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A  SYNOPSIS
CLINICAL  SURGERY
                          Y.
DURING THE SERVICE OF
 SAMUEL H. PINKERTON, M. D.,




     Surgeon to the Holy Cross Hospital,




              by





FRANKLIN A. MEACHAM,  A. B., M. D..




      ASSISTANT SURGEON TO THE HOLY

          CROSS HOSPITAL,




    Salt lake City, Utah,




         For the Year 1892
   SALT LAKE CITY:

Tribune Job Printing Company.


       1893- 
v/r
rA4^5 
A  SYNOPSIS OF CLINICAL  SURGEEY
             DURING THE SERVICE OF

       SAMUEL H. PINKERTON,  M. D.,
        Surgeon to the Holy Cross Hospital,

 By FRANKLIN A. MEACHAM,  A. B.. M. D.,
     ASSISTANT SURGEON TO THE HOLY CROSS HOSPITAL,
            SALT LAKE CITY, UTAH,
              For the Year 1892.
   The large number of  surgical cases possessing
points of unusual interest gave  rise to the idea of
publishing these cases, with a short history of  each
case, containing all the salient features.
   An effort has been made to avoid verbosity on the
one hand without sinking to the level of statistics on
the other.  The main  classification of the cases has
been  upon an anatomical basis  as regards the  field
of operation, divided as follows:
   Of these operations, 41 were performed upon the
abdomen; 91 upon the head, face and neck; 15 upon
the thorax; 46 upon the rectum  and anus; 62 upon
the genito-urinary  organs; 62 upon the upper ex-
tremities;  109 upon the lower extremities, and  206
miscellaneous; making a total of  632.  Each division
is further divided according to the pathological con-
ditions present.   The total number of deaths was 17, 
4
a synopsis of
or a mortality of  2.6 per cent.  Of  the 17 fatal cases,
11 were in extremis at the time of the operation.
   There were 90 fractures and 15 dislocations.
   A  few cases  dating further back have been  in-
cluded,  and  several  quite  recent  cases of  special
interest have been added.   The details of modern
antiseptic practice  have invariably been rigidly  ad-
hered to.
   The  operator  and assistant's  hands were made
surgically clean,  and it is the custom  in  the more
important operations, after the use of alcohol, to im-
merse the hands  successively in a saturated solution
of permanganate  of potassium, saturated solution of
oxalic acid, and a mild solution of hypo-sulphate of
soda,  followed by  sterilized water.  Their persons
duly protected by freshly sterilized aprons.
   The  preparation of  the field  of operation  was
carefully carried out, as described later in operations
on  the  abdomen.  Vessels  were   tied   with eatgut
sterilized just previous to the operation by boiling in
alcohol  for half an hour.  Clean incised wounds in
healthy  tissues were  closed.   Where drainage  was
necessary strands of sterilized catgut, or fenestrated
tubing,  was  used.  Dressings of  iodoform and  bi-
chloride (1:2000) gauze were used, making a satis-
factory  dressing.
   The  sponges were made of medicated gauze  and
pledgets of  cotton,  previously made into convenient
sizes and  placed in a porcelain dish and covered with
a sterilized towel.
   The  after treatment consisted in surrounding the
body by hot water bottles, if there was  any evidence
of shock, and morphine was administered if necessary. 
CLINICAL SURGERY.
5
   If surgical shock and anaesthetic collapse were
very pronounced, strychnine was gi^en in full doses
hypodermically, not less than one-twentieth of a grain
every half hour  to an adult, with a very surprising
and satisfactory result.
   Drainage tubes were removed from twenty-four to
forty-eight hours.
   In addition there has been added a report of 104
amputations performed for injury and disease extend-
ing over a period of three years.  Of these  104 am-
putations, there were ten deaths, or a mortality of 9.6
per cent.
   It is worthy  of  note that in some thousands  of
etherizations not once were symptoms noted which
occasioned serious  alarm;  while in not over three
dozen chloroformizations, one child and two adults
narrowly escaped  death  from the anaesthetic.  The
preference was  given to  chloroform  in children,
and  in  the  abdominal  cases in  which the  patients
were  already  weak and  suffering more   or  less
shock at the time of the operation.  When chloro-
form  was used  in emergency cases at  night, espe-
cially when it  was  used for  any length of  time, as
as for half an hour or more, a peculiar train of symp-
toms  were observed to  affect those present  in the
operating room as well as the patient himself.  These
symptoms consisted  at first of a dry, irritating cough,
gradually becoming  more severe, a  peculiar odor, a
smarting sensation to the eyes and nose, and a great
sense of oppression  in  the chest. This latter symp-
tom on one  occasion was of such a  severe character
that one of  the assistants was  forced to leave  the
room and the windows and transoms had to be opened. 
6
A SYNOPSIS OF
On these occasions chloroform was used in preference
to ether  because of the fact that the operating  room
was lighted by four gas jets just above the operating
table.  The patients' condition at these times caused
not a little anxiety, and in  one case it was with diffi-
culty that death was averted, although  all were not
like affected.  These observations caused considera-
ble comment, and no  satisfactory explanation could
be given, yet all agreed that it was in some way due
to [the chloroform vapor.   Squibb's chloroform was
used each time.  The room was large, well ventilated
and heated by steam.
    These facts  remained unexplained  to the writer
until an article appeared in the Therapeutic Gazette
for January,  1893, page 48, where a  doubtlessly cor-
rect explanation of the difficulty is given.   In this
article Charles Martin  shows that  chloroform in the
presence of a naked flame  has special  dangers, and
the after effects bronchitis no rarity.  He also shows
that the  final result is that for every two molecules
of chloroform that  are decomposed  in  the presence
of  the naked flame, six molecules of   hydrochloric
acid may be formed.  The  formulae for  the chemical
change he gives as follows:
    (1.)   2 C  H Cl3+C  02+0,=3 C O CL H_, O.
    (2.)   C O Cl2 H2 0=2 H C1+C02.
    (3.)   2 C H Cl3+C 02+02+2 H2 0=6 H C1+3C02.
   In the presence of this hydrochloric  acid gas be-
coming more and more concentrated on the mucous
membranes by being absorbed by the moisture cover-
ing them, that produces the  irritating cough, the acrid
odor, and the other unpleasant symptoms described. 
CLINICAL SURGERY.
7
   Dr. Paterson, of  Cardiff, refers to  the  same diffi-
culties in the Practitioner for June, 1889, and Prof.
Zweifel, abroad, shows that it is no peculiarity of a
gas flame, but that  the only essentials are the pres-
ence of chloroform  vapor in  the atmosphere  which
feeds a naked flame.
          OPERATIONS UPON THE ABDOMEN.
   There were 41 operations upon the abdomen, with
ten deaths, or a mortality of  24.3 per cent.  Of this
number, four were for cystic disease of the ovary, or
broad ligament, with one death  from  intestinal par-
alysis.   Three were  hysterectomies, with two deaths;
one from general septic peritonitis, caused by  a sup-
purating  fibroma,  and  the  other from  intestinal
paralysis.  Four were operations on  the  liver, with
one  death from  shock.   Four were on the kidney,
with no deaths.  One for ligature of the common
iliac artery,  with  one death from shock.   Eleven for
appendicitis, with three  deaths from  general  septic
peritonitis.   Nine for herniae of  different varieties,
with one death, the operation  being  done for pro-
longed  strangulation.  Five  were  unclassified, with
one death from intestinal paralysis.
   Although the mortality of 24.3 per cent,  is high,
yet six of the  patients were in extremis at the time
of the operation.
   Among the important abdominal  cases  may  be
mentioned the operation  for ligature of the common
iliac artery, for aneurism of the external  iliac artery
by  the  intra-peritoneal   method,  as  suggested  by
Frederick Treves.   Mr.  Treves,  in his "Manual of
Operative Surgery," states that "the recent  tenden-
cies of abdominal surgery render it probable that in 
8
A SYNOPSIS OF
the near future the artery will be reached by a simple
incision into the peritoneal cavity through the ante-
rior abdominal parietes;" but also states "that he is
not aware that the operation has been carried out on
the living subject."  Dr. Dennis of New York reports
three cases of ligaturing the internal iliac arteries by
the intra-peritoneal method as far  back as 1886.
   In the British Medical Journal for October 29th,
1892, Dr. Marmaduke Shield started a very interest-
ing question as to the propriety of  ligaturing the
iliac arteries through the peritoneum.
   Mr. Shield's letter elicited a communication from
Mr. Clement Lucas, in which  he states that in June,
1889, acting on the great safety with which coeliotomy
can  now be performed, ligatured  the  common iliac
artery through a  median abdominal  incision for  a
rapidly increasing aneurism  of  the  external iliac.
The operation was performed with ease and  the pa-
tient recovered rapidly without suffering from shock,
fever or any untoward  symptom.  Unfortunately the
details of  this case have never been published.
   W. Mitchell Banks, M. D., in the British Medical
Journal for November 26th, 1892, reports a case of
successful  ligaturing of the  external  iliac artery by
the intra-peritoneal  method  for aneurism of the ex-
ternal iliac.  The incision, three  inches  in  length.
was made in the right linea semilunaris.
   A large cyst of the pancreas.   Also an echinicoe-
cus cyst of the gall bladder,  which were successfully
opened and drained.
                OPERATIVE METHOD.
   In  all operations upon the abdomen the general
plan pursued may be summarized  as follows: 
CLINICAL SURGERY.
9
   Preparation of the Patient.—For two  or three
days preceding  the operation the bowels are mildly
purged and the diet carefully regulated.   In some
few cases, where the  conditions  were favorable  for
serious shock,  free  stimulation was  resorted  to.
When  possible,  the  night before  the  patient was
given  a warm  and cleansing  bath and  the field  of
operation carefully cleansed with  soap and water and
the parts shaved.  A large wet  dressing of  1-2000
bichloride solution was applied and  covered with oil
silk.   This was  allowed to remain over night and not
removed till just before the operation, when the field
of operation was again washed with  soap and water
and equal parts of ether and alcohol.
    Antisepsis.—The instruments were always boiled
for half an hour or more just before the  operation in
a  one per cent, solution of carbonate of  soda, and
during the operation were kept  in trays containing
either boiled water or a 1-60 solution of carbolic acid.
The sponges were kept in boiled  water, and no anti-
sepsis was used during the operation.  The abdominal
cavity was only irrigated in special  cases  and then
only with boiled water.
    Drainage.—The glass drainage tube  was used in
about  half the cases, and in only those where drain-
age was needed.   In some cases where there was any
tendency to oozing, a tampon  of  iodoform gauze was
inserted.
    Abdominal Suture.—The peritoneum was sutured
with continuous catgut sutures, the muscles and in-
tegument with silver wire and the integument by a
separate line of interrupted silk sutures. 
10
A SYNOPSIS OF
   Sutures.—For the past four or five months all cat-
gut, silk and wire sutures were boiled in alcohol for
one-half to one hour.  For tying bleeding points in
making the  abdominal  incision a small glass  reel
about one-half inch long by one inch in width, hold
ing about three yards of  fine catgut, previously boiled
for one-half  hour  in alcohol,  was used.  This  was
handled by no one except the operator.
   After  Treatment.—As soon  as  the patient  was
taken from the operating table, if there was  any evi-
dence  of  shock,  the body  was  surrounded  by hot
water bottles, and hot water and whisky injected by
the  rectum.   During the  first  twenty-four  hours
nothing was  given by the  mouth except a little hot
water.   Morphine  was  used  as little  as  possible.
Drainage  tubes were removed on the  second  day and
liquid  food given in small quantities.  Sutures were
removed  on  the  tenth day  or earlier if  the case
allowed.  The symptom  most dreaded was intestinal
distention, and all clinical aids, assistants and nurses
were on the watch for.  At the first onset  of  tym-
panites a stimulating enemata of soap and turpentine
was administered, more especially if there was no
passage of flatus per anum.   If  the enemata did not
answer, a mild saline purgative was given and repeat-
ed every  hour till it acted.  If vomiting occurred,
calomel was given instead of the saline purgative.
                     NEOPLASMS.
   Case I. Large Ovarian Cyst; Coeliotomy; Recovery.—
E. J. S., aged  thirty-four, unmarried, was admitted to the
hospital December 51h.
   Examination showed a  large tumor of the abdomen, of
three years' standing, which had been steadily increasing in 
CLINICAL SURGERY.
11
size  and accompanied by  pain.  The  whole  abdomen was
greatly distended with a  fluctuating  and symmetrical spher-
oid tumor.
    Operation.—Ether.   A  median abdominal  incision four
inches in width was made, through which  a  pearly  white
tumor could be seen  and felt.  The  contents, clear as spring
water, were  evacuated.   The pedicle ligatured and  a large
unilocular cyst of right overy was removed.  The abdominal
wound was closed and no drainage used.  Primary union and
a rapid and uninterrupted recovery.
    Case II.  Cystic Adenoma of Ovary; Coeliotomy.- Died.
—Mrs. E. T., aged thirty-four years, married, but had had no
children.  One miscarriage several years previous to her ad-
mission to the hospital.   She had been a sufferer for a great
many years with  pain and tenderness in the region of  the
right ovary.  About one year previous to her admission to the
hospital  she  first noticed that she suffered  intense pain low
down in the abdomen at every act of defecation, more espec-
ially when she was constipated, at which time the pain was so
great and of  such a sickening character that she had often
fainted.
    Examination.—The  uterus movable and the cervix high
up.  In Douglas' cul-de-sac, a tender mass about the size of
an English walnut was felt, exquisitely sensitive to the touch,
so much so that chloroform was administered and pushed to
complete anaesthesia  before  the  examination could be com-
pleted.   Examination per rectum revealed the same tender
mass as in the cul-de-sac.
    Operation.—Ether.   Median  incision three and  one-half
inches.   The right ovary and tube were found  displaced in
Douglas' cul-de-sac and bound down by firm adhesions. Both
tube and ovary  were  removed.  The  ovary was considerably
enlarged and contained a number of small cysts.  No drain-
age or irrigation  was used.  On  the second day intestinal
distention set in.  It  was only learned at this point that the
patient had  been an  opium  habitue".   It spite  of anything
that could be done the distention increased and the patient
sank  and died on the fifth day.   Cause of  death, intestinal
paralysis. 
12
A SYNOPSIS  OF
    Case III.  Cystic Adenoma of Ovary;  Coeliotomy;  Re-
covery.—E. B., aged nineteen, unmarried.  Her menstrual
history has been irregular and for several years has suffered
severe pain in the region of the right ovary at each menstrual
period, attended with a very offensive discharge.
    On examination the uterus was found movable and a dis-
charge coming from the cervix.  In the region of  the right
ovary can be distinctly  felt  a tumor  about the  size of  an
English walnut.
    Operation.—A median incision about three and one-half
inches in length.  The right ovary and tube were bound by
firm adhesions, both of which  were  easily removed.  The
ovary was considerably enlarged  and contained several small
cysts, each containing a  straw-colored  fluid.  No drainage or
irrigation was used.  Her recovery was uneventful except for
several stitch abscesses which  formed, retarding convales-
cence.
                   UTERINE FIBROIDS.
    There were six cases of uterine fibroids.   Three
of these  were materially  benefited  by intra-uterine
applications of galvanism, and the salient points are
tabulated below.  The remaining  three cases were
not benefited by the electrical treatment.
    In  Case  I., we  had, as  shown  by  abdominal
section, a broken down and  suppurating sub-peri-
toneal fibroid.  In this  case the  patient was intol-
erant of mild galvanism and the post-operative effects
were severe.  Diseased adnexae or pelvic suppuration
were entertained,  but she refused  an  operation  and
left the  hospital  only to return  six  weeks  later in
almost a state of collapse,  when  an  operation  was
performed  as a last resort and with only a little hope
of success.   In Case II., the hemorrhage was profuse
and not  benefited by the electrical treatment.   Re-
moval of the uterus by an abdominal incision showed
the organ a mass of small fibroids projecting  into the 
CLINICAL SURGERY.
15
uterine  canal.   In  consequence, the canal was  very
tortuous and its entire length could not be cauterized
by the electro-galvanic cautery.   In Case III., it was
impossible to introduce an electrode into the uterine
canal on account of the cervix being pushed well  up
against the symphysis pubis. Electro-negative punc-
ture was not tried.
    Case I.  General Septic Peritonitis,  dependent  on a
Suppurating Fibroid of Uterus; Abdominal Section; Death.
Mrs. M. L.,  aged  thirty-two, primipara.  Came to the hospital
on account of  frequent pelvic pain,  complaining of  great
pressure on the rectum and bladder, and a tumor in the lower
part of the  abdomen.
    On examination the patient presented the appearance of
good health.  There was a hard oblong tumor about  eight
inches in its long and four inches in  its short diameter, at-
tached to the fundus and left side of the uterus. The uterus
was only slightly enlarged, and its canal, which was posteriorly
directed  and to  the right, was about three  inches in depth.
Menstruation had been profuse, lasting six or seven days and
accompanied with pain.  She had had paroxysmal attacks of
severe pelvic pain.   Locomotion difficult.  A diagnosis of sub-
peritoneal fibroid growth and consecutive pelvi-peritonitis was
made, with a probability of diseased adnexae.  Intra-uterine
applications of galvanism were tried, but she was intolerant
of this and its use had to be discontinued.  Faradism was
used  and there  was some marked  amelioration of  the pain
only.  Abdominal section for removal of  the growth and dis-
eased adnexae was suggested, but the patient  at once refused
to submit to any operation and left the hospital. About six
weeks later she was  attacked with severe paroxysmal pain and
was confined to her bed, where she had  been  for some days.
She  was taken to the hospital  in a condition bordering on
collapse.  The day previous she had a severe chill, followed by
a high fever.  On admission November 29th, her temperature
was  103° F.; pulse, 140;  respiration, 40.  Considerable tym-
panites.  Nausea and vomiting.  General abdominal tender-
ness.  Abdominal section was made a few  hours later as a 
14
A SYNOPSIS OF
last resort and with only a very slight hope  of success.  The
intestines were found greatly distended, markedly congested
and adherent to each other by old adhesions which bled pro-
fusely on attempting to separate them.  A turbid serum was
found in  the abdominal  cavity.  Firmly attached to the ad-
joining parts  by old adhesions was a broken-down and sup-
purating  sub-peritoneal fibroid of  the  uterus.  This was re-
moved and the abdomen irrigated and drained.  The condition
of the patient did not permit  an examination of the adnexae-
She never recovered from the shock and died fourteen  hours
later.  No autopsy.
    Case  II.   Hysterectomy;  Recovery.—Mrs. M.  C, aged
thirty-two. No children.  Was sent to the hospital for  the
galvanic  treatment of a  bleeding  fibroid.  Hemorrhage was
excessive. The uterus was found to be about the size of  a
three  months' pregnancy and  its  canal  was four inches in
depth. Positive applications of galvanism of full doses were
used once in forty-eight hours.  Her  general health improved
but the hemorrhage did not cease  at all.   Abdominal section
was performed August 26th.  The uterus was found to be one
mass of  small fibroids on the  interior and exterior  of  the
uterine walls, varying in size from a hickory nut to that of the
fist, and some of these projecting into the uterine canal.  The
uterus was removed  and the pedicle  treated by the  extra-
peritoneal method. The patient made a rapid and uninter-
rupted recovery.
    F.  H.  Martin's   "Electricity  in   Diseases  of
Women," page  179,  gives  a  similar  case   where
electricity  failed  to  relieve  because  the   fibroid
masses,  projecting into  the  uterine  canal, so dis-
torted  it that a  proper  electro-galvanic  cauteriza-
tion of  its interior was impossible.
    Case III.—Hysterectomy;  Death.—J. L., aged  twenty-
eight, unmarried.  Came to the  hospital on account of  a
large  tumor of the abdomen of several years' standing, and
rapidly increasing, together with a great discomfiture  in the
bowels and bladder.  The growth  was a  large interstitial
fibroid tumor of the  uterus and producing a deformity simu- 
CLINICAL SURGERY.
15
lating a six months' pregnancy.  The cervix was pushed well
up behind the symphysis pubis, on which account it was im-
possible to enter the uterine canal with any form of  electrode.
For which reason intra-uterine galvanism was not used.  The
growth was removed through an  abdominal incision and the
pedicle treated by the extra-peritoneal method.  The patient
never recovered from the operation  and  died five  days after
from intestinal paralysis. 
CASES.	SIZE OF TUMOR.	SYMPTOMS.	DURATION OF TREAT-MENT AND METHOD.	ULTIMATE RESULTS.
Case IV. Mrs. McV.	Uterus, Q% inches in depth. Fills the entire pelvis and lower abdomen.	Large hemorrhagic, interstitial and subperitoneal. Nod-ular. Pain. Great pressure on bowels and bladder.	60 applications of galvanism every fourth day; 40—, and 20^ of 150 milleamperes each.	General health im-proved. Tumor easily reduced; pressure on bow'ls and bladder re-moved. Still under treatment.
Case V, Mrs. M. T.	Tumor about the size of child's head. Depth of uterus, 5 inches.	Myo-fibroina of right side of uterus. Ex-cessive hemorrhage accompanied and followed by excru-ciating pain.	Galvanism for four months. Positive applications of 160 milleamperes.	General health im-proved. Hemor-rhage and pain ceased. Tumor reduced three-fourths.
Case VI. Mrs. E. C. J.	Uterus, 43^ in. in depth ;gro wth about 10 in. in its long and 6 in. in its short diameter. Ir reg. in outline. At-tached to fundus & post, wall of uterus.	Large subperitoneal, non-hemorr h a g i c and painless.	Forty applications, negative galvin-1S111.	Tumor reduced about one-third. Symptomatic cure. (Lost sight of.)
 
