the gauze. The object of this is to prevent retention, 
and to secure ]>rompt disinfection of the discharges which needs mast 
absorbed by the dressings. The penis is enveloj>ed in an ample eomi>ross,' 
moistened with warm carbolic lotion (one per cent), over which is [daced a 
piece of rubber tissue to prevent evaporation. On the penis, tlaily change 
of dressings is to be done afteir a hip-bath, which will very much facilitate 
their painless removal. The febrile disturbance regularly noted with these 
most virulent forms of specific ulcer, and the 
general deiiility and aujemia, wliich is its 
main predisposing cause, rerjuire appropriate 
roborant aud anti-febrile general treatment. 
As soon as cicatrizatiot: shall have com- 
menced, the affection is to be treated like 
a simple ulcer. 

Tlio foregoing view of the relation of snp- 
(mration to sy}thilitic lesions is based exclu- 
sively uivon cliuical data, and ueeds corrobo- 
ration at the hands of pathologist* more ex- 
jMirt in .systematic aud exact research than 
the author. One object of these re- 
marks was to arrange the clinical 
facts i>ertaining to syphilitic ulcera- 
tions under a general principle, from 
which the therapeutic measures usn- 
ally employed for their cure could be 
easily and logically deduced. 




I N D 


E X. 


1 


AbrlomiDtil drainage, 18B. 


Ana>stlictir? in herniotomy, dtnt^rous depresa- 


I 


operations, 11 S, 


in<: i-fftH't of, 126, 


^H 


autiirc, 130. 


.VnciiriuDD, 48. 


^^H 


toilet, 13H. 


tiecdlc, 48. 


^H 


AbMKAs, anal, 254. 


Aauhylosi.t, bnny, 84. 


^H 


of Ikidp, 2aR. 


Ankle-joint, exaction of, 2tf3. 


^H 


WFTical, 220. 


Antisepsis, 27, 167. 


^H 


cold. •-'•'.l. 


Antiwptics appSied ti> i>riinary syphilitic ul- 


^H 


formation of, 170. 


cer:*, ,'124 


^^1 


9L gbudiilar, 189. 


Apn*ca after (racheotomy, 1"»1. 


^H 


1 iliac, 247. 


A[i[mrtttui* ftir the after- treatment of the vx- 


^H 


■ uf liviT, 'JM. 


eecl'.'d elbow- joint, 2St. 


^H 


1 liinilijir, 2.'! I. 


Aprons, 20. 


^H 


H manuiian', 22S. 


Arm, suppumlion of, 280. 


• 


H nijt)i(»id. Til. 


Arteries, ligature of, 47. 




H iiietaHUttic, 181. 


Artery forcvp«, 66. 




^^ pelvic, 24<». 


Arthrotomy, 7.'», 79. 




pcrincpbriiic, 261. 


for cibow fracture, SO. 




H peritypliliiit', 246. 


for djthx-ation, 7S». 




H prevesical, 247, 219, 


for Iwibvtual di.tlocfttion, 8. 




^1 psonH, 24)'i, 


,\rtiti4-iat nnieiniu, 66, 




^K retroi>eritonral. 246. 


aims. 122. 




^^^irfplf'limitiition of, 180. 


Aseptic cap, 89. 




^^^Onsillnr, 


Aiiepttlri, a. 




^M temporal. 221. 


in [teritoneal ojieiations, 115. 




^L Amdt'ntal wound::, 2V. 


A.icptic w«unij», a. 




^m Aotitie add, 1 1 . 


acctdeutiil wounds', 82. 




^V Active nioTeinent» after juiut cuHHrtioti, 278. 


Artepties of ain[iutati()n, 59, 




H Actual cautery for syphilitic ulcere, 326. 


of the orifice.s, 93. 




^m Adhesions, attdumionl, lUrt. 


of rectujn, l.'»4. 




^M ^K'.lt«r pn«umt>mii, 148, 119, lt»2. 


Axilla, cvncuulion of, 111. 




hcphritip, 118. 


Axillary jtlaixLs 238. 




A[iifMitiitirin.'<, M. 


vein, 111. 




H drcti.'^in}:.^ after, 72. 






H Annl ali.sce«.i, 254. 


B«ctcritt of piilrewence, 171. 




Anal fistula, 25». 


Bismuth, 1 1. 




^- eseision of, 2B6. 


Bladder, ivntiseplic:* of the, 159. 




H itutiirc of, 21j7. 


tn-alnicnt of, before ovariotomy, 1S8, 




" luberculoiiR, 269. 


Bloodclot, healing under the, 6. 




Atutomy of connective-tissue planes of neck, 


Bone ak-tceMt, 2<)S. 




H 208. 


tuberculo.xii", 27;i. 




H pUnes of pelvis, 246. 


Boro-salicylic lotion, 10, 


I 



808 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY 



of nitrate of silver. To i^nahle an exact npplicatiau of the caustic luw/rr ihi 
guidance of the eye, the e7tdosctipt' mui<t bt' used. 

The endoscope is u cyliniirifiil silver tube of from four to sis inches in 
length, arid of various calibers, {Fig. 244.) An obturator facilitaies ito 
painless introduction, and a flange or sbield made of bard rublnr. baviu»j 
**dcad finish," permits an easy handling of the instinment. Strong ani- 
ficial light or sunlight is needed for endoscopy. The patient reclines on a 
tall chair, or sits on the edge of a table, hi.^ back supported by a m\Mi 
rest, the examiner occupying the space between the jiatient'a legs. Topr> 
tect the patient's clothing against soiling with blood or chemicals, a piece 
of rubber cloth (eighteen inches square}, provided with a ^mall central dil 
just long enough to permit the slipping through of the penis, is spread on 
the pnbie region. Thus the only object exposed to view will bo the |>atieiit'i 



&.TIEMAKM KCQ. 




Fig. 244. — Klotz'n uretJirul cndo!»t.t>po. 



penis. Over the rubber cloth a clean towel is laid for wiping off fingers, 
etc. A basin containing a number of slender match-sticks, their emli 
armed with tnfta of absorbent cotton, is at hand, and a pus-basiu u neicito 
it, to receive the soiled sticks. On a little table adjoining the oiK*rating- 
chair are a small, wide-mouthed bottle of glycerin and a few glass suit- 
cellars or hour-glasses for the reception of such solutions as may be reqoinii. 
Of these the author uses two — a five-per-cent solution of nitrate of siUei J 
and a ten-per-eent solution of ttie same substance, both in dark buttles. ■ 

An endoscopic tube of suitable i^ize lieing selected, it is lubricated '^^ 
a little glycerin, and is introduced well into the bulbous portion of tbcnn.*- 
thra. The obturator is withdrawn, and the surgeon by his head-mii'^'r 
directs a ray of sun- or lamp-light into the bottom of the tube, where tb« 
mucous membrane of the urethra is visible in the shajie of a typical im*?*' 
consisting of several concentric folds uniting to a centml, fiinnel-s<ba?^ 
depression. 

In sunlight the normal muroux memhrane is pale, of about the same "^* 
as the normal buccal lining, and on it are visible a number of delicate *^^ 
ings, produced by minute vessels. It is vei-y smooth and glossy, an^ 
folds of the image are flexible jind rather delicate, and present no chan^^*^ 
color on deeper introduction or ivithdrawal of fiif tube. ^ 

Injlamtd urvihrtE show an entirely different aspect. The most del -^ 
manner of iuti-oducing the instrument i^ apt to cause slight hjemorrh^^*' 
which sometimes is verv troublesome, as the blood fills up the tube f^^** 
than it can be mopped away, frustrating for the time being all fur"^" 
manipulation. When the mucous membrane, exposed in the bottom o^^ 
endoscope, is dried off with a pledget of cotton, it has a dull, deadgT ■*** 



J 



^ ^ INDEX. 329 1 


FollJcukr lonBillitis", '2l± 


Inguinal p^laudd, euppuratiun uf, 238, 246. 