CLINICAL SURGERY.                17
                OPERATIONS ON THE LIVER.

    Case I.  Echinococcus Cyst of the Gall Bladder;  Chole-
cystotomy; Recovery.—This case is interesting on account of
the infrequency with which hydatids are found developing in
cavities lined with mucous membrane (Graham's hydatid dis-
ease).  Ziemssen, Vol. Ill, refers to cases where small hydatid
cysts have been  found in the gall bladder without any trace-
of the liver hydatid having been discharged  into it.  Harley
also speaks of the infrequency of hydatids of the gall bladder.
    J. L. B.. age 28.  No history of any  hereditary disease in
the family.
    Previous History.—In childhood was always delicate and
had all the diseases incident to that age.  Till he was 19 years
of  age was subject to what he  termed  bilious headaches,
these  attacks   coming  on  at  least  once  in two  weeks.
Has always been of a sallow and muddy complexion.  At 19
years old moved to Texas, where he spent the next four years
on a ranch, at the end of which time he had a severe attack
of dysentery, which lasted about one month.  A few months
after recovering from  the dysentery  he passed a tapeworm.
For the  next four years he was in what he considered  good
health.
     Present Trouble.—In the fall of 1890 he began  to  have
attacks of pain in the right hypochondriac region, which were
supposed to be biliary  colic.  One  year went by without any
further trouble, when  the attacks returned with greater fre-
quency till just before he entered the hospital, when they were
two a day.  These  attacks were paroxysmal, consisting of a
dull, deep-seated pain, attended with nausea and vomiting.
He lay in the dorsal decubitus, with knees drawn on the ab-
domen.  The pain could be relieved on pressure.  He was sub-
ject to severe constipation, frequently going two weeks with-
out a passage.  For about a year back the faeces had  been
pipe clay in color.   The passages from the bowels were slimy
and very offensive.
     Examination.—Icterus very marked.  Pulse, 76. No ele-
vation of temperature.  Tongue only slightly furred. A tumor
the  size of a foetal  head was  found  in  the region of the ga'l 
18
A SYNOPSIS OF
bladder.  No superficial oedema over the liver. The tumor was
painless.   The hydatid fremitus not present.
    Operation, February 9.—Ether.  An incision five inches
long was  made over the tumor, beginning at the free border
of the ribs and  two inches to the right of  median line.  An
oblong tumor about the size of a foetal head was found  pro-
jecting below the edge of the liver and between the two lobes.
Diligent  search proved this to be the gall bladder.  A needle
introduced gave  a negative result. An incision was  made in
the tumor, and  it was found to be filled  with a brownish
gelatinous mass.  The incision was  enlarged and the edges
brought up and  stitched to the abdominal wound, and  about
two pints of this  gelatinous material was removed.  The blad-
der was washed out with warm distilled water  and a rubber
tube left  in the wound.
    Subsequent Progress.—February 12th,  temperature  and
pulse  normal.  There  was a profuse discharge of normal  bile
through the fistula. Jaundice entirely disappeared. February
loth-Bowels moved three  times during the night;  slimy, very
offensive  and still pipe-clay color. February 23d—Walls found
to be  adherent  to abdominal wound.   Stitches removed.
Wound granulating and discharge of bile less.  March 20th—
A small biliary fistula remained.  Stools of normal color.  No
jaundice.  April  15th—Fistula closed.  Stools normal in color.
No recurrence of  pain. No  jaundice.   Patient  discharged
cured.

    A  specimen of the  gelatinous  mass was  sent to
Prof. William  H. Welch  of  Johns Hopkins  Hospital)
and appended  is his report:
    "The gelatinous mass consists of  several membranes,  pre-
senting in most places  a translucent appearance and in others
a more opaque whitish or yellowish aspect.  Here and there a
little hard, gritty material,  evidently deposits of  lime salts, can
be felt.  The membranes average 2-3 mm. in thickness.  They
have a consistence like that of  gelatine somewhat softened in
water. Microscopically, the membranous material  appears
clear  and transparent, and when seen on cross sections  pre-
sents  an  appearance  of parallel  strhe, indicating that  the 
CLINICAL  SURGERY.                   19
The accompanying cut represents the patient one year and a half after
                          the operation. 
20
A SYNOPSIS  OF
membranes are composed of super-imposed transparent lamel-
lae.  In addition, there is some fine granular material forming
a kind of matrix on the inner surface of the membrane.  There
are also some glistening, irregular, crystalline particles (lime
salts).  After considerable  search, an  unmistakable  echino-
coccus hooklet was  found.  No scolices could  be detected.
Diagnosis:  Echinococcus cyst.
    "Remarks—The diagnosis is positive simply from  the mi-
croscopical appearance  of the membrane (translucent, homo-
geneous, structureless, with parallel striation).
    "The finding of a hooklet is also decisive.  The type of the
echinococcus cyst cannot  be determined  simply  from the
specimen, but probably it  is the  ordinary endogenous form.
It is not the so-called multilocular echinococcus.''
    Case II.  Calculus of  Cystic  Duct;   Cholecystotomy;
Death.--A. E. G.,  a physician, age 43.
    For five or six  years he had been a great  sufferer with
severe and paroxysmal pain in the region of  the gall bladder,
and occurring at  frequent intervals.  His general health was
becoming impaired.   To relieve his intense  suffering he had
recourse to chloroform and chloral.  It was learned later that
he used morphine in  large quantities, and was also addicted
excessively to the use of alcoholic stimulants.  On his admis-
sion to the hospital, June 26th, he was  suffering severe and
intense pain in the epigastric and right hypochondriac regions,
preceded by rigor, accompanied by vomiting, and attended  by
profound constitutional disturbances, bordering on collapse,
the case being more  like one of perforation of some abdominal
viscus, but the  history of previous  attacks  confirmed the
diagnosis of  gall stones.  On  examination, no distinct  tumor
 could be made out, but there was much tenderness and a
 sense of fullness in the right hypochondriac region.  Jaundice
 slight.  Faeces normal in  color, in which no gall stones could
 be found. Urine normal, except that it gave Gmelin's reaction
 for bile pigment.
     Operation, June 30th.—Ether.  An incision three and a
 half  inches  in length was made in the  right mamillary line,
 beginning just below the  free border of the ribs.  The gall
 bladder did not appear to be enlarged, and no gall stones could 
CLINICAL SURGERY.
21
be felt through it.   An aspirating needle was introduced  and
a straw-colored fluid was withdrawn.  The gall  bladder  was
incised; its walls were found to be considerably thickened,
but no gall stones could be detected.  At this point the con-
dition of the patient became such that it was impossible to
carry the operation  further in the probing of the cystic duct.
The  walls  of the gall bladder  were then brought up  and
stitched to the abdominal wound, leaving a biliary fistula.  A
rubber drainage tube was introduced and the wound suitably
dressed.  Soon after the operation the patient began vomiting,
the temperature went up to 103° F., and the pulse became
rapid and feeble. On the next day pain  similar in character to
the old set in, and he sank and died on the third day.
   Autopsy.—No evidence of peritonitis. The cystic duct  was
found  enlarged and its walls were quite  thick.  Three  gall
stones, each about  the size of a large pea, were found  im-
pacted in the cystic duct.
    Case  II.  Empyema of the Gall Bladder;  Cholecystot
omy, and Removal of Gall Stones;  Recovery. - Mrs. L. L.,
aged forty.  Mother of four children.  Well developed and well
nourished, and her general health had always been good until
about one year prior to her admission to the hospital, at which
time she began to have severe pain in the  hepatic region,
paroxysmal,  and  occurring  at  frequent  intervals  attended
with nausea, vomiting and intense thirst.  There was a slight
jaundice at times, of varying intensity,  and  more pronounced
after each paroxysm.  These paroxysms consisted  of severe
pain attended  with a chill, sweating and  fever.  She  also
noticed an indefinite tumefaction on  the right side and very
tender on  pressure.  Admitted to  the  hospital July 10th.
Examination  showed  a distinct tumor in  the right hypo-
chondriac  region,  with  marked tenderness, which was  in
creased on pressure, dullness  on  percussion  and distinct
fluctuation.  Jaundice  very deep.  Epigastric disturbance
severe.  Temperature, 103° F.; pulse, 100;  respiration, 42.
Stools pipe clay in  color. Urine normal, except  that  it gave
the re-action for bile-pigment.
    Operation, July 12th.—Ether.  An incision four inches in
length was made in the right  mamillary line beginning  just 
22
A SYNOPSIS OF
below the free border of  the ribs, exposing an enlarged and
elongated tumor corresponding to the situation of the gall
bladder.  No calculi could be felt through  it.  A needle was
introduced and a syringe  full of pus was withdrawn, but no
calculi could be felt.  Sponges  were carefully packed in the
wound and  an  incision made  into the tumor, from which
about a tea-cup full of fetid pus was evacuated.
    On introduction of  the finger through  the incision a
second tumor was discovered filled  with gall stones, but con-
taining no pus.  The supposition was  that at some time one
of the gall stones had cut through the mucus membrane and
had started an inflammation and  formation of  pus between
the inner and middle coats of the gall bladder.  There was no
communication between the two cavities.
    An incision was made in the  second tumor, from which
170 gall stones were removed, of a dark brown color, facetted,
and varying in  size from a millet  seed to that of  a cherry
stone.  The  walls  of the gall  bladder were brought up and
stitched  to  the  abdominal  wound, thus  making a biliary
fistula.  The abscess cavity was irrigated and a rubber drain-
age tube  was left in the wound.
    Subsequent Progress.—The temperature never rose above
101° F., nor the pulse above 110. On the third day the jaundice
entirely disappeared, the stools became normal in color and a
large amount of normal bile was  flowing from the tube.  At
each subsequent dressing for about three weeks  several  small
calculi were found  in the gauze. She made a rapid recovery,
and with no  untoward symptoms. The biliary fistula remained
open for three months  after she left the hospital, and  there
has been  no  recurrence of pain or trouble.   Six  months from
the date of operation the fistula was entirely closed.
    Case IV.  Cholecystotmy; Removal of One Large Gall
Stone; Recovery.—Mrs.  B., aged  thirty-two.   Has always
enjoyed good health and is a mother of four children. In the
summer of  1888 she was attacked for the first  time with a
severe pain in the  region of  the gall  bladder, attended with
nausea and vomiting, which lasted about half an hour.   She
remained perfectly well till the summer of 1891, when she had
a second attack, similar in character to the first and lasting 
CLINICAL SURGERY.
23
about the same length of time. There were two slight attacks
in the next twelve months.  Four months prior to her admis-
sion  to  the hospital the attacks were  every fourteen days,
ague-like in character, preceded by a chill, followed by  fever,
and sweatings lasting from a half hour to an hour.  Epigas-
tric disturbances pronounced.  These attacks occurred with