Fresh aidavern, infec-tioiisnei^s of, 177. 


Injections, urethral, 308. 


Fnnne1-»ha>ii«l woiiiids, 40. 


In.striivnent-pflui.^h, 2H. 




tnteruiuseiilur Hftaee, 2W, 220. 


(?aatro»toroy, Hti. 


Internal urethroUiniy, 311, 


• iatize, 14. 


Interrupled !»uture, 45. '' 


comtsivv-subliniati!, 15. 


intuhutiun, 213. 


ioclnformizt'd, 15. 


lodofortn, 11. 


Giaijt fell, in iiibercuk»si», :J(i4, 


duating bos, 16. 


Ctlttndluliir tuberi-ulosiH, 209. 


Irrigation, 7. 


Gleet, 3ii7. 


eyntinuou.*, 23.'i, 


Goitre, li»7. 


of jdintH, 73. 


G«nrx>fw:cus, 2B9. 


of the neck of the bladder, 304. 


Giinorrfaifti, 'iM9. 


of the nrelhrn, 3(W. 


■ UCMtC, 301. 


IrrilBtioti, eiiloric, 176, 


H Anterior, 302. 


chemical, 17fi. 


H chronic, BO 7. 


mechanical, 175. 


H deep-seated, 304. 




H poistcriur, :S04. 


Joints, after-treatment of, 277. 
Joini-ex&eclion, 275. 


™^ (Jraniilar iiretlirili.x, 315. 


GraniilntionH, infeetion of, 1^4. 


Joint.«, T^uppuracion of, 78. 


tiroM dirt, 17S. 


tubereulosifi of, 275. 


Gunshot wouad«, 34. 


■ 


Kidney, Burgical, 253. ^ 


f Ilahittmiion to !>eptic influences, 183. 


Kloti's endoscope, 308, 


Hicmorrli'iidSj 154. 


Knee-joint esseelinii, technique of, 288, 


Hi*j)iostatie needle, 41. 


.•suppuration of, 242. 

Inberctilonis of, 289. J 


Halin'K incision for L'X!^.>ction of knei'- joint, 288. 


Hand, phlegiixjn of, 2<)0. 


Knock -knee, 83. 


HerniA, cun'.;enitiil, 130, 




H radieal operation for, 128. 


Lanpe'n position for nephrotomy, 262. 


H titrun^mbted, IIU. 


!.,aparotunty, eipioratory, 133. 
Laryngeal oiaTation?*, 87. 
Laryngofifisinn*. li*. 


Horninl H.ir, ireaiuient of, 120. 


Herniotomy. 117. 


■ iirt.>xsin>;K after, 127. 


Larynx, extirpation of, 104. 


H Halton-Roser'!< niotliad of incisitig nhdoesses. 


Loiidiihle pus, 184. 


■ 


Lead-plate i^ulure, Lister's, 45. 


m llip-reitt, Vuli{mami'.'>, 127. 


Le?, ulcer of, 241. 


IIi[i-joit>t eiucction, 285. 


L«p(uthris, 214. 

Ligatiirefl, 8. 


Hot appIiuUionn, 187. 


HydrtJcelF, 14 V. 


Litholapaxy, Bigelow's, 161. 


H tafipin^ of, Ifift. 


Little finsrer, suppurntion of, 232. 


H Rygronia, pmliferiiting, 271. 


Liver abucess, 2.'>1 


HyrterectoiHV, 143. 


Lumbar abBCCBH, 251. 




dressings, 254. 


Iliac abscesK, 247. 


LupuH, 268. 


bnnm, 250. 


Lyniphadenitii>, eaAeuus, 269. 


Iiiiinei-Kiun, tMntiMiiauft, 2715. 


Lvrnpliajigiti^, 185. ; , 


Incontinentia alvi, 2ft8. 


J 


H In/et-tiun, portals of, 171. 


Maas'a operation, 91. 


■ InlectiousnesH of tHin<«it!iti!<, :il4. 


Mamma, amputation of, 109. 


Inflaniinatinn, 178. 


Mammary iihsiees.x, 223. 


Injrrown toe-nail, 2Hy. 


Ma.xtili;i4, interstitial, 225. 


Inguinal glandu, 24S. 


yuppui-nlive, 22;{. 



^^^^330^^^^^^^^^^^^rNT)EX, ^^^^^^^^^^^^^^B 


^^M Mastoid absceMi, 2Sil. 


Phlegmon, cause of, lAO. ^^^^^^H 


^H Measles and tuberculosis, 260. 


Phlegmon, cutaneous, 186. ^^^^^^B 


^H Uwtotonty, 307. ^^H 


retro-phiiryngeal, 213. ^^^| 


^^H Mechanical irritation, l~ii. 


siubcuianeous, 1M5. ^^^B 


^^M Mikulicz's apcrution, 'IS'd. 


siibfasciul, ISi>. 1 


^^M Moist dre8(iing8, 13. 


treatment of, 1^<4. 1 


^H Mosx, 


Ililes^monous cry-'ipelos, 190. :J 


^^M MiifOii* tiicrnbruncs, tiiHcrculosis of, 2fl'.). 


Plastic operations, 88. ^^H 


^^M Multiple iiuiictiiring, VolkniannV, 186. 


Pleurisy, purulent, 226. ^^H 


^H Myiccdciua, InS. 


Pneumonia, from H-thcr, 148, 149, 1:^2. ^^H 




Predispojiition to tuberculosiii, 263. ^^ 


^H^ Nails, arrangement of, 84. 


Piepatellary bursa, 242. 


^^^^^H extraction uf, after cxsection of kate-joint, 


Prevesical abscess, 247, 249. 


^^^B 


Previsceral interspace, 208. 


^^^^^ for knoH'-joiiit cisicctioti, 289. 


Primary induration, syphilitic, 821. 


^^M Neck irf till' bladder, cuuterization of^ 306. 


ulcer, >ypliililic, 322. 


^^M irrigation of, 804. 


Probing of wounds, 193. 


^H Neck, c&seouB lyiDphadcniiis of, '270. 


Proctoplasty, 258. 


^^U canncclivc-liBsue gtlauoH of, 208. 


Prostatic syrinjje, Ult/mann's, 806. 


^^H Nec-rosi.s of hone, \9'A. 


Paeudoorjsipelas, 2110. ^^ 


^H of gut, 12». 124. 


Psoas aliscess, 246. ^^^| 


^^B NeiToiiitny, 194. 


PtoiiiuiueB, 4. ^^^1 


^H Noodle-holder, 41. 


Puncture of abiiomlnal ttnnors, 137. ^^^| 


^^1 Nephrectomy, H^ 


Pur.se-strini! suture, 126. ^^H 


^^M Neuber'g implantation, 2(iO. 


Putrescence, bacilli of, 171- ^^^| 




PyiPtnia, 182. 


^^M (Esophagus, retrograde calbeteriam of, 146. 




^^M cnni'er of, 14<i. 


Quadriceps, bursa of, 243. 


^H OlecraDic bursa, 238. 


Quilled suture, lr'.9. 


^^m Open treat nu'nt, t^6. 


Quinsy sore throat, 215. 


^^H Operating bu;;, 25. 




^H Oral cavity, «3. 


Radical operation for hernia, 128. 


^" Orehiiiti, tuberculous, 269 


for hydrocele, 150. 


Osteotnyelititt, acute infectious, 191. 


for varioocdc, 151. 


Otis'ji urcthroiueter, 807. 


Rectal lampon-tube, isr>. ^h 


Ovai'iau tumors, 140. 


HecCuni, aseptics uf, 154. ^^^| 




Retractors, 'A9, ■ 


Palmar bursa, 232. 


Retrograde cjitbelerism of cesuphagu^, 146. M 


suppuration, 231. 


Reiro peritoneal iibscess, 241). ^^^| 


Passive tiiovetrtents, 75. 


Retio-pharyn^eal abscess, 215. ^^^H 


after joint exeection, 277. 


Reiro-visceral triicrspaee, 208. ^^^| 


Pastfbnard splint*, 281. 


Uevision for tuberculosis, 274. ^^^| 


\ Pate'ila, Huturinp of fractured, 77. 


Rose's position of head, 213. ■ 


Pelvic absco9(*e.«, 24ft. 


Rublter sheet-', an aagciuent of, 75, So. I 


1 Pelvis, connective-tissue planes of, 240. 


Rubl>er tissue, 12, i:^. 1 


Perineoplasty, 91. 


I 


Pcrinepbritic abscess, 251. 


Sawdust, 16. m 


Peritoneal tuberculosis, 118. 


Sans, disinfection of, 68. ^^^H 


Peritona-uni, protection of, 138. 


Bi-heile's (In-ssing, 12, 20». ^^^ 


Periti>niti« aft»T abdominal Mctinn, 117. 


SiTliroedcr's suture of uterine stamp, 144. 1 


Perityphiitic obscesii, 24«. 


Scrofula, 2(J9. ^J 


Periviwcular interspace, 2<M>, 220, 


BepsiD, ^^H 


' Pes valguji. 8r<. 


Sepsis, ^^M 


Phelps's operation, 85, 

! 


Septic ferer, 179. ^H 


y ^ 


^^^a 




TREATMENT OF GOXORRHCEA. 



1, aod clierked funber bloodj inliltradua of the pmO» oA aeroCal lifMMM. 
ij, infection of the woond was rnnideA bj earefal asepcia, and thtu^ no teifw 
nmation following', th« entire eoonuoos extraTasation waa readilv abaorbed. 
ion of Urgie sounds iras commenced on the twelfth day, and after a itonits 
ODged coDvalesceni'e the patient rerovered. With tL« ivgnlar ase of the f ull- 
il 9oan(i, and an occasional irrivration 
»ck of the bladder, the patient i>uc- 
malntaJDiDtt a very comfortable state 




ie case just related, complete di- 
■ the posterior strictore, situated 
aJbo-membranous junction, led to 
ry of the bulbar artery, imbedded 
cicatricial mass constituting the 
'. Had the wound been infected 
se of uncleanly iDstrnmcnts. suj*- 
I and decomposition of the large 
infiltration might have brought 
snt into very great danger. 
rious objection to Otis's otherwise 
t urethrotome (Fig. 240) is the 
fficulty of thoroughly cleansing 
plicated instrument. 
author rerommpiuls the fitlhwin;/ 
d manner uf performing inttr- 
'hrotoynif of the anterior urethra 
*turt'a of wide caliber. A long 
It-shanked, rather narrow-hladed, 
linted tenotomy-kuife is first in- 
1 well beyond the ascertained 
if the Btrictnre. Alongside of 
lis'a urothrometer is inserted to 
e depth. The bulb of the latter 
eiit, being well dilated, is druwu 
until it is arrested by the strict- 
hilc the bulb of the urethrome- 
eld close to the mesial entrance 
stricture, the teuotomy-knife is 
and its sharp edge i.s applied to 
e cicatricial bands. It is drawn 
until the blade is psist the con- 
L Should the bulb of the ure- 
er follow without a halt, the stricture can be considered as suffl- 
divided ; should the division be insufficient, the bulb of the ure- 
er is closed, and the teuotomy-knife is slipped back past the stricture 
t the process of cutting. Thus the surgeon is sure of dividing onltf 




I 



d 



332 



INDEX. 



UrethrotomT, internal, 311. 
Uterine stump, 144. 

Varicocele, 151. 
Ydn, axillary, 111. 
Veins, exsection of, 61. 

injory of femoral, 66. 

lateral closure of, 66. 

treatment of, 42. 
Venereal vegetationa, urethral, 315. 



Vermiform appendix, necrosb of, 124. 
Vertical Buspensicm of limba, 236. 
Vesical tuberculosis, 269. 
Volkmann'a hip-rest, 127. 

multiple puncturing, 186. 

suspension splint, 286. 

T-splint, 74. 

White swelling, 276. 



THE END. 



TRKATMKVT OF GONOBRHCKA. SIS 

<ase8, in which strictaies vnre cat intifti. fully frooi vithin. Xo febrile ar 
inflaminatonr oomplicaDoii? wre tver ofaaeixcd. 

(b) Deep Creihrml Sfrieimre*. — Sciicmics of the deep niethni ar? locaU>i 
in the membnnoiu portion. Their deT^opment is preceded bj a stase 
of epithelial and solnmiooas hjperpbeiay idoitical with the process observed 
in the anterior oretlira. This hyperplastic condition is amenable to suc- 
cessfol treatment by dilatation and canstics, hot unheeded, will develop 
into permanent strictme. 

Internal nrethrotomy of a deep-aeated stricture is a much more grave 
undertaking than the cutting of a stricture of the anterior urethra. Both 
the danger of hemorrhage and the diflSculty of controlling it, should it 
occur, render the operation serious. Hemorrhage from the poisterior part 
of the urethra, lying behind the "cut-off" muscle, may long remain un- 
recognized on account of the absence of free bleeding from the meatus, as 
the escaping blood will flow back into the bladder, and can be expelled only 
with the urine. For these reasons treatment by gradual dilatation should 
be carried on whenever possible, and urethrotomy should be reserved for 
cases only that do not yield to dilatation after patient trial, or will not 
brook delay. When an operation is decided on as necessary, external tire- 
throtomy deserves the preference over the internal operation, eapeciallif in 
cases complicated by ammoniacal cystitis. Hsemorrhage will be eat^y to 
control. The good drainage resulting from the external incision will pns 
vent urine infiltration, and ready access to the bladder will facilitate anti- 
septic irrigations of the organ. 

External Urethrotomy. — The ansesthetized patient is brought in the 
lithotomy position, his hands being bandaged to the feet, which are then 
wrapped in clean towels, wrung out of corrosive-sublimate lotion. The 
perinaeum and anal region being shaved and rubbed off with the sanio 
lotion, the operation begins. Irrigation of the wound by Thiersch's solu- 
tion is carried on during the entire operation. When a staff or even a tili- 
form bougie can be carried into the bladder to serve as a guide, the opcni- 
tion will offer no diflSculty whatever. As soon as the urethra is opened and 
the stricture exposed, its division can be accomplished by the use of a blunt- 
pointed tenotomy knife. External urethrotomy without a guide is not as 
easy, but its difficulties can be overcome by patience and circumspection. 

While an assistant exerts gentle pressure over the distended hhuldcr, Iho 
bottom of the urethral wound being well exposed by small, sharp retractors 
or fillets of silk drawn through the lips of the urethral incision, one or two 
drops of urine will be seen exuding from one or another point of the strict- 
ure. A fine probe is inserted into the point in question, and will often 
penetrate the stricture. A narrow, grooved director is insinuated along the 
probe, and serves to guide a sharp-pointed tenotomy knifo through the con- 
traction, which then can be divided without difficulty. 