regularity until the last paroxysm, which lasted for ten days
and was only relieved by large doses of morphine.  On exam-
ination there was a sense of fullness in the region of  the gall
bladder, but no definite tumefaction.  There was no jaundice
nor had there ever been in any of  the attacks.  Stools normal
in color, on examination of which no gall stones could be
found.  The urine normal  in every respect.  From the  ague-
like  paroxysms,  attended  with  epigastric disturbances,  a 
24
A SYNOPSIS  OF
diagnosis of gall stones was made, and she was sent to the
hospital for operation.
    Operation.—Ether.  An incision four  inches in  length
was made in the right mamilary line beginning at the free
border of the ribs.  The omentum and transverse colon were
found  adherent  to the under surface of  the liver and to the
gall bladder.  After separating the adhesions, the gall bladder
was found not to be enlarged, but its walls  were considerably
thickened and through which a  large calculus  could be felt.
Sponges were carefully packed in the wound and an  incision
made into the gall bladder, through which one large stone
was  removed, weighing one hundred and forty-two  grains-
and measuring one and one-half inches in its  long and  one
inch in its short diameters.  The walls  of  the gall  bladder
were stitched to  the abdominal incision and a rubber drainage
tube inserted.   The  temperature never  rose above 100° F.,
nor the pulse above 86.  She made a rapid and unterrupted
recovery, leaving the  hospital two and a half  months later
with the biliary fistula entirely closed.
               OPERATIONS ON THE KIDNEY.
    Case I.  Nephro-Lithotomy; Recovery.—Mrs. S. G.,  age
twenty-eight. For the past seven years  had been suffering
with a heavy, dull pain in the left loin, just below the  last rib.
The  pain was of a dragging character, shooting down along
the course of the ureter, intermittent, and usually worse after
active movements, but not affected by posture.  On examina-
tion, there was marked tenderness in the  left  loin, and  the
patient gave a history of lithiasis.  There was a frequent de-
sire for micturition.   Specific gravity of  urine  1015,  acid in
reaction, and a  dark red sediment in abundance.  The color
of the urine  reddish brown.   Microscopical   examination
showed crystals of  oxalate of lime in abundance, blood discs
and pus in excess.  The blood discs and pus were readily mis-
cible  with  the  urine, promptly deposited  from  it, and  not
mingled with  mucus.  Careful examination of  the  bladder
gave a negative result. A diagnosis of pyonephrosis, due to
impacted calculus, was made.
    Operation.—Ether.  An oblique  incision four inches in
length was made across the costo-iliac space, beginning about 
CLINICAL SURGERY.
2o
half  an inch below the last rib and  to the outer border of the
erector spinae, and extending downward and forward toward
the crest of  the ilium.  The retractors lay open the severed
structures to the depth of  the wound down to the exposad
fatty capsule.  The fatty tissue about the kidney was opened
up with  the  fingers and the kidney surface exposed.  The
surrounding fatty tissues were firm and adherent, owing to
the long-continued inflammation.   The kidney was  systemat-
ically examined by the finger and found to be greatly enlarged,
and  gave evidence of  fluctuation.   An aspirating needle was
introduced and established  the presence of a stone, and like-
wise a syringe full of pus  was withdrawn.  The pelvis was
opened from behind and a large, irregularly-branched stone
was found filling the entire pelvis.  The stone was broken and
removed  in two fragments.   About six ounces of  pus were
evacuated.   The  wound was thoroughly irrigated, but  ro
attempt was made to close the rent in the renal pelvis. The
bleeding which f Dllowed the removal of the calculus was small
and  readily checked  by plugging with  strips of  iodoform
gauze.
    After Treatment.—For the first week the  urine escaped
through the wound in the loin, but gradually diminished and 
26
A SYNOPSIS OF
entirely ceased  in  a few weeks.  After  the  bleeding was
checked a rubber tube was inserted and kept in place for sev-
eral days, after which time it was removed.  She made a rapid
and  uninterrupted  recovery, the wound  healing slowly by
granulation.

    Case  II.  Nephrorraphy  and  Nephro Lithotomy; Re-
covery.—Mrs. C. G., age  twenty-nine.  Had always  enjoyed
good health, and was the mother of three children.  After her
last confinement, seventeen months previous, which was very
severe  and  instrumental, she gradually  failed  in  healtn.
About three weeks after the birth of the youngest child, while
sitting up in bed, she noticed a tumor in the ri^ht  side of the
abdomen on a level with the  umbilicus, which disappeared on
pressure  and when  in the recumbent position, only to reap-
pear when sitting up or lying on the left side,  There was very
little discomfort and scarcely any pain for about a year after-
ward, when  she was attacked suddenly one day with a severe
colicky pain, referred to this movable tumor, and  also shoot-
ing down along the course of  the ureter.  From this time on
there was always  a dull, aching and dragging pain, which
at times was very severe.   She failed in health, became sub-
ject  to dyspepsia,  sickness,  anorexia, diarrhoea, and was be-
coming greatly emaciated.  The attacks of colicky pain were
now very frequent, and only relieved by full doses of morphine.
She was first seen December 6th, and on examination a tumor
freely movable was  found on the right side and in the upper
part of the abdomen, of the shape and size of a  kidney.  A
subjective symptom of great value was a  peculiar, sickening
and  painful sensation elicited when  using  pressure on the
tumor, analogous to that experienced during compression of
the testicle in  man or the ovary in woman.  The tumor was
freely movable, but not  beyond the middle line  or  into the
pelvis.  On  account of  the  great  laxness of  the abdominal
parietes and the extreme emaciation of the patient, the renal
artery could be felt  pulsating on the inner concave edge of the
tumor.   Pain  of a neuralgic  character was referred to the
urethra, with a constant tlesire to pass water, and frequently
associated with haematuria.   Specific gravity of  the urine
1020, acid in reaction, and of a dark red color;  abundant sedi- 
CLINICAL SURGERY.
27
ment, but not mingled with mucus.  Microscopical examina-
tion  showed  crystals of oxalate of lime, red blood discs and
pus corpuscles freely mingled with the  urine.  The bleeding
was considerable in amount.  A diagnosis was made of mova-
ble kidney, associated with an impacted renal calculus.
    Operation, December 27th.—Ether.  Patient placed on her
left side, resting on a hard round pillow.   An incision three
and one-half  inches in length, beginning one-half inch below
the last rib and to the outer border of the erector spinae, and
extending downward  and forward toward the crest of  the
ilium.  The dissection was carried down to the circumrenal
fat, which  bulged into the wound.  While  the  retractors
stretched the wound  to its utmost capacity an  assistant
pushed the kidney into the lumbar incision.  The fatty tunic
was closely  adherent to the fibrous capsule.  After tearing
open the fatty capsule the surface of the kidney was system-
atically explored with the finger, and a hard and elevated area
being made out in the pelvis of  the kidney, an  exploring nee-
die was pushed into it and the presence of a stone established.
The pelvis of the kidney was opened by a blunt instrument
and a large pronged calculus and seven small calculi removed,. 
2N
A SYNOPSIS  OF
"together with  about three ounces of pus.  No attempt was
made to close the wound  in the pelvis, into which a drainage
tube was inserted.  Fixation  of the kidney  was  secured by
means of four silk sutures carried through its fibrous capsule
3,nd the margins of  the incision.
    After Treatment and Subsequent Progress.—There was a
free discharge of urine and pus for several days, which gradu"
ally ceased, the wound healing by granulation.  She made a
rapid and uneventful recovery.
    Case  III.  Nephrorraphy;  Recovery.—Mrs. H. D., age
thirty-seven.   She had always been well  and strong, and was
the mother of three children, the youngest  three and a half
years old. Some weeks after  her last confinement, which was
"very severe, she was taken with a violent pain in the right side,
and on examining  the parts  she discovered a growth in the
upper part of the  abdomen, which disappeared on pressure
and to reappear on turning on the opposite side.  On recover-
ing from  her puerperium she noticed on standing that the
growth, which  she  felt in the upper part of the abdomen,
would drop  to the lower portion of the abdomen on a level
with  the anterior superior spine, and the range of mobility
gradually increased, but never beyond the middle line or into
the pelvis.  The growth always resumed its normal  position
on lying down.   It was impossible to nurse the child owing to
her extreme debility, and four months after her confinement
her menstruation returned with great difficulty, attended with
severe pain situated in the right side.  At the next menstrual
period she was seized with a violent pain in  the region of the
right ovary and tube, of  such a severe character that she be-
gan to vomit  blood, and her  menstruation  suddenly ceased,
since which time she has menstruated vicariously at intervals
of three to six months.
    On examination, a movable tumor, of the shape and size
of a kidney, was found in the upper portion of the abdomeni
whose range of mobility extended as far dosvn as the anterior
superior spine of the ilium  and to the middle line.  A pecu-
liar, sickening sensation was  elicited  on  compressing  the
tumor. A diagnosis was made of  a movable  kidney.
    Operation.—Ether.  The patient was placed on her left 
CLINICAL SURGERY.
29-
side, resting on a hard, round pillow.  An incision four inches
long was made in the costo-iliac  space, beginning just  below
the last rib and one inch from the erector spinae on the right
side, extending downward and  forward.  The  lumbar  fas-
cia being opened, the wound was  dilated with retractors, while
an assistant with steady pressure held the kidney in the lum-
bar incision.  The viscus was found to be sound and not en-
larged.  The fatty tunic was closely adherent  to the fibrous
capsule.   Several sutures of large  size chromic gut were in-
serted  at  the lower end, several at  the outer end and several
at the inner border, and passed well into  the kidney tissue
and brought up through the lumbar fascia and muscles.  The
kidney  now  no longer fell away when the assistant's  hands
were removed.  The wound was  not closed, but packed with
iodoform  gauze and allowed to  granulate.  Her recovery wa&
slow and uninterrupted.
    Subsequent Progress.—Six weeks after the operation she
menstruated, and thinking herself well, returned to her home,
some two hundred miles from the city. The patient returned
about one year later, stating that since she had left the hospi-
tal she had menstruated vicariously four or five times, attend-
ed  with  great  pain low down in  the  abdomen, especially
referred to the right  side.  Previously to  her menstruation
she  experienced a sense of fullness in the epigastric  region,
followed sooner or  later by paroxysms of acute pain, referred
to the region of the right ovary.  The paroxysms increased in
severity and frequency until relieved by  vomiting  a small
quantity of dark and  clotted blood.  As the  paroxysms in-
creased in severity the quantity of vomited blood was increased.
There occurred also, at this time, quite an offensive discharge
from the uterus, slightly tinged with blood.   She continued
in this  condition for four or five days, suffering extreme pain
attended with  great prostration. Between the menstrual pe-
riods the patient was seemingly well, with the exception of
the pain in the region of the right ovary.
     On examination, a mass about  the size of  an egg was felt
in the region of the right ovary, exquisitively  sensitive to the-
touch.  Vaginal:  Uterus subinvoluted and cervix lacerated-
The same sensitive mass was found in the right fornix. 
30
A SYNOPSIS OF
     A diagnosis of diseased adnexae was entertained, and as
 the  patient had  come to the hospital for the devout purpose
 of having the uterus and appendages removed, so great  had
 been her suffering,  an operation was  advised  and readily
 assented to.
     Operation;   Coeliotomy;  Recovery.—Ether.  A median
 incision  of  three and a  half inches was made.  The mass
 felt  in the right fornix proved to be an enlarged and broken-
 down  ovary firmly adherent to the surrounding tissues.   The
 tube was very tortuous, its  canal  obliterated, and the walls
 about 3-8 inch in thickness.  These  were removed and  the
 wound closed, with drainage. She made a rapid recovery, her
 temperature never going above 99^° F.
     Sufficient time has not elapsed since the  operation to say
 whether her menstruation has been benefitted or not.
     Case IV.  Nephro-Lithotomy;  Recovery.—Mrs. M.  B.,
 age 35. Born in London, and twelve years ago came to Amer-
 ica on occount of her delicate health.  Since  her childhood
 she  had  scarcely ever seen a well day, yet she was the mother
 of four apparently healthy children.  Her mother, two sisters
 and  a brother died  of consumption,  and she herself had  a
 well-advanced tubercular  deposit in the apices of both lungs.
 For  many years she had complained of a dull, aching pain in
 the left loin.   About fifteen  months previous the pain in  the
 loin  became   exceedingly  severe,  lancinating in  character,
 shooting downward into  the left  groin  and down the thigh.
 This severe pain was intermittent, recurring about once in
 two  week, and finally becoming as frequent  as  every two or
 three days, attended  with profound  constitutional disturb-
 ances. When first seen she had been confined to her bed for
 several weeks.  On examination, a distinct tumor was found
 on the left side of the size of a foetal head; marked tenderness
 on pressure,  dullness on percussion,  cutaneous  oedema  and
 fluctuation could be made out.  Temperature 104  F;  pulse
 120;  respiration 36.   Complete anorexia.  Vesical irritation
 great.  The urine was found to be normal in reaction, of  a
 yellowish color and containing pus, which formed a deep sedi-
 ment not mingled with  mucus.  An aspirating  needle  was
introduced into the tumor and a syringe full of pus with- 
CLINICAL SURGERY.
ol
drawn.   A diagnosis was made of  pyo-nephrosis, due to an
impacted calculus.
    Operation.—Ether.   An  oblique  lumbar  incision three
inches long, beginning at the edge of the erector spinas and
half an inch below the lower border of the twelfth rib, and
carried downward and  forward toward the crest of the ilium.
After division of the  deep lumbar  aponeurosis and the  ex-
posure of the  circum-renal fat, the  kidney  was exposed and
distinct  fluctuation felt.  The kidney was found to be greatly
enlarged, and  after a  systematic exploration with the finger,
no stone being discovered, an  incision was  made into the pel-
vis of the kidney from  behind, and  about  two pints of fetid
pus evacuated.  On introducing the finger into the abscess
cavity, a large, irregular-shaped calculus was found and read-
ily removed.   A rubber drainage tube was inserted  and  the
wound suitably dressed.  For several weeks there was  a free
discharge of pus, with decided improvement of her condition.
The wound healed slowly by granulation.
                        ANEURISM.
    Case I.   Ligature of the Common Iliac  Artery by  the
Intra-Peritoneal  Method;  Median  Abdominal  Incision;
Death.—James  C, aged thirty-six, a miner  by occupation,
was admitted to the hospital  August  9th, on account of a
rapidly-increasing and pulsating tumor situated in the right
groin. He had  contracted syphilis six years  prior.  About
one year ago, while lifting  some heavy  timbers, he  felt a
sudden pain in the right groin, and one month  later noticed a
swelling at the point of supposed injury, accompanied, as he
said, by  a  throbbing sensation.  This  rapidly increased  in
size and  was accompanied  by considerable pain, so  much so
that he was compelled to give up his work.
    Examination.  There  was found an  inguinal aneurism
involving the upper part of  the femoral  and affecting the
external  iliac above the origin of  the  deep epigastric, and
occupying the iliac fossa and  the lower part of the abdomen.
The aneurism was  rapidly progressing and was not amenable
to pressure or to the old operation. It was fully decided to
ligature  the common iliac by the intra-peritoneal method, as
suggested by Frederick Treves. 
32
A SYNOPSIS  OF
    Operation,  August  11th.—Ether.  The  bowels having
been well evacuated the night before, the field of operation
was carefully prepared and the abdominal cavity was opened
by a median incision four  inches in length, beginning half
way between the symphysis pubis and umbilicus and extend-
ing up to the umbilicus.  The incision being made in the peri-
toneum, the patient was placed in the Trendelenberg position.
The common iliac was found without  any difficulty, the in-
testines gravitating  to  the  most dependent position.   The
area of the deep wound was packed with sponges and so cut
off the field of operation from the  general peritoneal cavity.
The right common iliac  was seen in close relation with the
vena cava and both common iliac veins.  The external iiiac
artery was found to be diseased as high up as the bifurcation
of the common  iliac artery.  A point about  one  inch  above
the internal iliac artery was selected as the point  of ligatur-
ing.  The peritoneum over the artery was well exposed and
was divided to the extent of  an  inch.  The sheath of the
vessels was next picked up and nicked, and a solid aneurism
needle, carrying a stout chromic acid catgut  ligature, was
passed between the artery and the vein from without inwards.
The ligature was tied so as to stop all pulsation in the aneur-
ism but not to rupture  the inner coat of the artery.  The ab-
dominal wound was closed without drainage.  The limb was
evenly and thickly enveloped in cotton from the toes upward.
He was placed in  bed, surrounded by  hot water bottles and
injection of hot water and whisky administered per rectum,
and the limb kept elevated.
    Subsequent Progress.—Ten  hours after  the  operation,
slightly nauseated  from the  ether.   Temperature, 99D F.;
pulse, 110.  Complained of numbness and tingling in the en-
tire limb, all parts of which  felt  warm except the  toes,  which
were cold and bluish.
    August 12th, 9 a.  m.—Pulse, 115; temperature, 100c  F.
No nausea or vomiting.  Had some sensation in the foot and
the limb felt warm to the toes.  9 p. m.—Pulse, 120; tempera-
ture, 101° F. Sensation and warmth gradually improving.
    August L3th, 9 a. m.—Pulse, 130:  temperature, 100"  F.
Pain in limb considerable.   9 p. m.—Pulse, 140; temperature. 
CLINICAL SURGERY.                33
99° F.—Entire limb felt  quite warm and  sensation almost
normal as far as the toes.  Stimulants administered.
    August  14th, 9 p. m.—Pulse, 160;  temperature, 98° F.
Stimulants administered.  The patient  gradually sank  and
died seventy-two hours aft3r  the operation.  There was no
gangrene of the limb, and collateral circulation had become
established.
    Autopsy.—No  signs  of  peritonitis  and no  secondary
hemorrhage.
    Remarks.—The advantage of  this  operation is
that it is  simple and  involves but little  time.  The
vessel can  be  easily and freely exposed, the ligature
accurately applied and the   needle passed without
risk of injuring the vein.  The extent of the diseased
artery can be made out and the diagnosis confirmed.

                      APPENDICITIS.
    Case I.  Operation;  Recovery.—M. L. G., male, aged
twenty-five. Was first taken  sick February  3rd, eight days
ago, with pain all over the abdomen, but on  the fourth day
became localized in the right iliac fossa and was quite severe.
Admitted to hospital  February 11th.  Temperature, 102° F.;
pulse, 110, and was suffering considerable pain.
    Examination.—There was a  distinct tumefaction in  the
right iliac fossa  and  resistance to the touch over an area of
about  three inches in length running parallel  to Poupart's
ligament.  The  oedema  was slight,  but the  tenderness and
pain was severe, markedly so at  a point about midway be-
tween the anterior superior spine  of the ilium and umbelicus.
The right thigh  was flexed on the hip.
    Operation.—Ether.   An  incision was  made  over  the
tumefaction almost parallel  with Poupart's  ligament.  The
tissues in the abdominal wall were found matted together.
On carrying the incision  a  little  deeper pus escaped to the
amount of several ounces. The appendix was found adherent
to the  head of the colon and easily separated.  A silk ligature
was thrown around the  base of  the appendix and removed
together  with  all its  surrounding inflammatory  tissues. 
34
A SYNOPSIS OF
The  free end  of  the  appendix  was gangrenous and  had
sloughed away.  The  abscess cavity was sponged dry and
packed with iodoform gauze.
   Subsequent Progress.—There  was considerable suppura-
tion for some days, with gradual shrinking of the cavity, till it
was  entirely closed.  He was discharged from the hospital
cured, in twenty-four days.
    Case II.  Operation;  Death.—L. B., aged twenty-nine.
Previous health had always been good, with  the exception of
several attacks of  severe pain in the right iliac fossa during
the past few years.  The present illness began twelve  days
ago  with severe pain in the right iliac region, attended  with
chills and  slight  fever. Bowels have been confined, but not
absolute.  The pain increased and a swelling appeared in the
same region.   On entering  the hospital May 20th, he was
almost in a state of collapse and an operation was performed
with little  hope of success.   Temperature, 99° F.; pulse, 130;
respiration, 32; abdomen tympanitic.  There was an area of
induration  and marked tenderness on the right side.  Liver
dullness absent, and he was in a cold and clammy  sweat.
     Operation.—Ether. An incision three and a  half inches
was  made along the outer border of the right rectus muscle
parallel with the median line.  The deeper muscles were in-
filtrated, the omentum and caecum were bound down in the
iliac fossa  by firm adhesions.  An abscess  containing about
one  ounce of pus  was found in the region of  the caecum, and
the general abdominal  cavity had become infected, and a sup-
purative peritonitis resulted.  The appendix was not removed.
After thorough irrigation with warm water and an iodoform
tampon was placed in the wound, the external incision was
partially closed.  The  temperature gradually rose, the pulse
became rapid and feeble and he died in about ten  hours after
the  operation.  No autopsy.
     Case III.  Operation;  Recovery.—P. O. D., male, aged
twenty-eight.   Admitted to hospital   June 1st.  General
health good.  His present illness began ten days prior to his
admission, with general tenderness in the abdomen.  At first
the  abdominal pain was general, and it continued of a dull
and  constant  character, occasionally  severe, and  markedly 
CLINICAL SURGERY.
35
so in the right lower abdomen.  At the end of seven days he
noticed a swelling in  the right iliac fossa, at which time he
had  a  chill, followed  by a high elevation  of  temperature.
Bowels constipated.   Two days  later nausea and vomiting
set in.
    Examination.—Temperature, 102.6° F.;  respiration,  30;
pulse, 118.  A tumor, tender to pressure, was felt in the right
iliac fossa low down, associated  with general abdominal ten-
derness and muscular rigidity.
    Operation.—Ether.  An incision  four inches long was
made extending  upwards from the middle of Poupart's liga-
ment.  An abscess cavity containing  about three  ounces of
pus was opened,  the caecum forming the floor of the abscess.
The appendix was found terminating in  this abscess, which
was removed, after tying off the base by a silk ligature, to-
gether  with the  inflammatory product. The wound was
packed with iodoform gauze and allowed to granulate.  He
made a rapid and uninterrupted recovery, having been in the
hospital twenty-two days.
    Case  IV. Operation;  Death.—Charles B., aged twenty-
one, butcher by trade,  and a young  man of  robust health.
January 24th was seized with  great pain in the abdomen
shortly after his  dinner, more marked in the right iliac region.
Three  days later he  noticed a swelling in the same region.
His bowels had been  constipated, but not absolute.  This was
the  third attack of the same nature in the past year.  When
admitted  to  the hospital, February 1st, he was  in a state of
collapse.  Temperature  103°  F.;  pulse  130;  repiration 35.
Right  thigh flexed on the abdomen. A distinct tumor was
found in the right iliac fossa, fluctuating and almost breaking
through the  integument.   Tympanites great, attended with
severe  abdominal tenderness.  Tongue dry and parched.  As
soon as possible after his admission  he was put under ether
and  an incision was made over the site of the tumor.  The
tissues were gray and infiltrated with serum.  An abscess of
the most  foul character, showing traces of faecal matter, and
containing about a pint of pus, was  opened and evacuated.
The pelvic cavity was found to  contain pus; this was washed
out with a warm three per cent, carbolic solution, and a large 
36
A SYNOPSIS OF
rubber drainage tube inserted, and  the external wound par-
tially closed.  The pulse was very rapid and weak at the close
of the operation.  The temperature gradually rose, and  he
died thirty-six hours after the operation.  No autopsy.
    Case V.  Recurrent Appendicitis;  Operation; Recovery.
J. W. J., male, age seventeen, a sickly boy.  Was admitted to
the  hospital  February 28th.  On February  8th, on coming
home from school, complained of pain in the right lower ab-
domen. He remained in  bed three days, at the end of  which
time he had a chill, followed  by a high fever.  He gradually
became worse, and started for Salt Lake City on February
24th.  His journey consisted of a stage ride of sixty miles over
the  mountains, and all the while the pain was most intense.
He reached the hospital twenty days  after the onset  of the
attack, and  a distinctly fluctuating  tumor was found in the
right iliac region of about the size of an orange.  Temperature
99° F.; pulse 110; respiration 24.  No general abdominal ten-
derness except on pressure in the region  noted.  Bowels not
constipated.
     Operation.—Ether. An  incision three  inches long was
made  over  the site of the tumor, beginning  about two and  a
half inches above the middle of Poupart's ligament and par-
allel to the  median  line.  An abscess cavity was opened and
about four ounces of pus was evacuated.  The omentum was
found firmly adherent to the caecum.  The appendix was  not
removed.   The wound was sponged dry and packed with
iodoform gauze.  Twenty-eight days later the wound had en-
 tirely healed by granulation, and the  boy went home  March
26th.  He remained well for about four weeks, when there was
 a repetition of  the same symptoms, and he again returned to
 the hospital.  On May 10th, at 9 o'clock in the evening, he was
 operated on the  second time.  The same incision was made
 and a careful search was  made for  the base of the appendix
 which was  found by carefully examining the caput coli, and
 the appendix was traced upward and inward to an Mamma'
 tory tumor.  The base of the appendix  was  ligated  with a
 silk ligature, and the appendix,  with the entire inflammatory
 tumor, was removed, after carefully separating  the adhesions,
 but not  without  considerable  difficulty.  The base  of  the 
CLINICAL SURGERY.
37
appendix was disinfected by cautery. The wound was sponged
out without irrigation and packed with iodoform gauze to the
external wound.  He made a rapid recovery, and union was
complete twenty-nine days after the operation.
    Case VI. Operation;  Recovery.—J. C. B., male, a healthy
young man, aged twenty-four, had an attack of severe abdom-
inal  pain  last May, lasting two days.  His health remained
good till October 26, at which date he was seized with  severe
abdomial pain,but most intense in the right lower abdomen, and
which  was attended with nausea and vomiting.   The pain
remained severe for several days, but he still kept at his work
as a butcher.  He was admitted to the hospital November 8th,
thirteen days from the beginning of his illness, able to walk,
though looking worn.  Five days prior to his admission he
attended a ball and danced several times, but was compelled
to return to his home early in the evening.  On admission his
pulse was 96; temperature 99.5° F.: respiration 23.  Marked
tenderness existed at  the typical  situation, and on deep pal-
pation a small tumor could be felt.  The abdominal muscles
were very rigid and the belly flat.
    Operation, November 9th.—Ether.  The peritoneal cavity
was opened by a four and one-half inch incision about one-
half an inch outside the linea semi-lunaris.  No inflammatory
products were seen till finding the base of the appendix and
following  this upward  and  inward to a  small inflammatory
tumor. The appendix  was  ligatured at  its base, and there
being  only a few adhesions, the appendix, together with the
inflammatory tumor, was removed with ease.  The wound was
packed with iodoform gauze and  the upper part of the exter-
nal incision was sutured.  He left the hospital in thirty-three
days.  The end of the appendix terminating in the inflamma-
tory tumor was  showing signs of sloughing, and there were
only a few drops of pus.  This  in a few days would undoubt-
edly have been a large abscess.
    Case VII. Operation; Recovery.—P. C, a sturdy Swedish
girl, age twenty, was first  seen March 1st, after she had been
suffering severe abdominal pain for three days. This pain was
continuous and  remained general till March 3d, when it be-
came localized in the right iliac fossa, in which region there 
38
A SYNOPSIS OF
was great tenderness on pressure, attended with slight nausea
and vomiting.  Temperature 100° F.; pulse 112; respiration
24.  On March 5th the pain and tenderness had almost ceased
and she sat up for a while, contrary to all advice.   Tempera-
ture 99.5°; pulse 100.  The general appearance of the patient
was good, and on  the whole it seemed that she was on the
road to recovery, when on March 6th the  symptoms returned
with greater severity, ushered in by a chill. Temperature 103°
F.; pulse 126; respiration 30.  The point of maximum inten-
sity was the typical point.  The bowels had been constipated
since the attack, but not absolute.  There was no marked
muscular  rigidity.  Though no tumor existed, yet  the symp-
toms were becoming more aggravated and the local signs were
clearly those of a sharp inflammatory process.
    Operation, March 8th.—Ether.  An incision four inches
long was made just to the outside of the linea semi-lunaris
and the peritoneal cavity opened.   The appendix was found
lying deep behind the caput coli surrounded by  an inflam-
matory  tumor,  and  attached to the  small  intestines.  The
base of the appendix was severed  after having been ligated.
The appendix ended  in the inflammatory tumor,  which  by
careful dissection was opened and about  a dram of pus was
caught on a sponge.   The  appendix was removed  with diffi-
culty on account of its firm adhesion, the end  of which was
quite destroyed.  In this abscess cavity, at the opening of the
appendix,  was found a fsecal concretion about the size of a
pea. Strips of  iodoform  gauze were  placed in  the  deep
wound,  the  seat of  the  abscess, and  allowed to protrude
through the external wound, which  was  half  closed  by
sutures.  Usual  dressings  applied, and two days afterwards
the evening temperature was 99° F.; pulse, 90.  She left the
hospital on the thirty-second day.
    Case VIII.  Operation; Recovery.—J. C, aged eighteen.
Came to the office to consult concerning  a tumor  low  down
on the right side of the abdomen, having been sick for several
days.  He was taken suddenly with  severe pain in  the  right
side attended with nausea and vomiting.   The pain continued
all that day and the next and on the following morning he
had a severe rigor, followed by a high and delirious fever. 
CLINICAL SURGERY.
39
On the fourth day his condition was much improved, except
that the pain in the right side continued.  On the evening of
the sixth day he noticed a swelling in the right iliac fossa.
On the afternoon of the seventh day, feeling much better, he
left his home for the  office.  On  coming into the office he
rather dragged himself than walked and was bending forward
and to the right side, with  his hand on the abdomen.  His
face bore the expression of intense suffering and was  of that
peculiar  hue so characteristic of  septic-intoxication.   The
trouble was suspected at once, and on examination a distinct
tumefaction about the size of the  fist was discovered in the
right iliac fossa, fluctuating and exquisitely tender  on press-
ure.  Temperature, 102° F.; pulse, 130;  respiration,  36.  No
tympanites.  Muscular rigidity great.  Bowels severely  con-
fined. He was sent to the hospital for operation, but  did not
reach there till 9 o'clock in the evening.
    Operation,  November 10th,  9:30 p. m.—Ether.  An in-
cision was made over the tumor and about two teacupsfull of
foul-smelling pus was evacuated, but no attempt was made to
remove the appendix that evening.  The  abscess cavity  was
irrigated  with  warm  water, sponged dry and  packed  with
iodoform gauze.  On  the  second day, his condition being
greatly improved, he was again put under  ether and the ap-
pendix searched for, which was easily found penetrating the
abscess cavity and  gangrenous at its extremity.  A ligature
 was thrown round its base and removed.  The usual dressing
 was applied and there was a free discharge of pus for  several
 days, which  gradually diminished,  the  wound healing by
 granulation.  He left the hospital in twenty-five days.
     Case  IX.  Operation;  Recovery—J. J. G.,  male,  aged
 thirty-one, of heavy build and excellent health.  While on his
 way  from Pocatello to this city, he was suddenly seized with
 severe abdominal pain attended with nausea and vomiting.
 His  illness continued severe and on reaching this city, Sep-
 tember 10th, was taken to the hotel, where  he  was first  seen.
 He was visited frequently  during the  day and acute appen-
 dicitis was suspected.   His temperature was 102° F.; pulse,
 118;  respiration, 28.  The pain in the right  iliac  region in-
 creased and next morning his temperature was 103.5° F., 
40
A SYNOPSIS OF
pulse, 124; full and bounding.  Great tenderness in the usual
situation and he had the looks so characteristic of beginning
sepsis.  Operation was advised to be done without delay,
which was consented to and he was removed to the  hospital.
    Operation, September 12th.—Ether.  No distinct tumor
could be felt, but there was considerable  muscular rigidity.
An incision about five inches was required on account of the
thickness of the abdominal  walls, to the  outer  side of the
linea semi-lunaris.  The appendix was found lying to the out-
side of the colon, about three inches long  and about the size
of the index finger, the outer half gangrenous but not perfo-
rated, and no pus had formed.  The appendix was ligated at
its base and was completely removed. The cavity was sponged
dry and packed with iodoform gauze.  The  bowels  acted on
the second day without either  a saline or an enema.  He left
for home in thirty-five days from time of operation.
    Case X.  Operation; Recovery.—Thomas C, age twenty-
five, a healthy young man, had had  during the past year and
a half several attacks of a severe abdominal pain, and their
nature remained unknown till he was seen  in his present  ill-
ness by Dr. Carter, of  Fort Bridger,  Wyoming.  He had three
attacks, all  of which were in  the time of six weeks.  On Octo-
ber 10th he had a fresh attack,  when for the first time he had
medical aid, occurring under the observation of  Dr. Carter.
The attack lasted about eight days, after  which time he was
able to be around, but there remained a dull, constant pain in
the right iliac region.  Believing him to have what is called
the recurrent or relapsing appendicitis, an operation was  ad-
vised, and he came to the hospital  for that purpose.  On  his
admission,  October 28th, his temperature was 99° F.; pulse
86; respiration 18.  The local pain  had  almost  disappeared,
but there was a characteristic tenderness in the typical situ-
ation when deep pressure was  used.  No tumor could be felt.
He had not fully recovered from the attack; had lost flesh and
was anaemic.  He looked a man forty-five years old.  Believing
that he had a case of relapsing appendicitis, and relying upon
the accurate observations of Dr. Carter,  an early operation
was decided  upon  as the safest plan.  To  this the patient
readily assented, and on November 4th the operation was per" 
CLINICAL SURGERY.
41
formed.  The appendix at first was not easily found, but was
finally discovered deep in the pelvis, ending in an inflamma-
tory tumor, which was adherent to the common iliac artery.
The intestines were  carefully protected  by sponges and the
base  of the appendix ligated  and  cut.  The  appendix was
finally removed by slow dissection, and a small  abscess cavity
opened, containing  about half a drachm of pus, which was
caught on a small sponge.  The abscess  cavity was sponged
dry and strips of iodoform  gauze carried to the seat of the
abscess.  The external wound was left open.  His condition
improved from the time of the operation, and he made an un-
broken convalescence, and when he left the hospital he was in
good  spirits, and had gained much in flesh.  He was in the
hospital thirty-one days.
    Case  XI.  Operation;  Death.—E.  I.,  female,  a rather
delicate child of nine years  of age, was attacked by severe
abdominal  pain, which was  at  first regarded and treated  as
colic, till she was seen by Dr. Shores, of Provo, December 26th,
who at once strongly suspected acute appendicitis.  At the
time  the child was seen by Dr. Shores she had already been
sick five days, suffering the  most exquisite pain, especially
marked in the right iliac fossa.  Her temperature was  103.5° F.;
pulse 128; respiration 33.  Nausea and vomiting were exces-
sive.  She was taken  at once to Salt Lake City and  conveyed
to the hospital, accompanied by Dr.  Shores, and the operation
was performed that night.  There was a distinctly fluctuating
tumor in the right iliac fossa. She had the gray, tired look
so characteristic of sepsis.  Her pulse was 130, and  tempera-
ture 104° F.
    The  operation was performed  without delay,  with the
hope of saving her life.  The appendix was found gangrenous
and perforated  near  its base. A large abscess cavity was
opened, in which was  found an orange seed.  The  appendix
was removed and the  cavity washed out and  packed with
iodoform gauze.  The pulse was very rapid and weak  after the
operation, and the temperature gradually rose, and  she died
about ten hours  after the operation.   No autopsy. 
42
A SYNOPSIS OF
                      HERNIA.
   There were nine operations for hernia, as follows:
inguinal, six; femoral, two; ventral, one.
   Of these operations, there were eight recoveries
and one death (strangulated).  In the ordinary cases
the method of: operation was as follows: A two and
a half to three and a half inch  incision was made in
the line of  the inguinal canal.  The sac having been
exposed just below the external ring, was cut across,
and the intestines returned to the abdominal cavity.
The sac was then ligated as high up as  possible.  The
pillars of the ring were then brought  together with
interrupted catgut sutures, embracing the conjoined
tendon as well as  the external and  internal pillars.
The external wound was  closed with a small rubber
drain at the lower  extremity.   Antiseptic dressing
with a hernia bandage was  applied and allowed to
remain about five days.  A  light truss was worn as
soon as the cicatrix had become  firm.  The average
time of  the cases in the hospital  was about four
weeks.
    Mortality.—The only fatal case was one in which
the operation was performed for prolonged strangu-
lation.  The patient,  being in  his  seventy-second
year, was almost in a state of collapse at the time of
the operation.  Time has not been long enough to
judge whether the operations have been beneficial or
not.  The  ordinary cases have  been  arranged in a
tabular form, giving only the important points, while
those of unusual  interest have been given with more
or less detail.
    Case I.  Strangulated  Inguinal  Hernia;  Operation:
 Death.—T. J. B., age seventy-two, had a hernia twenty-seven 
CLINICAL SURGERY.
43
years, which  had become strangulated  two days previous to
his admission.  At the  time of the  operation  there was  a
tumor of the size of the fist in the left inguinal region, which
was very tender and  resonant  on  percussion.  Temperature
102° F.; pulse 140.  The whole abdomen was  tympanitic and
distended.  The operation was performed July 31st, soon after
his admission.  A knuckle of  small intestine, about six inches
in length, greatly congested, but soon  regaining its  normal
color on removing  the  constriction, was found in the hernial
sac, together  with  a  small amount of  bloody serum.  The
intestine was  returned to the abdominal  cavity and the sac
ligated  high up and  removed.   The  wound  was closed by
the usual method.  The patient's condition was very bad at
the time of the operation, but he  rallied under stimulants.
On the following evening his temperature rose to 104.5° F., and
continued high, and on the third day death ensued.
    Case II.   Ventral Hernia;  Operation;  Recovery.—Mrs.
E. P., age thirty-five, was operated  on one and one-half years
prior to her  admission  to the  hospital for  a large ovarian
tumor.  Admitted May 27th, and on  examination there was
found a  large visible tumor, in which,  after coeliotomy,  the
recti and fascia had separated along the line of incision, leav-
ing the abdominal contents separated from the external world
by only a covering of peritoneum, fat and skin.
    Operation.—Chloroform.  After opening  the sac  it was
found to contain the omentum  and greater part of  small in-
testines, all  adherent  to each other,  and  to a large hernial
aperture, circular in form, and situated in  the median line
just below the umbilicus.  After liberation of the adhesions,
which was only accomplished  after considerable difficulty, the
fibrous margin of the aperture was split all  around  by the
knife to obtain fresh surfaces for union.  Silver wire sutures
were used, embracing  both the skin and  the margin of  the
hernial aperture.  Superficial  silk sutures  were used, and the
wound closed without drainage.  The silver wire sutures were
removed  on  the  eleventh day, and she returned  home five
weeks after the operation, wearing a suitable  abdominal sup-
port.  Chloroform was used in preference to ether because of
the severe  after effect experienced  in her former  operation,
and its use was followed by only slight  nausea and vomiting. 
44                   A SYNOPSIS OF
    Case III.  Large Irreducible Scrotal Epiplocele; Oper-
ation ; Recovery.—The patient, a German,  aged thirty-nine,
very fleshy and  weighing 210 pounds, was  admitted to the
hospital in February, 1890, with an irreducible scrotal epiplo-
cele, about the size of  a child's  head.  At  the operation the
sac was found to contain a large mass of adherent omentum,
which was separated with great difficulty and returned to the
abdominal cavity.  The  testicle on that side was found dis-
eased and was removed together with the cord high up.  The
sac was ligated  high up and then removed.  The external
incision was carried from the spine of the pubes up to within
an inch and a half of the anterior superior spine of the ilium.
Six or eight interrupted stitches were taken  on the upper side
of the wound, binding into  one thick  edge  the skin, the ex-
ternal abdominal aponeurosis, including  the inner pillars of
the ring, the transversalis and internal oblique  muscles and
conjoinded tendon.  Six or eight  stitches were taken en the
lower side of the wound, binding together into one thick  edge
the skin and Poupart's ligament, including below the outer
pillar of the ring.  Iodoform gauze was packed in the result-
ing open canal, which slowly filled by granulation.  He left
the hospital in nine weeks' time from  the operation, wearing
a suitable abdominal support.  The history of this  case has
been followed up for three years, and in February, 1893, the
result was perfect.  The patient has not worn an abdominal
support for  nearly two years.
    Case  IV.  Incarcerated  Femoral  Hernia;  Operation;
Recovery.—The  patient, a  woman,  fifty  years  old, had  a
femoral hernia for  thirty years,  which had  been reducible
until four days previous to  her admission to the hospital, at
which time the tumor  was about the size of the  fist, very
tender on percussion.  The hernia could not be reduced  by
gentle taxis or by the employment of ice bags. An operation
was decided on without delay, for the  hernia showed signs of
positive strangulation.
     Operation, March 30th.— Ether.  An incision two inches
long was made near the inner side of the neck of th3 tumor.
The  superficial fascia was divided and  a  hernia  knife was
introduced  to the neck of the tumor, through the crural ring, 
DIAGNOSIS	AGE.	SEX.	DURATION.	SIZE.	TEUSS. (WOBN)	OPEEATIONS.	DRAIN-AGE.	TIME IN HOSPITAL.	WOUND HEALING.	REMARKS.
Case V. Oblique inguinal of right side. Incarcerated 4 days.	75	M.	30 years.	Fist.	Truss.	Sac liga-tured high up and re-moved.	Rubber drain.	30 days.	Primary Union.	
Case VI Oblique inguinal of right side	43	M.	2 years.	Fist.	Truss.	Usual meth-od.	Rubber drain.	26 days.	Primary Union.	Omentum tied off.
Case VII. Oblique inguinal of left side.	14	M.	Congenital	Walnut	None-	McBumey's.	Packed with iodoform gauze.	29 days.	Wound healed by granul a -tion.	This is the second oper-ation ;the first was perform-ed 4 yrs. pre-viously.
Case VIII. Oblique inguinal of right side.	25	M.	12 years.	Egg.	Truss.	Usual meth-od; unde-scended testicle.	Rubber drain.	33 days.	Primary union; tube sin-us.	Testicle re moved.
Case IX. femoral, right side. Incarcer-ated 5 days.	23	F.	5 years.	Egg.	None.	Usual meth-od.	Rubber drain.	27 days.	Primary union.	
 