Should this expedient fail, on account of inflammatory swelling of \hv 
tight part of the urethra, suprapubic aspiration of the bladder may serve t.o 
tide over the difficulty. Relief of the distention of the bladder is often fol- 



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a feature which will be agreoble to nuoier- 

>^ .,. , _ i>uii purchasers. Some seeming excess of 

»^^ ^ ' conciseness in certain portions is exptainrd 

' by the fact that this is but one volume of a 

series proposed b^ the autlior, which will 
cover the whole domain of special pathology and therapeutics."'— .V<'</jVij/ and Surgual Reporter. 

"That six editions of such a work should be " The deser\-ed pmpularity of this work is attested 

called for in six years is, perhaps, the mofit flattering by the fact that the tirst edition was issued in itt^ 
testimonial that a book can receive, and must out- that a second was demanded in three montha, and 



<r ''»\ 



weigh every other comment, favi>rablc or unfavor- 
able. In the preface to thus edition is an announce- 
ment which will be welcomed by all of Dr. Barthiv 
low's numerous admirers, namely, that he has now 
in preparation another work on the ' Principles of 
Medicine ' which, together with the one under review, 
and his ' Matt-ria Medica and Therapeutics,' shall 
constitute a trio of volumes, each containing matter 
complementary to the others. Certainly three such 
volumes must constitute a monument whldiwill ren- 
der the writer's fame almost undying." — Medical 
Press 0/ Wester K New York. 

" Professor Bartholow announces m the preface 
o( thb edition his intention of preparing; a work iti 
three volumes which shall cover the whole domain 
of special pathology and therapeutics. The volume 
on ' Materia .Medica ' appeared some time ago, but 
the third volume, which will treat of the ' Principles 
of Medicine,' is now in course of careful preparation, 
and will, when p«h|t*hMl, complete a most valuable 
set. The pres** ' '''■' ■f Professor Bartholow 's 
' Practice ' is cor> r jjer than the last, several 

new subjects hav 1 introduced, tt^cther with 

numerous new iUusiratiuiis. It is deservedly popu- 
lar with practitioners and students, and likely ere 
long to become one of the standard works on prac- 
tice, if it has not already attained this position." — 
Fitcifii Medical and Smrgicjl Journal and H'es/em 
Lmmctt. 



that the others have followed there to rapid 
cession and l>een met by appiedative stufueots al> 
ways. The author says in his preface to this editioB 
that he has sought to make it wonhv of the appiv- 
bation of his readers by increasinp; tlr* practical re- 
sources id his work, devotmg hi' .hiefly to 
the clinical asp^-tsof medicine. ' riookine 
the advances made in the sden: .u. This 
book, like the previous editions ut Uic wurk. is the 
product of a master and an honored authority, and 
in its new form, with such of the latest ideas »s the 
author can conscientiously indorse or present Ux 
consideration, continues to hold its place among the 
standard text-books on all matters included in it."— 
North Carolina Medical jfoHmal. 

*' This valuable work appears in its sixth cdhiOM 
considerably enlarged, and improved materiallv ia 
many respects. The arrangement of the sul^ects 
appears to be pretty much the same as in former 
editions, and the description of diseases is also little 
modified. Some n« "^ ^ — have been added. 
however, and new v ' •diioed, making the 

volume completely f ' tire domain of prac- 

tice, without anylhini; i>u(,itrfluou5, Consideritit 
the immense scope of subjects, the directness of 
statement, and the plain, terse manner of dealiJtt 
with the phenomena of disease, this ptadical won 
has no counterpart." — A'atuas City Medumt Jl» 
i-rd. 





D. APPLETON 6- CO:S AfEDfCAL WORKS. 



ON THE ANTAGONISM BETWEEN MEDICINES 

AND BETWEEN REMEDIES AND DISEASES. Being the Cart- 
wright Lectures for the Year 1880. By Roberts Bartholow, M. A., 
M. D., LL. D., Professor of Materia Medica and Genera! Therapeutics in 
the Jefferson Medical College of Philadelphia, etc., etc. 
I vol., 8vo, Cloth, $1.25. 



<* We are ^lad to possess, in a fonn convenient 
for reference, this most recent summary of the physi- 
olofHCAl action of important remedies, with elie de- 
ductions of a careful and accomplished observer, re- 
garding^ the applications of this knowledge to dii- 
eased states." — College and Cliniciil Record, 

"There are few writers who have taken the 
trouble to compile the lucubrations of the multitude 
of scribblers who find a spwcific in every drug^ they 
happen to prescribe for a self-fSmited, non-malijj- 
nant disea-se , and fewer who can detect the trashy 
chaff and jjamer only the ripe, plump grains. This 
Hartholow has done, and no one is more ripe, nor 
better quahfied for this herculean task ; and. the 
best of all is. condense it all in his antagonisms. 
No one can peruse it.s pregnant poRcs without no- 
ticing the p.iinstaking research and large collection 
of authorities from which he has drawn his conclu- 
sions. The practitioner who purchase* these antag- 
onisms wnll find himself better quali6ed to cope with 
the multifarious maladies after its careful perusal." 
— Indiana AfedicaJ fif porter. 

" The criticisms made upton these lectures have 
invariably been most favorable, the topic itself is 
one of the most inleresting in the entire range of 
medicine, and it is treated of by the accomplished 
author in a most scholarly nianper. Dr. Bartholow 
worthily ranks as one of the best writers, while at 
the same time one of the most diligent workers, in 
the medical field in all America, and there can be 



no doubt that this, his latest contribution to medi- 
cal science, will add materially to his previously high 
reputation. Much profit, no little pleasure, and 
material assistance in the solution of many thera- 
peutical problems are to be obtained fn^ra a perusal 
of these lectures. The author has done wisely and 
conferred a boon by permitting their publication in 
the present book-lunn, and we are .satisfied it will 
be extensively asked for, and just as extensively read 
and appreciated.'"— 6"««<i</o Medkal and Surgical 
yournal. 

" It will be obsen-ed that the scope of the work 
is extensive, and, in justice to the author, not only 
is the extent of this indicated, but the character of 
it is also furnished. No one can read the synopsis 
given without being impressed with the importance 
and diversity of the subjects considered. Indeed, 
most of the important forces in therapeutics and 
materia medica are herein stated and analyced " — 
American Mfdical Bi- Wetkly. 

" Probably most of our readers will consider 
tliat we have awarded this treatise high praise when 
we say that it seems to us the most carefully writ- 
ten, best thought-out, and least dogmatic work 
•which we have yet read fnmi the pen of its author. 
It is indeed a very praiseworthy book ; not an origi- 
nal research, indeetl, but, a-s a r^svmJ of the world's 
work up<^>n the subject, the best that has hitherto 
been published in any language." — Philadelphia 
Medical Times. 



■WINTER AND SPRING ON THE SHORES OF THE 

^" MEDITERRANEAN; or, the Genoese Rivicras, Italy, Spain, Corfu, 

I Greece, the Archipelago, Constantinople, Corsica, Sicily, Sardinia, Malta, 

^H Algeria, Tunis, Smyrna, Asia Minor, with Biarrilz and Arcachon, as Winter 

^H Climates. By Jamks Henrv Benneit, M. D., Member of the Royal College 

^H of Physicians, London, etc., etc. 

' Fifth edition. With numerous Illuslratious and Maps, i vol., lamo, 655 pp. Cloth, $3.50. 

This work embodies the experience of fifteen winters and springs passed by Dr. Rennet on the 
shores of the Mediterranean, and contains much valuable information for physicians in relation to 
the health-restoring climate of the regions described. 



" ' \N''e commend this book to our readers as a vol- 
ume presenting two capital qualifications — it is at 



once entertaining aj)d instnictive." — New York 
Affdital yotirnal. 