46
A SYNOPSIS OF
 and insinuated between the neck of the tumor and Gimber-
 nat's ligament, cutting inwards, dividing a few fibers of the
 ligament.  This done the tumor was reduced en masse with-
 out opening the sac.  A  stout catgut  ligature was  thrown
 around the neck of the sac high up and removed.   The in-
 cision was closed and a small drainage tube  placed in the
 lower end of the cut.  Union  by first intention.  She left the
 hospital in four and a half weeks' time.
                       UNCLASSIFIED.
    Case I.  Encysted Peritoneal Dropsy;  Coeliotomy;  Re-
 covery.—John H., age seventeen, was admitted to the hospital
 May 30th.  Had noticed a fullness in the epigastric region for
 about one and one-half years, which of late  had rapidly in-
 creased.  No satisfactory history could  be  obtained  from the
 boy.  No history of an injury.
    Physical Examination.—There was a marked  tumefac-
 tion occupying the median line and situated above the umbili-
 cus.  No degree of mobility  was present.   Fluctuation free.
 There was resonance  between the pubes and  the tumor.  No
 distinctly outlined cyst wall could be made out.   Dullness ex-
 tended  on percussion to both sides and from above the ensi-
 form cartilage to just above the navel.
    Operation.—A median incision four inches in length, mid-
 way between the umbilicus and ensiform cartilage, evacuating
 about six quarts of a clear, limpid fluid.  Drainage tube in-
 serted in  the lower part of the wound, which was allowed to
 remain  for several days, there being a continual discharge of
 the fluid.  The tube was removed on the fifth  day, the fluid
 having  entirely  discharged itself.   He left the hospital  five
 weeks after the operation, with no  accumulation within  the
 abdominal cavity.
    Case II.  Chronic Suppurative Salpingitis; Ceoliotomy;
 Recovery.—Mrs. M. C. A., age twenty-eight, had been in poor
 health for six years, during which time she had  been confined
 to her bed for the greater part of the time.  She had never
 had any children, and her present illness dated from a miscar-
 riage six years previous.  Admitted to the hospital June 22d.
    Physical Examination.—She was  reduced almost to  a
skeleton.  Skin very sallow; temperature 102° F.; pulse 110; 
CLINICAL SURGERY.
47
respiration 30; tongue dry; cold and clammy sweat.  For sev-
eral years had had severe pains in the lower part of the abdo-
men, accompanied by a white discharge from the cervix.   Her
menstrual history  had been very irregular.  A very tender
swelling  about the size of a  large orange was found in the
right  side and fluctuating.  Abdomen markedly tender and
slightly  tympanitic.  Nausea  and vomiting.  Vaginal:   The
same fluctuating tumor was found in the right fornix.
    Operation.—Chloroform.   A four-inch  incision (median)
below the umbilicus.  On  the right side, deep down in the
pelvis, was a mass the size of an orange, to which the intes-
tines were bound by old and firm adhesions.  Here and there
the intestines were bound together with well-organized fibrinous
exudation.  The mass was found to be an enlarged suppurat-
ing Fallopian tube and right ovary. The adhesions were very
firm and vascular,  and on this account it was found impossi-
ble to remove the suppurating mass.  The abscess cavity was
aspirated and an incision made into its walls, which were then
stitched to  the lower part of the abdominal incision, and a
drainage tube inserted. She was put in bed in a very critical
condition, but rallied well under  stimulants. There was a free
discharge of pus  for  several days; the tube was  removed on
the tenth day and  the wound thereafter packed with iodoform
gauze.   She made a slow recovery, and left the hospital Au-
gust 18th, cured.
    Case III.  Chronic Suppurative Salpingitis; Ceoliotomy;
Death.—Mrs. M. V., age twenty-nine, was  on her way  from
San Francisco to  Chicago, when she was taken with a severe
pain in the  lower abdomen, preceded by a rigor and attended
with nausea and vomiting. She was taken to the hotel, where
it was learned that she had suffered for about nine years with
attacks  of sharp, shooting pains in the lower portion of the
abdomen, accompanied by a white discharge from  the cervix.
Her  menstrual history for several  years had been irregular,
and she had been addicted severely to the use of morphine.
    Physical Examination.—Temperature 103° F.; pulse 120;
respiration 26. Tongue dry and  parched; skin sallow;  abdo-
 men  remarkably tender and  tympanitic.  A tender swelling
 was found in the region of the right tube and ovary, about the 
48
A SYNOPSIS OF
size of a cocoanut. Vaginal: The same tender swelling in the
right fornix and fluctuating.
    Treatment.—An ice coil to abdomen, when the symptoms
quickly became less, and on the following day (November 14th)
she was taken to the hospital.  November 20th the pain and
tenderness, now localized in the region of  the right tube and
ovary, recurred with greater severity than ever.  Nausea and
vomiting.   Temperature 104.7° F.; pulse 138; repiration 29.
    Operation, November 20th.—Chloroform.  A  four-inch
median incision was made below the umbilicus, and on the
right side, deep down in the pelvis, was a mass about the size
of a fcetal head, bound to  the surrounding organs with firm
and old adhesions.  The mass was found  to be an enlarged
suppurating Fallopian tube and ovary.   On account of the
firm and vascular adhesions the tube and ovary were not re-
moved, but after  evacuating the abscess cavity through an
incision, first carefully protecting the peritoneal cavity, the
walls of the abscess cavity were stitched to the lower part of
the abdominal incision  and a  rubber drainage tube was in-
serted.  Intestinal paralysis set  in  on  the fifth  day,  and
in spite of  anything that  could  be done she sank  and  died
on the tenth day after the operation.  Cause of death, intes-
tinal paralysis.
    Case  IV.  Pistol  Wound   of the Abdomen;  Lumbar
Abscess; Lumbar Incision; Recovery.—H. P., male, aged
eleven, on October 12th, was accidentally  shot in the abdo-
men with a 32-caliber  pistol.  He was not seen until three
weeks after the injury, when he was brought to the hospital.
    Physical Examination.—There was  a  bullet wound  four
inches to the left and on a line with the  umbilicus.  His left
thigh was flexed on the abdomen. All the symptoms so char-
acteristic of  sepsis  were  present.   Temperature, 102.7° F.;
pulse, 130.  Abdomen flat and hard.  No tympanites.   Bowels
have moved regularly.   A tender swelling was localized in left
lumbar region  into which an  aspirating  needle  was intro-
duced and a syringe full of  pus withdrawn.  With the needle
as a guide an incision two  and  a half inches long was made
into  the  left lumbar  region, opening up  an abscess cavity
along the Psoas muscle, from which about  one pint of pus 
CLINICAL SURGERY.
49
escaped.  In this cavity was found  the  ball, together with a
small piece of the clothing.  There was a profuse discharge of
pus for about two weeks, which gradually ceased.  His re-
covery was slow, regaining the full use of his left leg.  He left
the hospital in six weeks' time.