ON THE TREATMENT OF PULMONARY CON- 

k SUMPTION, by Hygiene, Climate, and Medicine, in its Connection with 
Modem Doctrines. By James Henry Bennet, M. D., Member of the 
Royal College of Physicians, London; Doctor of Medicine of the Uni- 
versity of Paris, etc., etc, 

I voL, thin 8vo, 190 pp. Cloth, $1.50. 

An interesting .ind instructive work, written in the strong, clear, nnd lucid manner which ap- 
pears in ali the conlrihutiotis of Dr. liennet lu medical or general literature. 



" VV'e cordially commend this book to the at- 
tention of all. for iLs [iractical, common-«ense views 
of the nature and treatment of the scourge of all 



temperate climates, pulmonary coDSUOption." — Df 
tr<Hf Jiniitw 0/ Median*. 




PART V. 

SYPHILIS : 

EPTIC AND ANTISEPTIC TREATMENT 
OF ITS EXTERNAL LESIONS. 



CHAPTER X. 

ASEPTICS AND ANTISEPTICS APPLIED TO EXTERNA L SYPHILITIC 

LESIONS 

1. Aseptic Treatment of PrimMy Induration.— The nature of the specific 

^"irns of syjiliilis is not kMowii, In most ca.scs its local and general mani- 
■^«statioiis are amenable to appropriate systemic and topical remedies. 

It is not intended here to dwell upon the nature and treatment of 
^lyphilis as a general disease ; only inasmuch aa some of its more common 
^ocal phenomena require surgical treatment will their consideration bo 
<leemed within the limits of this chiipter. 

The anatomical structure of the primary induration, of tuberous syphi- 
lides, and of gummy swellings, resembles closely that of recent tuberculous 
deposits; and their course of development and termination in central 
coagulation necrosis, fatty changes, or caseation, also bears much general 
resemblance to the affections caused by the bacillus of tuberculosis. But 
there is a third point of jiarallelism. 

As long as softened tuberculous or syphilitic foci remain subcutaneous, 
and are not exposed to the infliuence of the air and its pus-generating germs, 
their course is bland and slow, and their tendency is to fatty degeneration, 
encapsulation, and final absorjition. But, as soon as such a softening deposit 
comes under the intluonce of the pyogenic elements contained in the at- 
mospheric air, its slow and bland character is changed to a most destructive 
one. Thus syphilitic nodes of the internal organs, being protected from 
contact with the outer air, rarely, if ever, terminate in ulcerative destruc- 
tion : they generally tend to fatty involution, absorption, and cicutrimtion. 
Specific dejvosits of the outer skin, the mucous membranes — as, for example, 
of the nasal and oral bones— on the other hand, are all noted for their pro- 
nounced tendency to rapid ulceration or gangrenous defitruetion. 

As an illustration of a parallel behavior of tuberculous foci, cold ab- 
scesses and articular tuberculosis may he mentioned. Before perforation, 
their course is mild and slow ; but after the establishment of one or more 
sinuses they become the source of profuse secretion, and their course is 
characterized by rapid local destruction with general emaciation. 

The explanation of this ]>ecnliar difference in the behavior of syphilitic 
indurations or tumors, essentially identical in morbid character, is to bo 
found in the fact that the poor nutrition and low vitality of the cellular 



lO 



D. APPLETON &> CO.'S MEDICAL WORKS. 



CYCLOPAEDIA OF PRACTICAL RECEIPTS, and Col- 
lateral Information in the Arts» Manufactures, Professions, and Trades, 
including Medicine, Pharmacy, and Domestic Economy. Designed as a 
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Reference for the Manufacturer, Tradesman, Amateur, and Heads of Fam- 
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Complete in 2 vols., 1,796 pp. With Illustrations. Cloth, $9.00. 

Cooler's '• CyclupwdJa of Practical Receipts " has for many years enjoyed an extended reputa- 
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(including vanitatlon, the composition and adulteration of foods), as well as to the Arts, Phar- 
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The design of this work is briefly but not completely expressed in its title-page. IndepentI 
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trial ajul useful arts, it contains a description of the leading properties and applications uf ll 
substances referred to, together with ample directions, hints, data, and allied information, Cf 
culatcd to factlitnte the development of the practical v,alue of the bix^k in the shop, the laborator 
the factory, and the household. Notices of the substances embraced in the Materia Mctlica, 
addition to the whole of their preparations, and numerous other animal and vegetable sabstJric* 
employed in medicine, as well as most of tho.se used for food, clothing, and fuel, with their e<.»>-' 
noniic apiilicatiims, have been included in the work. The synonyms and references are other addi^ 
tions M'hich will prove invaluable to the reader. Lastly, there have been appended to all the 
principal articles referred to brief but clear directions for determining their purity and commercial 
value, and for delecting their presence and proportions in compounds. The indiscriminate adop- 
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ula or process been admitted into this work, unless it rested on some well-known fact of ^enc«, 
had been sancti'ni' I '"' ^^~^^^,■ .,r , ,,rne recommended by some respectable authority. 

^^^^Svir% "^^ ^^^ DOMES- 

TICA 1 J ..S. By .\. LiiAUVEAUjTrofessor at the Lyons Vet- 

erinary School. Second edition, revised and enlarged, with the co-operation 
of S. Arloing, Sate Principal of Anatomy at the Lyons Veterinary School; 
Professor at the Toulouse Veterinary School. Translated and edited by 
George Fleming, F. R. G. S., M. A. L, Veterinary Surgeon, Royal Engineers- 
I vol., 8vo, 957 pp. With 450 Illustrations. Cloth. $6.00. 

ShTCIMEV of ItUtSTKATION. 



^.^ : ^^: 



" TaldoR^ it altogether, the book is a very wel- 
ooRie addition to Kn^tish literature, and great credit 
is due to Mr. Fleming for the excellence of the trans- 
lation, and the many additional notes he has ap- 
pended to Chauveau's treatise." — Lancrt {Ijondon), 

" The descriptions of the test are illustrated and 



assisted by no less than 450 exctUeni woodcoii. In 
a work which ranges over so vast a field of anatomic 
cal detail and description, it is difficult (n selrct ati 
one portion for review, but our examinatinn of 
enables us to speak in high terms of its general ev* 
ceUence. . . "^MtdUal Times and G^ttt* (f^ 

dfiH). 



ASEPTICS AND ANTLSEPTICS IN SYPEtlLITIC LESIONS. 323 

^^idjoiuing non-infiltrated parte of the skin, and the formation of guppurat- 
ive baboes and otiier complications, will be obTiated. The following caee 
may genre as au illustration : 

Oabb. — H. B., Aged twentv-five, presented himself January 2, 1887, with u hard, 
clcvattid nole, the size of a nickel, occupying the dorsnro penis, und anotlier jitnaller 
tadiiration near the frennlnm. Su-^picioas cohabitation hii<l been indulged in for some 
time until within a few dars of the Ti!<iit. Bilateral indolent iuguinal lymphadenitis 
was noted, and the presence of 8j>e«.'ific infection was assuuied. The patient was kept 
under daily "bservalion, and was directed not to meddle with any Idister that might 
appear on the indurated sputs. January Sth. — A yellowish discoloration was observed 
occupying the apex of the larger nrjde, aud was looked npon aa ati indicatiou that a 
pii.stule was fonuinjr. The entiru penis was farefiilly cleansed with (rreen soap and 
Karm water, and was disinfected with a 1 : 1,W0 solution of corrosive sublimate, good 
care being taken not to break the transparent layer of epidermis covering iho dis- 
colored spot. A thick layer of iodoforro powder was sprinkled over both indurated 
nodes, and a small patch of iodoforinized j^auze was placed over them — this being held 
driwn by a narrow, oblong fompre,*** of corroHive-siibrmiate gauze, snugly bandaged on 
>iyith a muslin roller. The meatns was left exposed for mlctnrition, and the patient 
^wa:^ direotud not to interfere with the drcwilngs and ro ri-port <hnly. The first dress- 
ing remained undisturbed until January 17lh^ when its external part, getting disar- 
ranged, was removed. The strip of iodoform gauze was found tirnily attathed to the 
underlying indurated nodes, and had the appearance of a hard, flat cake, that had been 
evidently soake<l through by lynifdi or serum some time since its application. Eva]i- 
oration of its aqueous contents had converted it to the shape just described. It was 
left in Bitu, and a fresh outer dressing was npidied. 