    Case  V. Cyst of the Pancreas;  Coeliotomy;  Recovery.
—William  W.  Y., aged  forty-five,  miner  by occupation.
Father and mother both  living.  Grandparents lived to  an
old age.  Two of  his sisters, twins, died  within a few days of
each other of cancer of the stomach, at the age of thirty-four.
About one  year  prior to  his  admission to the hospital he
noticed a swelling in the right side of  the abdomen, which for
the  last  three  months  had  been rapidly  increasing  and
attended with considerable pain.  Admitted  to the hospital
July 27th.
    Examination.—Has lost  flesh rapidly during  the  last
three months.  Complexion of  an ashen hue.   A tumor occu-
pying the whole  epigastric and left hypochrondriac regions,
and most prominent to the left of median line, about three
and a half inches below the ensiform cartilage.  The swelling
is smooth and round,  non-pulsating, and no  pulsation  im-
parted to it from its proximity to the abdominal aorta.  Dull-
ness extends from the left  nipple to half an  inch  above the
umbilicus  in front and posterior  from  the  eighth to  the
twelfth ribs on the left side.  Resonance between tumor  and
liver.  Heart displaced upwards.  Liver normal in size and no
ascites. Tenderness on pressure and considerable pain of a
gnawing character.  The tumor has been steadily increasing
in size. There is absolutely no history of an  injury. Alvine
discharges  normal.   Temperature,  98   1-5°   F.;  pulse,  76.
Urine acid, specific gravity 1,021.  No traces  of albumen or
sugar, but large amount of phosphates.   A needle  was intro-
duced, which moved up and down with respiration, and drew
off a dark  brown turbid fluid;  re-action alkaline;  specific
gravity 1010; rich in albumen, forming on boiling and slightly
acidifying  a solid coagulum.   Tasteless and  odorless.   On
standing, a  one-half dark precipitate goes down—the upper
part turbid  and of a yellow color.  The precipitate  consists of
blood cells, and debris of  cells.  The  fluid does not  contain
     4 
50
A SYNOPSIS OF
bile.  When boiled  with equal parts of starch-paste it  does
not convert the starch into sugar. It forms only a slight
emulsion with olive oil.
    A specimen of this fluid was sent  to Dr. W. T. Council-
man, of  Johns Hopkins Hospital, and appended is his report:
    " The fluid  has  a dark brownish color, which is due to
admixture with blood.  It contains no  bile.  There is no evi-
dence of  hydatid  disease.   On microscopic examination it
contains numerous bacteria of putrifaction and large numbers
of  red  corpuscles.   There are also a few  other elements
present, but they are so altered by putrifaction that I cannot
say what their character  is.  The general appearance  of the
fluid resembles that from cysts of  the pancreas, but the  con.
cretions so often  found in this are not present.  I should
incline  to the opinion that the fluid  rather comes from a
pancreas cyst than from the liver."
    Operation.—A six-inch incision was made over the most
prominent part of the tumor, through which the tumor could
be seen and felt, presenting a smooth, whitish and  glistening
surface.  An aspirating  needle was introduced and about
three quarts of a dark  brown fluid were  drawn off.  Before
making an  incision  into the cyst  it was brought  up and
stitched to the abdominal wall, and an incision was then made
into the cyst, the walls of which were found to be about an
eighth of an  inch in thickness, rough and of a dark brown 
CLINICAL SURGERY.
51
color on the inside.  Two more quarts of the same fluid were
drawn off.  The cyst was not adherent  to  the  omentum or
peritoneum.  The interior of the cyst was explored, the index
finger passing directly backward  to the tail of the pancreas,
which could be felt through the walls of the cyst.  A rubber
drainage tube was  inserted and packed  about with iodoform
gauze.  The cyst discharged this dark brown fluid for several
weeks.  The patient made a rapid and uninterrupted recovery
from the operation, and left the hospital September 24th.

    It will be of  interest to record  here a case of in-
testinal obstruction, due to that somewhat rare condi-
tion of  volvulus or twisting of the sigmoid flexure:
    Case VI.  Volvulus;  Autopsy.—J.  G.,  age twenty-six,
came to the hospital  on the night of November 7th, and died
suddenly, shortly after his admission, while going to stool. An
accurate history of his condition could not be learned, save a
little  from  a friend of his.  He was taken, ten days prior to
his coming to the hospital, with colicky pains in the abdomen
and persistent vomiting.  His bowels had not moved for sev-
eral days, and believing himself constipated, he had been
taking freely of  cathartics of all kinds, especially large doses
of salts.  When he was seen at the hospital his skin was pale
and cold, his pulse  small and rapid. The abdomen was enor-
mously   distended, and he  was vomiting  incessantly.  His
breathing was difficult and his  temperature was sub-normal.
When the attendant  was out of the room he  got up from his
bed to  go  to stool,  and fell dead just  as  he reached the
closet.
    Autopsy.— Intestines found greatly congested, enormously
distended and filled  with fluid.  The  colon  measured seven-
teen inches in circumference  and contained a great quantity
of fluid.  The obstruction was in the sigmoid flexure at the left
sacro-iliac symphysis, where the gut ends in the rectum.  The
twisting of the gut was twice around its axis from left to
right, and above  the obstruction  was greatly  dilated and
elongated.  No signs of  peritonitis.  The mesentery was of
abnormal length.  Where  the bowel was twisted the lumen
of the intestine was narrowed (stenosis). 
52                 A SYNOPSIS OF


  OPERATIONS ON THE  HEAD, FACE AND NECK.
(A) Operations upon the Head:
  (a) Compound  depressed  fracture  of
     skull..............................
  (o) Mastoid necrosis...................
(B) Operations on the Face:
  (a) Neoplasms—
     Epithelioma of tongue............
                  lip.................
     Carcinoma  of superior maxillary
       bone............................
     Recurrent fibromata of ears......
     Sarcoma of parotid...............
  (b) Deformities—
     For hare Up.
        "   "  single................
        "   "  double complicated...
     Plastic...........................
  (c) Eneucleation of eye...............
(C) Operations on the Neck:
     G^sophagotomy for foreign body..
                   " stricture......
     Carcinoma thyroid body.........
     Abscess            "  .........
     Lipoma..........................
     Tubercular lymphadenoma.......
(D) Miscellaneous......................
NO.	RECOV-ERED.
2	2
7	7
4	3
6	6
2	2
1	1
1	1
4	4
1	1
7	7
9	9
2	2
1	1
1	1
1	1
2	•>
10	10
27	27
    (^4)—OPERATIONS ON THE HEAD.   (a)—HEAD.

  Although  the number of cases here  reported are
only two,  where  an  operation upon the skull was
necessary  for  traumatism,  yet  they  add  to  the
evidence which has  been collected durirg  thejast
eight or  ten years  in  favor of  the early  use  of
the trephine  in all cases of  depressed fracture  of
the skull.   Trephining was  largely  practiced  as a
prehistoric religious  rite, and must have been harm-
less, judging from the great  number of  skulls which
have been  found with trephine  openings  healed be- 
CLINICAL SURGERY.
53
fore death.  Prior to the nineteenth century the tre-
phine was used frequently, and it is said that Chaborn
trephined Philip of Nassau for epilepsy twenty-seven
times, and even a greater number of operations have
been performed  upon a single individual.   The most
discordant opinions have prevailed  in modern times,
and even within  a very recent period, as to the neces-
sity of the operation for depressed  fracture.  To go
no  further  back than Pott, who, it is well known,
established it as the general rule of  practice in every
case of  fracture  with depression, the skull should be
perforated and  the depressed portion of the bone
either raised to  its level or entirely  removed.  Many
of  the best army and hospital surgeons in  the early
part of this  century went  so far  as to believe that
trephining was an absolute necessity to prevent conse-
quent intracranial inflammation in cases of simple un-
depressed fracture of the skull; but since their time
a great  change of opinion has taken place on this sub-
ject, and  it became the general rule not to interfere,
even in cases of  depression, unless symptoms of com-
pression have supervened.  Such was the  practice up
to a very  recent  period, and it might be asked: What
have  been the  results?  On this point, Dr. Laurie
of Glasgow, a surgeon of ample experience, published
some very trustworthy  statistics in  the London and
Edinburgh Medical Journal, 1844, in which he took
an  opposite view to that established forty years be-
fore, namely, that in cases of depression, symptoms
of  compression  should be our guide to the  employ-
ment of  the  trephine. For he  says that "Out  of
fifty-six cases operated upon in the Glasgow hospi-
tals, including,  in  point of  time,  a period a little 
54
A SYNOPSIS OF
short of  fifty years,  there  does not appear in our
records a single  unequivocal instance of  profound
insensibility in which the mere operation of trephin-
ing removed the coma and paralysis, or in any way
conduced to the  recovery of the patient.   We wish
to be clearly understood  as speaking of the trephine
used in reference to the  state of the bone in cases of
profound insensibility, not employed to remove  ex-
travasated blood.   Nor does the cause of our want of
success appear at all  obscure.   We believe that  in
practice  the cases of urgent  compression dependent
on  depressed  bone alone are very  few indeed.  We
are well aware that many such are on record.  We  do
not presume  to impugn  their accuracy.  We merely
affirm  that the records of  the Glasgow Infirmary  do
not add  to the number.  From what we have said, it
will appear that we coincide with those who, in using
the trephine in  cases of compound fracture  of the
skull, look more to the state of the bone than to the
general symptoms, and who employ it more as a pre-
ventive of inflammation and its consequences than as
a cure for urgent symptoms, the immediate result of
the accident."   He goes on to state that "the  details
we have given are by no means in favor of the tre-
phine.  Of the fifty-six cases operated upon, eleven
recovered and forty-five died.  We feel assured that
this affords too favorable a view of the actual results."
The bold and active interference in  cases of injury to
the head, during the early part of  this century, was
followed  in the last seventy-five years by a conserva-
tive treatment,  which consisted principally in  watch-
ing and waiting until  the patient recovered or died;
while  along in the  fifties  and sixties the operation 
CLINICAL SURGERY.
;)•)
was  almost  unknown, so  great  was  the  reaction
against its general adoption.  At St. Bartholomew's
Hospital it was recorded  by Callender in 1867 that
the operation had not been performed for six years.
Only in the most severe and often hopeless cases was
the operation ever performed, and, as a consequence,
the high rate of mortality, unjustly attributed to the
operation itself, told still more against it.  And it  is
only of a very recent  date  that  the operation,  and
similar operative  interference, has come into promi-
nence, owing to the  modern  methods  of operative
surgery.  Bryant's Practice of Surgery  (p. 212) says
that  at  Guy's  Hospital, during  a period of seven
years, trephining  and elevation  of  bone for  head
injuries  have been performed in fifty-one cases, and
of these only twelve recovered, thus making a mor-
tality for the operation of  76 per cent.  But this
must not  be considered a proper estimate, for tbe
operation was performed upon cases severe and hope-
less.  Dr. Stimson has  collected thirteen cases of
operation for  a single  year  at  Bellevue Hospital
(1880-81).  Ruling out a gunshot fracture and a case
where the fracture was  not discovered until an abscess
had formed in the brain, there remained eleven cases,
with  nine  recoveries, or a  mortality of  18 per cent.
In seven of  the cases collected by Dr. Stimson there
were  no brain  symptoms  beyond stunning,  all of
which recovered. In the two cases reported below, the
operation in one was performed immediately, and in
the other five days elapsed from the date of iujury.
Prompt recovery followed both.
   Case I.  Compound Depressed Fracture of the Vault of
the Skull; Trephining: Recovery.—J. M.. male, age 12.  Fell 
56
A SYNOPSIS OF
from a tree, striking on his head.  There was a lacerated  and
contused  scalp wound, filled with dirt, three inches long, in
right frontal and parietal regions.  An extensive longitudinal
fracture was found with the upper edge depressed. First seen
five days after the injury,  in consultation. The boy was then
conscious, and could tell how he received his injury.  The left
arm and lower extremity were paralyzed.
    Operation, Six Days after Injury.—Ether.  Through a
curved incision four  and a half inches long trephining  was
performed.  After removal of a button half inch in diameter
in anterior portion of the fracture, the  depressed  bone  was
elevated  to its level.  Dura mater  not  injured.   A perfectly
sterilized catgut drain was used, and the scalp wound sutured
with the same.  The  catgut drain was removed on the third
day.  There was no elevation of temperature.  Primary union.
The paralysis gradually cleared up, and at  the end of six
weeks' time recovery was complete, and now, thirteen months
after the operation, is perfectly well.
    Case II.   Compound  Depressed Fracture of Vault of
Skull; Trephining; Recovery.—J. P , male, age thirty-five, in
the employ of  the R. G. W. Railroad as bridge carpenter, fell
from a trestle a distance of thirty feet, striking on the back
of his head. Was brought to the hospital that same day, May
1st, delirious.
    Physical examination. — There was a  contused scalp
wound about two inches square just above and a little to the
right of the posterior occipital protuberance.  He was put un-
der ether four hours after the injury, and by a curved incision
the scalp was turned down.  There was found a comminuted
depressed fracture about  the size of  a half-dollar above  and
to the right of the posterior occipital protuberance.  A but-
ton of bone half  an inch  in diameter was removed and the
opening enlarged with rongeur forceps to a little larger than
a half-dollar.  A  horse-hair drain  was used and the scalp
wound closed with fine catgut.   Horse hair drain removed on
fourth day, and the wound healed by first intention.  There
was delirium and semi-coma for several days, which gradually
disappeared, and recovery was complete at  the end of six
weeks' time, He is now—eleven months after the operation—
perfectly well. 
CLINICAL SURGERY.
57
         (6)—suppurative disease of the ear.
   It is estimated that there are not far from 2,000
deaths annually from  ear  disease  in  Great Britain,
with a population of but little more  than  one-half
that of the United States.  Of all these a very large
proportion are  caused by cerebral disorder resulting
from ear  disease  (Barker).  Of  43,730  cases of ear
disease tabulated by Burkner, 66.9 per cent, were dis-
eases of the  middle ear, and 29 per cent,  were sup-
purative middle  ear  disease.   Four-fifths  of these
were chronic,  among  which  are to be sought  the
greater number of brain  lesions.  It  is generally
thought  that the excessive fetid discharges  which
often accompany ear diseases are far more dangerous
than those  without  much  odor;  but  Rohrer  has
shown that the non-fetid discharges are the causes
of the most  dangerous cerebral  sequels, since fetor
is due to bacilli which are not  pathogenic, but merely
saphrophytic.   Therefore, the presence or absence of
odor in  the  discharge is no  test of danger.  Of all
the  discharges, the inspissated pus that is found in
the ear in many cases  is the  most dangerous, being
filled with pathogenic micro-organisms  (American
Text Book of Surgery).
   Case  I. J. C. F. Aged 32, male.  In  October had an
attack of la grippe followed by inflamation of the  middle ear.
On November  8,  when he entered the  hospital the mem-
branum tympanum of left ear was  perforated and a profuse
discharge of pus flowing from the external auditory meatus.
The pain over the mastoid process was severe and of a boring
character.  The mastoid region  was swollen and cedematous.
The hearing was nil.  The external ear was swollen.
   Operation, November  10th.—Ether.   A curved incision
was made over  the mastoid process, beginning  one-half  inch 
58
A SYNOPSIS  OF
below the temporal ridge and one-half inch posteriorly to and
parallel  with the  external auditory canal.  The mastoid
antrum was  opened by chisel and hammer, when one-half
drachm of pus  was evacuated.   Free  communication was
made between the antrum and the  middle ear.  Wound left
open and packed with  iodoform gauze. Was  entirely free
from pain after recovery from  the  anaesthetic.  He made a
speedy recovery.
    Case II.   E. M., Female, age three and a half.   Came to
hospital November 21st, with a  profuse discharge from  the
mastoid region.  Her mother stated that two years previous-
ly the child had an attack of inflammation of the  periostium
of right mastoid process.  Poultices  were applied and a dis
charge soon ensued.  A fistulas opening, however, remained
and the discharge continued for  the greater part of the two
years prior to her admission.
    Operation.—The usual curved incision was made over the
mastoid process and a large superficial sequestrum was re-
moved, together  with a quantity of  cholesteatomatus material
from  the  mastoid cells,  and  necrosed  material  from
the same region.   The wound  was  packed with iodoform
gauze and allowed to granulate.   No elevation of temperature.
The patient made a gradual but complete recovery, with no
impairment of hearing.
    Case III.  R.  A., male, age 33,  and of robust  health.
First complained of pain  in left ear, February 11, which radiated
over the corresponding side of  head and face.   Twelve days
later he was admitted to the hospital.   Temp. 100° F.  The
mastoid region was  oedematous and there was deep tenderness
over the same  region.   The external  auditory canal was
swollen. The tympanic membrane was bulging out and  had
lost its lustre. Hearing in the ear  was  nil.  Paracentesis of
the tympanic cavity was performed. The symptoms increased
and a few days  later Schwartze's  operation was performed.
A few drops of pus  were found in the cells, together with con-
siderable granulation material.  The wound  healed slowly
and  recovery was  complete.  The hearing  was entirely re-
stored. 
CLINICAL SURGERY.
59
    Case IV.  Mrs. J. G., age 32.  Came to the hospital May
25th for examination of left ear in  which  she complained of
severe pain, radiating from  the ear over the same side of the
head, and of a boring character.  On  examination there  was
found  all the symtoms of  suppurative inflammation  of the
middle ear.  She was treated in the usual way but the symp-
toms increased, and on May 31st, there was a free discharge
of fetid pus from external ear.  Pain was very severe and
tenderness over the mastoid process developed simultaneously,
to which was  added on  the next day swelling and oedema.
Ear very prominent.
     Operation, June 1st.—Ether. The usual incision and open-
ing of the mastoid antrum by chisel and hammer.  Free com-
munication was made between the antrum and middle ear. Half
teaspoonful of pus flowed from the antrum.  The wound was
not closed, but dressed and  treated open, to insure free drain-
age. She was perfectly free from pain after recovering from
the  anaesthetic, and made  a  rapid recovery.   Hearing com-
pletely restored.
    Case V.  B. F. G.; age, 40; male. Had  an attack of  la
grippe  in  the fall of 1891,  followed by inflammation  of the
middle ear.  All the usual means were resorted to to control
the  chronic suppuration from the ear,  but without avail.
When first examined, December 20th, 1891, the membranum
tympanum was perforated and a small quantity of fetid pus
was oozing out.  He complained of intense pain  in the mas-
toid region, especially  at night, hearing  markedly impaired
and dizziness  at  times.  The operation  was postponed  for
some days because  of refusal.  The symptoms  became so
alarming that an  operation  was insisted on.  An  incision, be-
ginning at the temporal ridge, was made  over the  mastoid re-
gion, posterior to  and parallel with the auditory canal.  Peri-
ostium  markedly  thickened over the antrum.  With chisel
and mallet the external table of skull was  perforated, and, at
a depth of three-quarters of an inch in the deeper cells, found
a cavity containing two-thirds of a teaspoonful of pus.  Wound
was packed with  iodoform  gauze and allowed to granulate.
Patient made a good recovery, with  hearing about  half the
normal  distance,  and complete freedom from  pain from the
date of  the operation.  Was able to be about in five weeks. 
60
A SYNOPSIS OF
    Case VI.  Mrs. E. K.;  age 37.  Was first seen about Feb-
ruary 12th.  For about three weeks had been suffering from
pain in left ear and mastoid region.  Four days  previous a
fetid discharge of  pus took place from the ear.   Hearing
markedly impaired. Schwartze's operation  was  performed
February 13th. Pus was found  in the  mastoid antrum, with
marked destructive changes in the cells.  Free communication
was established between the middle ear and the antrum.  The
wound was packed with gauze and left open.  After recovery
from the anaesthetic she expressed relief from the deep boring
pain of the mastoid region.  There was no elevation of tem-
perature at any time following the operation.  She went on to
a complete recovery.
    Case VII.  T. B. C; male; age 32. Entered hospital April
19th.  On January 9th was seized  with  a severe boring pain
in the right mastoid process, whioh kept up for several days,
and on January 25th there was  a free discharge of pus from
the ear.  He was treated in the usual manner, but  of no avail,
and the symptoms became  worse.  He came to Salt Lake, and
entered the hospital on the date above.  On examination the
mastoid region was oedematous, the ear was prominent and a
profuse and fetid discharge flowing from  the external audi-
tory canal.   Hearing nil.   Schwartze's operation was  per-
formed and about a teaspoonful  of pus  flowed from the mas-
toid  antrum.  Free  communication was made between the
middle ear and the mastoid cells. The wound was packed
with iodoform gauze.  He went on  to a good recovery.  The
hearing distance was about half  the normal.