At the same date (January I7tb) the girl with whom the patient had held com- 
merce, presented herself for examination at the author's reijuest, and wai* fonnd to be 
covered with a small, papulous, specific rash. The appearance of her throat, the uni- 
versal adenitis, and two freshly -cicatrized spots on the labia minora, left no douht of 
her being suliject to florid syphilid. She remained under ])rolouged spccrtic treat- 
ment, and In July, 1H87. still exhibited phuryngeal ulcerations. 

January 25th. — The dressings applied to the patient's [tenis Lccaine again disar- 
ranged, and had to be renewed. The immediate covering of the nodes, oonsiijting of 
iodoform gauze, was still firmly adherent, and was left unchanged. 

Ft'bntary 12th, — A general maculous rush ai>[ieared on the patient's body, and sys- 
temic treatment by mercurial inun<tiitns was commenced. 

Fdtrunnj 20th. — The entire dressings came off — the strip of iodoform gauze in the 
shape of a perfectly dry scab, to the inner side of which was found nttncbed a patch 
of shiny scales, consisting of effete epidermis. The nodes, which were fonnerly promi- 
neot. had reeedetl to the level of the surrounding akin, and the induration, which still 
conld be felt, was marked by a coat of fresli-lo<»fcing young epidermis. The patient 
received fifty inunctions of blue ointment, which freed him from all cahmeous symp- 
toms of the disease. In May, pharyngeal ulcerations appearing, the inunctions were 
resnmed. Size and hardness of the initial sclerosis were visibly diminished by this time. 

It seems in the fnregoing case that the ulcerative destruction of the pri- 
mary induration was forestalled by disinfection and subsequent aseptic 
management. Without them tlie iramineut formation of nu initiiil sore would 
have iuevitnbl}- occiirro*!. The treuttueut of the fullv-dovflupt>d t^luuicro 
would certainly have been a much more disagreeable, painful, and filthy ex- 






« 



4 



824 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

perience than the simple manipulrttion of onee cleansing and protecting 
initial iiidiirution. Tlie Kite of the morbid procosn thus protected against "• ^^^ 
tenial irritatiun'" — that is, pyogenic infliction — mn, as it were, a subcuc;:^^. 
neons and bland course of slow involution, the aggregate of discbarge dur^^^ 
forty-three days not exceeding the small finantity required to pitrmea. 
strip of four layers of iodoforniized gauze, covering an area of aboat . 
thirds of a square inch. 

2. Antiseptic Treatment of the Primary Syphilitic Ulcer. — The f^^^vits 
obtained hy tlie vacion.s timo-honored and we!l-estabiished formn of ^o«t/ 
treatment of the primary syphilitic ulcer all bear out the assumption that 
the specific alteration of the affected tissues only serves as a pre«lispo.*ju< 
condition to the subsequent ulcerative destructimi of the initial sclertwj, 
The ulceration is directly produced by the ingnifting of purulent infectioa 
on a soil, devitalized by the dense cellular intiltration, characlcristic of 
initial sclerosis. The rapid destruction observed tn chancre is alwaw «g. 
nalized hy the detachment of the e|tiderniis ratised in the shape of a pustule, 
under vvliieh we iiad a yellowish, brittle neerubiotic nucleus*, which i« Ibe 
first to succumb to the onslaught of the pyttgenic organisms, dejtosiledoD 
it by the manipulations of the jiaticnt or otherwise. 

TJte various forms of local treatmcni succesiffully cmphyed for Ihccun 
of chancre are all aniiseptit' in character. 

Their aim is either the |>rom])t removal of the infectious dii^rharge by 
prolonged baths and frequent moist dressings, or disinfection by weak i>r 
concentrated caustics, or a combination of measures directed toward a rapid 
raechanieal removal of the deleterious secretions, with chemical disinfection. 
A« the most powerful and most effective arrester of the destructive conr« 
of phagedenic chancre, the actual cautery is to ha mentioned — the sover- 
eign destroyer of all microbial parasites. 

a. Chemical 8terilization axi> Sirface Drainage by Medicated 
Moist Dressjnos. — The energy to bo applied to the local treatment of an 
ulcerating initial sclerosis should be proportionate to the virulence uud de- 
gtructivenoss of the morbid process, in most cases the resistance of Ibe 
Tital forces combating the morbid process will be sufficient to chwk llm 
damage. This is attested by the nnmerous ctises of neglected chancre that 
end ultimately in spontaneous cure. Hence, in most instances, a niiW 
treatment by local antiseptic baths, combined with moist antiseptic dre* 
ings, will answer the purpose. 

Frequent removal of the soiled dressings forms the most easential pwt 
of this ])lan of therapy. The patient is directed tu provide himself with a 
wide-mouthed, one-ounce vial, which is fdled with suitably proportioDed 
small, square pieces of lint or gauze, over which is poured a moderate quaiK 
tity of a one-per-eent solution of carbolic acid, or a 1 : 5,000 solution 
corrosive wnblimate. The cork-stoppered vial can be easily carried by tl 
patient, who is enjoined to dress the sore or sores at least once every 
and oftener if the discharge be very ])rofnsc. In the morning and evenin] 
a prolonged local bath in the same solution is advisable. In many 





ASEPTICS AND ANTISEPTICS IN SYPHILITIC LESIONS. 

trhis plan will be sufficient to check the extension of the ulcer, aud to bring 
aabout cleansiDg of it.s bottom. 

Another niild form of antiseptic treatment consists of the application of 
iodoform powder to the ulcerating surface. The objectionable odor of the 
drug can be excellently masked by the admixture of etjuul parts of freshly 
roasted and ground coffee. An soon us the appearance uf u cicatricial border 
is apparent, these modes of treatment should be abandoned in favor of the 
application of strips of mecuriai jdaster, which should be renewed in pro- 
jwrtion to the amount of discharge. Cicatrization will be wry much h^is- 
tened by this change. 

L CnEMicAL Sterilizatiox by SxiiONfl Catstics. — Cases of greater 
vtrnlence which do not yield within a fortnight or .so to the mild plan of 
treatment by seru[iuloiis cleansing and disinfection, or in which rapid ex- 
tension of the ulcer doert not justify temijorizing, re4(uire the application of 
escharotics. The author has found a fifty-pfr-cent mlufion nf chhridv of 
zinc the most convenient and most effective of all cliemicids recommended 
for the cauterization of chancre. Its ap])lication is to be done as follows : 
1'he ulcer and it« Ticinity are subjected to a careful cleansing by a moj) of 
cotton dipped in a 1 r l.OOQ solution of corrosive sublimate. Crusts and 
ecabs overlapping the edge of the sore must be gently removed. A snnill 
"piece of clean blotting-pajjcr is applied to the ulcer and its vicinity with 
gentle pressure to remove ail nuMstnre. A moderate quantity of the caustic 
solution is ajiplied t<» ihe sore with a glass rod or match-stick, care being 
tjiken not to corrode unnecessarily the surrounding healthy skin. Previous 
thorough drying of the integument with blotting-pujier will best prevent 
overflowing of the caustic. All the nooks and indentations of the margin 
of the ulcer must be carefu!ly covered by the solution. As soon as the base 
of the sore assumes the color of parchment, which will occur in from three 
to five minutes, cauteriKation is completed, whereupon the surjilusof caustic 
should be removed by the aj>plication of another piece of blottiiig-|>aper. 
The eschar is dusted with a little iodoform and coffee-powder, and is jtro- 
tected from injury by a strip of moist lint or gauze. 

If the cauterizalion was sufficient, further extension of tlie ulcerative 
process will lie arrested thereby. In from two to six days, aci-ording to the 
depth of the eschar, a narrow line of demarkation will appear, and, the 
eschar being detaciied, a healthy granulating surface will Ijecome visible. 
This should be dressed with strips of mercurial plaster until cicatrization is 
completed. 

Insufficient chemical cauterization will not check the uleerntive decay 
of tlie tissues. In proportion to the incompleteness of the application, par- 
tial or total extension of the ulcer will be observed. In some cases only a 
toDgue of renewed ulceration will be seen extending outward from the mar- 
gin of the eschar. In others, the ulceration will sjtread all around the 
cauterized patch, thus demonstrating the entire inadequacy of the apjilica- 
tion. The surgeon's error sliould be in favor of too much rather than too 

little of the caustic. 
43 




14 



D. APPLETON &* CO:S MEDICAL WORKS. 



EMERGENCIES, AND HOW TO TREAT THEM. 

The Etiology, Pathology, and Treatment of Accidents, Diseases, and Cas 

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SPzaMBN or Illustration. 



A TREATISE ON THE DISEASES OF THE NERV- 
OUS SYSTEM. By William A. Hammond, M, D., Surgeon-General 
U. S. Army (retired list) ; Professor of Diseases of the Mind and Ner\ous 
System in the New York Post-Graduate Medical School and Hospital; 
Member of the American Neurological Association and of the New York 
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With 112 Illu&tratjons. Eighdi 
eflition, revised, ccrrccle<Lj 
and enlarged by the Acltf 
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Certain Obsctire Ncrvotl 
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Cloth, $5.00: sheep. ^.OD. 

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Paris, and an Ilali ' 

tion by Prcifes.sor ! ■ 

relli, of the Royal I 

has eotie through the pre&s at 
Naples. 

" In the Buddhist faith the 
eight i^tes of purity are de- 
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Comrct thoughts ; 3. Convd 
words ; 4. Correct works ; 5. 
Correct life ; 6. Correct endeav- 
ors ; 7. Correct judgment ; and 
8. Correct tranquiUitj. If I>r. 
Hammond has not attained the medical nirvana, and passed those eight gates ctf purity, he has at leaA 
realized the Buddhist beatitude : ' Much in(*ight and education. self-contnU and plp.iant speech : and 
whatever word be well spoken, this is the greatest blessing.' At least, tl»e thcHi).'li 
Hammond have been so appreciated by the medical profession of America aitd I 1 

already pas.sed thnnjgh eight editions .Mnce iu first appearance in 1871. As novs^ .._ __ ..or 

and published by the Appletons, it constitutes decidedly the best work in the Englisii language upon dis- 
eases of the nervous system." — Kansas City Medical Index. 

ten anything but this one work, it wnuVd have been 
a monument of learning that would have lasted for 
ages." — Kansas City Medical Record, 



" ThLi excellent work has now been fifteen years 
before the profession, its popularity being sufSdent- 
hr evidenced by the fact that it has rapidly passed 
UlTOUgb eight editions." — College and Clinical Rtc- 
ord. 



'* This great work of the gifted author has now 
reached its eighth edition, A work of this charac- 
ter that has within fifteen years, gone through right 
revisions needs but little commendation from us, 
being fully able to speak for itself. It is, like it>< au- 
thor, without a peer In the sjiecial line of medicme 
k takes up. . . . If Dr. Hammond had never writ- 



"The author of this work justly conj^atu kites 
himself that the various previous edr 'i 

h.ivc lieen called for Itave received thi 1 

the profession beyond that ever given u> ...._, .....tt 
work of like scope and objects published m any pari 
of the world, in orrler »n maintain the hiph cTiar» 
acter thus attrib " ■■ ihe l>est jn " " iv 

suljircted thisf<{ rough revi- j- 

added a mew aett: u > , i -.^ ol certain . ;. i^ 



INDEX. 



-A-lxkaiuial drainogo, 188L 
operations, 116. 
autore, 189. 
Mlet, 138. 
'Abaoeas, anal, 264. 
of bone, 20S. 
cem'cal, 220. 
eold, 204. 
fonoation of, 179. 
glandular, 189. 
iliac, 247. 
of liTer, 2S1. 
lumbar, 20 1. 
mammary, 228. 
uaatoid, 221. 
metastatic, 181. 
pelTic, 246. 
pariDepkrMc, S0I. 
pwiljphUtle, 246. 

247, 240. 
M6. 

fiMpKHoDcal, 246. 
' HlMtaritadoii of, 180. 
tSWOUr, 118. 
ftBHpo^d,221. 
Aridwitd wwmda, 29. 
JaitiBmM, 11. 

JMtn novflments after joint ezsection, 278. 
Aetoal eantery for syphilitic ulcers, 826. 
Adhetioiia, abdominal, 186. 
.£lber pneonKmia, 148, 149, 1S2. 

nefdirHiB, 118. 
AmpotatiooB, 69. 

dreisingi after, 72. 
Anal absoeia, 264. 
Anal fistula, 266. 
excision of, 266. 
suture of, 267. 
tuberculous, 269. 
Anatomy of connective-tissue planes of neclc, 
208. 
planes of pelris, 246. 



Antesthetics in hemiotomr, dangerous depress- 
ing effect of, 125. 
Aneurism, 48. 

needle, 48. 
Anchrlosis, bcny, 84. 
Anicle-joint, exsection of, 298. 
Antisepsis, 27, 167. 

Antiseptics applied to primary syphilitic ul- 
cers, 324. 
Apncpa after tracheotomy, 101. 
Apparatus for the after-treatment of the cx- 

sected elbow-joint, 28 1. 
Aprons, 20. 

Arm, suppuration of, 280. 
Arteries, ligature of, 47. 
Artery forceps, 6«. 
Arthrotomy, 75, 79. 

for elbow fracture, 80. 

for dlMocation, 79. 

for habitual dislocation, 8. 
Artificial ansemio, 66. 

anus, 122. 
Aseptic cap, 89. 
Asepsis, 8. 

in peritoneal operations, 115. 
A.<<cptic wounds, 5. 

accidental wounds, 32. 
Aseptics of amputation, 69. 

uf the orifices, 93. 

of rectum, 154. 
Axilla, evacuation of, HI. 
Axillary glands, 238. 

vein, 111. 

Bacteria of putrescence, 171. 

Bismuth, 11. 

Bladder, antiseptii^ of the, 159. 

treatment of, before ovariotomy, 188. 
Bloodclot, healing under the, 6. 
Bone abscess, 205. 

tuberculosis, 273. 
Boro-salicylic lotion, 10. 



328 



INDEX. 



Bose'fl methods of tracheotoiny, 99. 
BotUe-ehaped wounds, 40. 
Bow-leg, 83. 

Bozeraan's position, 154. 
Breast amputation, 109. 
Broad ligament, 142. 
Bursa, iliac, 250. 

olecranic, 238. 

prepatellary, 242. 

of quadriceps, 248. 