 (B)—OPERATIONS ON  THE  FACE.   (a)—NEOPLASMS.

    There were  sixteen  cases of neoplasms, including
face and neck, in all of which there was a careful micro-
scopical examination after the operation.  These are
given  in tabulated form.  An  analysis of  the  cases
shows that of the six operations for  epithelioma of
the lip one was for recurrent, and five for  primary
disease.   In the  recurrent  case the primary growth
had  been removed from the lower  lip about  eight 
CLINICAL SURGERY.
61
months ago.  The recurrence took place  in the sub-
lingual and sub-maxillary glands,  and also formed
a characteristic epitheliomatous ulcer, about an inch
in diameter on  the lower lip.  In the primary cases
the duration of  the growth  had  been,  one  year,
eleven months,  two and a  half years, one and  a half
years  and  ten  months respectively.  Heredity was
absent in every case  and a source of irritation—e. g.
pipe,  was found in only one case.   The age ranged
from  46 to 70 years, the average  being about 53.
Enlarged glands were present in only one case.
    In the ordinary cases  the operation  was by a V-
shaped incision including the growth and a margin
of healthy  tissue, about a  third of  an inch in width.
Where the disease was extensive the rectangular flap
was used.  The edges were brought into imposition
by one or two silver  wire sutures, supplemented with
additional sutures of silk and cat-gut.
    In the  four  operations for epithelioma of the
tongue, in three cases was half  the  organ removed
and in one the entire tongue.  The lingual artery on
the corresponding side was first found  and ligated,
and the tongue was drawn forward and partially re-
moved with  the  knife and scissors.   Hemorrhage
was slight  in all the cases, and recovery was prompt
and satisfactory.
    In the case  where the entire tongue was removed,
the method pursued was  as follows:   After finding
and ligating both lingual  arteries access to the organ
was  facilitated  by  dividing the lower lip and the
symphysis of the jaw, the parts being wired together
again after the completion  of the operation. The
organ was  removed  at its base by the knife.  The 
62
A SYNOPSIS OF
hemorrhage though not excessive  was controlled by
the paquelin.   The  wound was  dusted  over with
iodoform and the patient regularly fed.  The disease
was extensive and  the patient in a  bad condition.
Death ensued on the seventh day from septic-pneu-
monia.  Heredity was absent in every case as well as
a source of irritation—e. g.—a pipe or  sharp tooth.
The  duration of the  growth was,  five  years, two
years, eight  months  and ten months  respectively.
Enlarged glands were present in only one case.
   Subsequent History.—Sufficient time has not yet
elapsed  to enable one to determine  how  many per-
manent  cures have been effected.   The cases have all
been followed, and ruling out one who died from the
effects of the operation, they are all living and in no
cases of epithelioma has the disease  returned at the
time of this writing, eleven to sixteen months  since
the first operation.  Butlin's work on the operative
surgery of  malignant disease has the most complete
statistics as to the subsequent history of epithelioma
of the  lip.   It  is  chiefly derived  from  German
sources.  The three-year limit  is the one generally
adopted by surgeons  as judging  a cure due to the
operation.  Of 424  cases collected by him no fewer
than 160 passed the three-year limit,  so that the per-
centage  of successes  is a  fraction  over 38.   As
regard the percentage of cures due to operation, it is
considerably less in epithelioma of the tongue.   Ap-
plying the three-year limit to 170 cases  collected by
Barker,  the percentage of successes is less than five.
Of these 170 patients, seventeen were alive  and free
from disease at the end of one year, while at the end
of three years the seventeen cases were  reduced to 
CLINICAL SURGERY.
6a
eight.   On the  other  hand  of  70 cases operated
on  by  Butlin  six  were cases  of  cure  on  the
three  year  limit,  a   percentage of   just  over
8.5.  Barker did not take into account  the num-
ber  of cases  lost  sight of, for, had  he  done
so, he would in all probability have found some cured,
and the percentage of successes would have been im-
proved.  As to the removal of the glands in the cases
here reported they were  not  removed except in one
case where they were considerably  enlarged.   Some
of the German surgeons, and more especially Bruns,
advocate the removal in all  cases  whether enlarged
or not.  As to this latter move a sufficient number of
cases  have not been  reported  so as to give any
satisfactory  conclusions, but it  is  well  to  note
that  in  all   the  successful  cases   reported   as
having passed the three-years' limit, there was an
absence of glandular affection.    In  regard to  the
other cases, the fibro-myxo-sarcoma of the  parotid de-
serves mention on account of  its rarity.   The tumor
occurred in a man forty-three years old, was  of slow
growth and at  the end of two years was about  the
size of  a pigeon's egg.   It was found encapsulated
and was easily separated from the gland.   Its growth
was attended with little or no pain till  the  last  few
months.  There  was   no  facial  paralysis.   The
microscope proved it to be  a fibro-myxo-sarcoma.
Several of the neighboring glands were found  affected
and removed.  The growth  returned in  six  months
after removal, exhibiting a grave malignancy, but the
patient was alive when last heard of.  Butlin reports
only twenty-nine cases in which the operation of re- 
64
A SYNOPSIS OF
moval of a  parotid sarcoma was performed, with two
deaths.
    Carcinoma of Thyroid Body.  The growth had been in
existence eight months, was about the size of the fist and con-
fined to the right lobe.  Irregular in outline, and the surface
was tuberose, on which soft spots  were observed.   The lym-
phatic glands were  involved.   The  superior  and inferior
thyroid arteries were  found and ligated.  The right lobe and
part of the isthmus were removed, as also enlarged lymphatic
glands.  The bleeding though free was easily controlled.  The
disease rapidly returned  in  two months,  and he  died six
months after the operation. The cause of death was multiple;
dyspnoea, collapse, and the presence of metastasis. At the
autopsy the  lungs,  liver, kidneys  and bones  were  found
affected.
    Sarcoma  of the  upper Jaw.   The disease occurred in a
girl 11 years old.  She had had considerable pain in the right
cheek prior to the appearance of a swelling over the antrum.
This swelling  gradually increased in  all directions so that
when she entered the hospital  it  had  extended to  the orbit,
pushing the eye up, and below to the angle of the mouth, and
back into the sphenomaxillary fossa.  The nostril on the af-
fected side was almost completely obstructed, the color of the
integument was natural but adherent to the tumor, which was
rounded, lobed, and firm to the touch.  Pressure and handling
caused considerable pain.  The tumor had been growing ten
months. The usual operation by Fergusson's method, in which
the incision was carried along the  side of the  nose and hori-
zontally along the  lower margin  of the  orbit.  Tracheotomy
was first performed and the ether administered by the inhal-
ing portion only of Trendelenburg's apparatus, attached to
the ordinary tracheotomy-tube.
    In the second case of sarcoma of the upper jaw, the dis-
ease occurred in a man 38  years old.  Tracheotomy  was first
performed and ether  administered  as  in the preceding case.
The operation consisted in the removal of the upper jaw with
the exception of the  orbital plate.   Fergusson's method was
carried out, but the horizontal incision was  omitted.   The
alveolar process and palate were  cut through, as in the pre- 
AGE AND SEX.	DURATION OF SYMPTOMS. REGION.	SIZE OF GROWTH.	EN-LARGED GLANDS.	HEREDI TARY TENDENCY.	OPERATION.	TIME IN HOSP.	WOUND HEALING.	PATHOLO-GIST'S REPORT.	REMARKS.
Case I. 46 years. Male.	I year. Lower lip.	%-inch diameter.	None.	None.	V-shaped incision. Silver and silk su-tures . Ether.	10 days.	Primary union.	Epithe-lioma.	
Case II. 39 years. Male.	8 months. Tongue.	Right side tongue.	None.	None.	Ligature, right lingual artery. Right half of tongue removed. Hemorrhage not exces-sive. Ether.	29 days.	The wound healed rapidly.	Epithe-lioma.	
Case III. 56 years. Male.	2 years. Tongue.	Whole dorsim of tongue.	En-larged glands,	None.	Ligature, both lingual arteries. Lower jaw divided and tongue drawn out and cut off at base.	7 days.		Epithe-lioma.	Died.
Case IV. 45 years. Male.	5 years. Tongue.	Right side tongue.	None.	None.	Ligature, right lingual artery. Right half of tongue removed. Hemorrhage slight.	25 days.	The wound healed rapidly.	Epithe-lioma.	
Case V. 47 years. Male.	1 year. Lower lip.	l/2-inch.	None.	None.	V-shaped incision. Silk and wire sutures.	17 days.	Primary union.	Epithe-lioma.	
 
AGE AND SEX.	DURATION OF SYMPTOMS. REGION.	SIZE OF GROWTH.	EN-LARGED GLANDS.	HEREDI-TARY TENDENCY.	OPERATION.	TIME IN HOSP	WOUND HEALING.	PATHOLO-GIST'S REPORT.	REMARKS
Case VI. 60 years Male.	2^ years. Lower lip.	Half lower lip.	None.	None.	Rectangular flap. Silver wire, silk and catgut sutures.	10 days.	Primary union.	Epithe-lioma.	
Case VII. | V/i years. 70 jears. Lower lip. Male.		Half lower lip.	None.	None.	Rectangular flap. Silver wire, silk and catgut sutures.	29 days.	Primal y union.	Epithe-lioma.	
Case VIII. 50 years. Male.	10 months. Lower lip.	M inch.	None.	None.	V-shaped incision. Silk and silver wire.	12 days.	Primary union.	Epithe-lioma. Li-poma.	
Case IX. i , 40 years. 2Kyears. Female. , Neck-		Fist.	None.	None.	Excision.	5 days.	Primary union.		
Case X. 45 years. Female.	VA years. Neck.	Egg. Pigeon's egg.	None.	None.	Excision.	4 days.	Primary union.	Li-poma.	
Cape XI. 43 years. Male.	2 years. Parotid.		En-larged glands	None.	Found attached to par-otid. Dissected out Encapsulated.	20 days.	Primary union.	Mixed tu-mor. (Fi-bro-Myxo-Sarcoma).	Returned in 6 mos. exhibiting a grave malignancy.
 