Cachexia strumipriva, 108. 
Cancer of tongue, 94. 
Caries, 273. 
Carbolic acid, 10. 
Carpal exsection, 284. 
Caseation, 264. 
Caseous infiltration, 264. 
Castration, 162. 
Cataplasms, 186. 
Catgut, 8. 

impure, 8. 

slipping of, 69 
Catheters, cleansing of, 159. 
Catheterism, 159. 
Cervical abscess, 220. 
Change of dressings, 20. 
Chisels, 198. 

Chloride-of-zinc solution, 826. 
Clap, 801. 

Cleanliness, surgical, 7. 
Cleansing process of feet, Gl. 
Club-foot, 86. 
Cold abscesp, 264, 273. 

applications, 187. 
Colotomy, lumbar, 147. 

inguinal, 148. 
Compressor urethrse, 801. 
Continuous suture, 46. 
Corrosive-sublimate lotion, 10. 
Coryza, scrofulous, 269. 
Cotton dressings, 16. 
"Cut-oflf" muscle, 160, 301. 
Cynanche, parotid, 219. 

sublingual, 217. 
Cyst of broad ligament, 142. 
Cystitis, 316. 
Cystotomy, perineal, 162. 

suprapubic, 168. 
Czerny's suture for hernia, 130. 

Deformities, 83. 
Diphtheria of fauces, 211. 
of intestine, 126. 



Dissection, technique of, 85. 
Dislocation, irreducible, 1i. 

habitual, 79. 
Drainage, 69. 

abdominal, 188. 
Drainage-tubes, 9. 

T-shaped, for cystotomy, 164. 
Dressings, 11. 

for hand and forearm, 80. 
Dry dressings, 12. 

spores, 178. 
Dust, 5. 

Elastic ligatures, 9, 136. 

in anal fistula, 258. 
Elbow apparatus, 281. 

fracture, 80. 

joint, exsection of, 280. 
Embolism, septic, 181. 
Emergencies, 28. 
Emphysematous gangrene, 191. 
Empyema, 226. 
Endoscope, urethral; 308. 
Epididymitis, tuberculous, 269. 
Erysipelas, 170, 269. 

phl^^onous, 260. 
E:$march's bandage, 67. 
Estlander's operation, 228. 
Excihion of anal fistula, 266. 
Exsection of ankle-joint, 298. 

of elbow- joint, 280. 

of joints for tuberculosis, 275. 

of hip-joint, 286. 

of knee-joint, 287. 

of shoulder- joint, 278. 

of wrist, 284. 
External urethrotomy, 818. 
Extirpation of axillary glands, 289. 

of cervical glands, 61, 68. 

of inguinal glands, 56, 246. 

of tumors, 50. 

Face, carbuncle of, 210. 
Fauces, diphtheria of, 211. 
Faudal suppuration, 211. 
Feet, cleansing process of, 61. 
Femur, necrotomy of, 208. 
Fibrinous arthritis, 74. 
Finger-joints, exsection of, 288. 

suppuration, 287. 
Fistula in ano, 264. 

in ano, tubercular, 269. 

thoracic, 228. 
Floating bodies, 77. 



D. APPLETON &- CO:S MEDICAL WORKS, 



17 



rBREATH, AND THE DISEASES WHICH GIVE 
IT A FETID ODOR. With Directions for Treatment. By Joseph W. 
Howe, M. D., Clinical Professor of Surgery in the Medical Department of 
the University of New York, etc. 

Second edition, revised and corrected, i vol., lamo, 108 pji. Cloth, $1. 

Philadtlpkia Atedical 



> 



"This little volume well deserves the attention 
of physicians, to whom we commend it rausl high- 
ly."— c'^^tv/^iJ Medical Journal. 

"To any one suffering from the alTection, either 
in his own person or in lliat of his intimate ac- 
quaintances, we can commend this volume as con- 
lainiog all that is known concerning llic subject, set 



forth in a plea&aat style, "- 
Ttmis. 

" The author jjives a succinct account of the dis- 
eased contliliotis in which a fetid breath is an im- 
portant symptom, with his method of treatment. 
We consider the work a real addition to medical lit- 
erature." — iJiHctHHOti Medical Journal. 



ON THE BILE, JAUNDICE. AND BILIOUS DIS- 

E EASES. By J. Wickh.^m Lego, M. D., F. R. C. S., Assistant Physician to 
St. Bartholomew's Hospital^ antj Lecturer on Pathological Anatomy in the 
Medical School. 
Isone volume. 8vo, 719 pp. With Illustrations in Chromo-lithography. Cloth, $6; sheep, $7. 
the 



r^ 



. And let us turn — which we gladly do — to 
ihe mine of wealth which the volume itself contains, 
for it is the oulcome of a vast deal of labor ; wi 
great indeed, that one unfamiliar with it would be 
surprised at the number of facts and references 
which the book contains.'" — Medical Times and Ga- 
x*tlf, Londan. 

" The book is an exceedingly jjood one, and, id 
some points, we doubt if it could be made better. 
- . . And we venture to say, after an attentive 
perusal of the whole, that any one who lakes it 
in hand will derive from it both infnrniation and 
pleasure ; it gives such ample evidence of linnest 
hard work, of wide reading, and an impartial at- 
tempt to state the case of jaundice, as it is known 
by obiervation up to the present date. The book 
will not only live, but t>e in the eajoyraent of a vig- 
orous existence long after some of the more popular 
productions of the present age are buried, past all 
hope of resurrection." — Loudon Medical Record. 

"This portly tome contains the fullest account 
fut the subjects of which it treats in the Kn;;li<.h lan- 
'_ age. The historical, scientific, and practical de- 
tails are all equally well worked out. and together 
constitute a repertorium of knowled]^ which no 
practitioner can well do without. The illustrative 
chromo-liihopraphs are Ijeyond all praise." — lidin- 
burgh Medical Journal. 



•• Dr. Legg's treatise is a really great book, ex- 
hibiting immense industry and research, and full of 
valuable information." — AtnericoH Journal 0/ Med- 
ical Science. 

" It seems to us an exhaustive epitome of all 
that is known on the subject." — Fhiladelfhia Medi- 
cal Timns. 

"This volume is one which will command pr«»- 
fcs-sional rejspect and attention. It is, perhaps, the 
most comprehensive and exhaustive treatise upon 
the subject treated ever published in the English 
language."— J/i/ry/awi/ Medical Journal. 

" It is the work of one who has thoroughly stud- 
ied the subject, and who, when he finds the evi- 
dence conflicting on disputed points, has aliempied 
to solve the jirobtem by e.vperiments and observa- 
tions of bis own." — Practitioner, London. 

"It is a valuable work of reference and a wel- 
come addition to medical literature. — DudJin Jour- 
nal 0/ Medical Science. 

"... The reader is at once struck with the ira- 
raensc amount of research exhibited, the author 
having left unimproved no accessible source of in- 
formation connccled with his subject. It is, indeed, 
a \-aluable book, and the \xs\ storehouse of knowl- 
edge in its department that we know of." — Pacific 
Medical and Surgical Journal. 



" If onljr it can pet a f«r hearing before the pro- 
fession it will be ihe means of aiding in the de\'el- 

I Opment of a ther.ipeutic* more rational than wc 
now dream of. To medical students and practi- 
li<mers of all sorts it will open up lines of thought 
and investigation of the utmust moment." — Detroit 

I Lancet. 



RST LINES OF THERAPEUTICS as Based on the 

Modes and the Processes of Healing, as occurring spontaneously in Dis- 
eases; and on the Modes and the Processes