AGE AND SEX.	DURATION OF SYMPTOMS. REGION.	SIZE OF GROWTH.	EN-LARGED GLANDS.	HEREDI-TARY TENDENCY.
Case XII. H7 years. Male.	7 years. Ears. Operated on 3 years ago.	Hazel nut.	None.	None.
Case XIII 41 years. Male.	8 months. Thyroid. 10 months Tongue.	Fist.	En-larged glands.	None.
Case XIV 4 years. Male.		Left side of tongue.	None.	None.
Case XV. 47 years. Male.	13 years Lower lip.	Half lower lip.	En-larged glands.	None.
Case XVI. 11 years. Female.	10 months. Superior max-illa.	Tangerine orange.	None.	None.
OPERATION.	TIME IN HOSP.	WOUND HEALING.
Excision.	7 Primary days union.	
Removed left lobe of thyroid.	6 mos.	Primary union.
PATH010-
 GITS'S   REMARKS.
 REPORT.
Recur- I
 rent  i  Returned
 fibro- I   in 3%
 mata. i  months.
Carcin-
oma of  Returni
  thy-   in - iik
 roid.     Died.
Ligature,  left lingual    20  | Healed ■ Epithe-
 artery.  Left half  of   days,  slowly. ! lioma.
 tongue removed.
Hemorrhage slight.
Rectangular flap.  Ex-
 cised  portion  lower
 jaw.
Second operation—six
 weeks later. Excision
 of submaxillary gland.
Tracheotomy.   Com-
 plete removal of  the
 upper jaw bone.
 10
wks.
  2
mos.
Healed
slowly.
Healed
slowly.
Epithe-  First operation
lioma.    8 mos. prior.
         V-shaped piece.
         Recurrent.
Epithe-
lioma.
Returned
in 3 mos.
  after
 leaving
hospital. 
68
A SYNOPSIS OF
ceding case.  The molar process was sawn through from above
downwards and from within outwards.   A section of- bone was
made from the molar process through to the nostril just below
the orbital plate.  The bone was removed with lion-jawed for-
ceps.  The outer wound was closed and the cavity was treated
as when the whole jaw is removed.  This modified operation
was used as the disease was found to affect the lower part of
the bone only.  He made a rapid and uneventful recovery.
                    (b.)  DEFORMITIES.
    Case I.  Double Congenital Hare-Lip, complicated with
Cleft Palate.—M. B., male,  age seven  months.   Operation,
September 21st.  A well marked protrusion of the intermax-
illary bone added greatly to the difficulty in making a satis-
factory closure of the cleft.   The projecting  portion of the
bone was removed.  The  lip was sufficiently  freed from its
attachment to allow the flaps to be brought into apposition
without too great tension.  The edge  of the cleft was  fresh-
ened by curved incisions made from above downwards as far
as the muco-cutaneous junction.  Prolabial flaps were formed
by cutting upwards and inwards at  an angle of 60°  to the
preceding incision.  The extremity  of the  philtrum  was cut
into a V-shape, and the raw margins were carefully implanted
between the edges of  the  lateral  flaps at the upper  part.
Silver wire sutures were used  and  other fine  catgut sutures
for accurately adjusting  the edges.  The  sutures were re-
moved on the seventh day.   Primary union.  The improve-
ment was greatly marked.
    Case II.  Single Congenital Hare-Lip, Uncomplicated.
Operation, October 10th.—The incision was begun at apex of
cleft cutting downwards in a curved direction, till  the muco-
contaneous junction was reached and  then the edge of the
knife was turned so as to cut through the  mucus membrane
of the lip at an angle of 60° to the former incision.  A corres-
ponding incision was made on the opposite side.  Silver wire
suture were used instead  of  hare-lip pins, and intermediate
fine catgut sutures.  Good primary union.
    Case III.  Single Congenital Hare-Lip, Uncomplicated.
Operation, April 9th.—This case differed from the preceding
in that the cleft  was complete.  Good primary union. 
CLINICAL SURGERY.
69
    Case IV.  Single Congenital Hare-Lip, Uncomplicated.
Operation, April 9th.—This case differed very little from the
preceding.  Good primary union.
    Case V.  Single Congenital Hare-Lip, Uncomplicated.
Operation, December 7th.—Boy aged five months.  Here the
operation consisted in removing the inner margin of the cleft,
while on the outer side  a flap was turned down by cutting
from above downward commencing at the apex and extending
to the middle and lower thirds, where it remains attached. It
was then carried horizontally across the cleft and applied to
the opposite margin, and the raw surfaces sutures together,
using silver wire and fine catgut.  Good primary union.
    Plastic Operation for Burns and Injury of the Eyelids—
Pour cases.
    Removal of Depressed Cicatrices of Face—Three cases.

          (C) ENEUCLEATION OF EYE—NINE CASES.

    All of  which were  the  result  of injuries  re-
ceived   while  blasting.    In  all  cases   the  oper-
ation consisted' in  dividing the conjunctiva and sub-
jacent  fascia with  scissors, in  a circle  as  close as
possible to the margin of the  cornea.  The tendons
of the ocular muscles were then caught and  divided
and drawing the eye  forwards and outwards the optic
nerve was cut.   The wound was  packed and  dressed
with iodoform gauze.

             (C) OPERATIONS ON THE NECK.
    Case 1.  Stricture of Oesophagus, external CEsophagot-
omy. Recovery.—E. R.,  female, age 20.  When eight years
old  swallowed some concentrated lye.  For twelve years has
had a stricture of  oesophagus, with inability to swallow any-
thing but liquid food.   For many years the stricture was not
tight enough to be a complete barrier, hence did not present
herself so that the dilitation treatment could be carried on
earlier.  In the last year it has become such as to allow a
moderate quantity of milk to pass through, but is utterly im-
passable  to  even the smallest whalebone bougie.  Entered 
70
A SYNOPSIS OF
hospital June 23.  On examination it was found that we had
to deal  with  a very tight  stricture of the oesophagus, the
treatment of which by small pointed bougies is often not only
a matter of extreme difficulty but fraught with great danger
of rupture through the soft  and dilated wall of the tube above
the sight of trouble.   As the stricture happened to be in the
upper part of the oesophagus it was determined to  open the
gullet in the neck and split  the dense  cicatricial tissue.  She
was becoming rapidly emaciated.
    Operation, June 25th,  Ether.—An incision three inches
long was made on the left side of the neck at the inner margin
of the sterno-mastoid, the muscles and deep fascia, pulled well
towards the outer side, exposed the sheath of  the great ves-
sels.  The dissection was carried carefully between these and
the trachea,  avoiding the thyroid  artery and  vein, the thy-
roid gland, and the inferior  laryngeal nerve, until the oesopha-
gus and lower part  of the pharynx were exposed.   A sound
was passed through the mouth and made to project into the
wound.  The oesophagus was then opened about three quar-
ters of  an  inch above the  seat of stricture.   A small probe
was successfully passed through  the stricture  and dilated
sufficient to introduce an Otis' urethrotome.   The  stricture
was cut at its maximum  and bougies were passed with re-
markable ease the  entire  length of  the  oesophagus.  The
bleeding was insignificant.  The patient experienced little or
no shock from the operation and subsequently  had no fever.
The wound  was  left open  and  a  rubber  drainage tube
placed in the superficial wound.   The neck  was kept fixed
and rigid.  She was  fed by a  tube on the second day passed
by the mouth.  On the seventh day the wound in the gullet
had closed, and feeding by the tube was discontinued on the
ninth day.  She left the hospital July 6th.  The bougies were
passed by the mouth twice  a week for  several months, and at
time  of writing, eight months after  the operation, she eats
everything and has no  difficulty in  swallowing.   She has
gained in flesh and weighs 130  pounds.
    Case II.   Foreign Body Lodged in Oesophagus, External
OJJsophagotomy—Two cases; two recoveries.
    (1) Thomas B., age 69. A piece of chicken  bone was
lodged in the upper  part of the gullet and after failure to re- 
CLINICAL SURGERY.
71
move by the usual method, external cesophagotomy was re-
sorted to.  The operation and after treatment were the same as
described in the preceding case.  The piece of bone was re-
moved through the incision.  His recovery was rapid and un-
interrupted.  Twenty days after he left the hospital.
    (2) F. C, male,  age 31.  Was admitted with  a piece of
chicken bone lodged  in the  oesophagus.  It was found impos-
sible to remove it by  the usual method and external cesopha-
gotomy was performed.  He left the hospital in eighteen days.
The operation and after treatment were the same as described
in the two preceding cases.
    Case III.  Abscess  of  the Thyroid Body.—P. R.,  male,
age 36.  Was first taken with rigor and high fever which con-
tinued for several days.  Two days later there was a diffuse
enlargement in the neck attended with intense pain." He en-
tered the hospital ten days after the onset of the attack.
    Examination.—There was a swelling in the right side of
the neck about the  size of the fist.   The tissues of the neck
were  red  and oedematous.  The superficial veins were dis-
tended, and the trachea and oesophagus compressed against
the spine.   There was  dysphagia.  The swelling moved up
and down with the swallowing. A slight cough was present and
his voice was stirdulent.  Pressure elicited great pain  and a
peculiar noise in the  throat. Fluctuation was plainly present.
Temp., 101°F; pulse,  100; resp., 30.  A diagnosis of abscess of
thyroid body was made.
    Operation; Ether.—An aspirating needle was  introduced
and a syringe full of pus withdrawn.  An incision one and
one-half inches in length was made over the most prominent
portion and the superficial structures divided layer by layer, till
the tissues of the thyroid were recognized.
    An  incision was  made into  the swelling from which pus
flowed freely.  The  opening  was enlarged and a rubber tube
inserted.  The discharge of  pus was quite free for several
days. His recovery was slow.
    Two operations for Lipomata of the Neck.
    Tubercular Lymphadenomata of Neck.—Ten Operations. 
72
A. SYNOPSIS OF
                 (D) MISCELLANEOUS.
    Empyema of the Antrum.—One case.
    The symptoms consisted of oedema of the overlying soft
parts,  and a purulent discharge from the nose when the
patient lay down and turned on the sound side.  The antrum
was drained by pulling the canine tooth on the affected side
and a small gouge pushed up through the alveolus.  Recovery
was complete.
    Six operations for extensive Necrosis of the Lower Jaw-
    Twenty miscellaneous cases of too little importance to be
given in detail. 
CLINICAL SURGERY.
73
          OPERATIONS ON THE THORAX.

    (a)  Tumors of the breast; an analysis of six cases.
The accompanying table contains a brief history of
each case.  The most important  points may be sum-
marized as follows:
    Classification.—A careful microscopical examina-
tion was made in each ease.  Of  the  six cases three
were carcinomata and three adenomata.
    Age.—In the cases of carcinomata the ages were
45, 62 and 44, respectively, of which two had born
children.  In one case the patient was a man aged 44,
whose mother  and sister had died of cancer of the
breast.  The  tumor was situated in the left breast
and was the size of the fist, and had been  growing
fourteen months,  attended  with great  pain.   The
axillary glands were invaded.  He received an injury
about four months prior to  his first noticing the
growth.  The breast and axillary glands were excised.
The growth  was  shown by the microscope  to  be
scirrhus.  The glands were invaded by the carcinom-
atous  infiltration.   In the other two cases of cancer
no  history of trauma could be obtained, nor was it
possible to attribute the neoplasms to heredity.  The
same holds true of the cases of adenomata.   The pa-
tients with adenomata were 40, 20  and 28 years old
respectively, only one of whom had born children.
    In only two of the cases were the axillary glands
invaded, and the microscope showed the enlargement 
74
A SYNOPSIS OF
to be due to carcinomatous infiltration.  In the two
cases the enlarged glands were detected prior to the
operations.  The  axilla  was free from disease in all
the other cases.
    Diagnosis.—In the majority of  the  cases the
diagnosis was reasonably sure from  the clinical his-
tory and the physical examination, but in all the
cases the diagnosis was subsequently confirmed by
the microscopical examination.  In the doubtful cases
an exploratory incision was made through the tumor
itself and the nature and extent of the operation was
determined by such exploration.
    Plan of Operation—(1) Removal of the tumor
alone.   This was done in the cases of adenomata.
    (2) Removal  of the breast and axillary glands.
This was done in  the carcinomatous  cases, where the
breast and axillary contents with the tissues between
them were removed.
    (3)  Removal  of the breast  including the tumor.
This was done in  one case of carcinoma of the breast
where the axillary contents were not found  to be in-
vaded.  Rubber drainage tubes were used where the
operation had been extensive.  After the removal of
the tumor in the cases of adenomata no drainage was
used, in all of which the wound healed by  primary
union.   The dressing employed consisted of gauze of 
(a.) TUMORS OF BREAST.
AGE.	DURATION OF SYMPTOMS.	POSITION AND SIZE.	HERED-ITY.	HIS-TORY OP INJURY.	OPERATION.	AXILLA inva'd. No.	DAYS IN HOSPI-TAL.	DRAINAGE.	WOT'ND HEALING.	PATHOLOG-ICAL.
1—45 yrs. Married. Female.	lyr— Pain.	Rt breast, egg.	None	None. None.	Ether. Excision of breast.		21 d.	Rubber.	Primary union.	Carci-noma.
2—40 yrs. Single. Female.	6 mos— No pain.	Tumor in each breast size of orange.	None.		Ether Excision of tumors only.	No	18 d.	Rubber.	r> ■ Cystic-Primary A(,,.no. umon- fibroma.	
'■'>—62 yrs. Married. Female. 4—44 yrs. Male.	ll/4 yrs— Pain.	lief t breast, size of orange.	None.	None.	Ether. Excision of breast and axillary gl'ds.	Yes. Yes.	25 d.	Rubber.	Delayed union.	Carci-noma.
	14 mos — Great pain.	Left breast, size of fist.	Mother & sister died of cancer of brst.	Yes.	Excision of brst. and axillary glands. Ether.		27d. 12 d	Delayed union.	Rubber. Primary union.	Carci-noma.
5—20 yrs. Single. Female.	lyr— JNo pain.	Rt breast, size of egg.	No.	No.	Excision of tu-mor only. Ether.	No.		No drainage. No drainage.		Adeno-fibroma.
6—28 yrs. Married. Female.	8 mos— Pain.	Left breast, egg.	No.	No.	Excision of tu-mor only. Ether.	No.	lid.		Primary union.	Cystic-Adenoma.
 
76
A SYNOPSIS OF
bi-chloride of mercury 1 to 2,000 and firm pressure
was secured  by a  binder applied externally.   The
drainage tubes were taken out at the end of 48 hours.
The average time spent in the hospital was 19 days.
    The operation  consisted  in an  eliptical incision
including breast and tumor, the long axis of  the in-
cision being in the direction of the fibers of  the pec-
toral muscles.  In  the  two cases where the axilla was
explored the  incision was prolonged and the enlarged
glands removed.
    Butlin gives an analysis  of 411 cases, showing a
mortality of  nine  per cent,  in 141  cases where the
breast  alone  was  removed,  and a mortality 23 per
cent, in 170 cases where the breast and  axillary con-
tents were removed.

                (6) MISCELLANEOUS CASES.

    Case I.  Empyema;  Estlander's Operation.—Recovery.
Thomas, J. T., age 30. a miner. His early life was spent on a
farm and at  18 began mining; no  history of tuberculosis in
family; always of sound health up to nine years ago  when he
received an injury while working in the Ontario mine, fracturing
two ribs of right side. Six months after the  injury he had
an attack of pneumonia(?) on  the  injured  side,  and  the
right pleural cavity  became  filled with fluid.  Six months
later about one quart of pus was aspirated.  The aspiration
was repeated many times in the next six months, removing at
each time a considerable quantity of pus.  In 1888, six  years
later, a piece of the sixth rib was taken out.  He first came to
the hospital  in 1889,  and  on the 29th day of  March of that
year the fifth, sixth, seventh,  eighth and ninth  ribs  from the
costal cartilage  to their angles were removed.   In September
of the following year the  end of the ribs were removed for
necrosis.  In May, 1891, the sternum was curetted for diseased
bone.  In June, 1892, the wound had so far healed and  the
cavity collapsed that  the integument was brought together. 
CLINICAL  SURGERY.
77
 
78
A SYNOPSIS OF
He has entirely recovered from the operation, has no cough,
expectoration or night sweats.   He is five feet five inches in
height and weighs 145 pounds. Previous to the operation in
1889, he weighed less than 100 pounds.  One noticeable feature
is the extreme clubbed condition of the terminal phalanges of
the fingers and toes which were perfectly normal prior to the
injury to the side. 
CLINICAL SURGERY.
79
    Case II.  Estlander's Operation for  Chronic Empyema.
—Recovery.
    J. B., age 27, of a tuberculous history on mother's side.  In
November, 1890, while working on the Bear River Canal, Utah,
was suddenly taken with acute pleuritis of left side following a
wetting.    The sero-fibrinous exudate persisted  for  many
months, re-accumulating after  aspiration  and resisting  all
treatment. He was admitted to  the hospital February 20th,
1892.  Greatly emaciated, slight cough, dyspnoea and marked
pain in the chest.  Symptoms of septic-infection not wanting.
Intercostal spaces  bulging.   CEdema of  the chest  walls.
There were all  the  physical  signs of  purulent pleurisy, the
fluid reaching to the clavicle. 
80
A SYNOPSIS  OF
    Estlander's operation February 27th.   Removal of the
fifth, sixth, seventh and eighth ribs, of the affected side, from
the costal cartilages to their angles.  The operation ended in
recovery with  complete  obliteration  of  cavity.  He  steadily
gained  in flesh and strength,  and when  last heard from,
twelve months after the operation, was living in Boston and in
good health.
    Case III.  Extensive necrosis of Ribs.  Re-section of part
-of eighth and ninth ribs.  Recovery.
    Necrosis of Ribs, following typhoid fever; two cases.
    Necrosis of Sternum, following typhoid fever; three cases. 
CLINICAL SURGERY.
81
    OPERATIONS ON THE ANUS AND RECTUM.

   (a.)  Fistula in Ano; ten cases.  Tubercular ori-
gin, in all probability, in six cases.
   Treatment.   Free incision, scraping and packing
the wound with iodoform gauze.  The bowels  were
kept confined for four or five days, an  enemata  hav-
ing been given previous to the incision.   At the end
of five or six days a  mild saline cathartic was given.
Incision occasionally stimulated with silver nitrate.
   (6.)  Internal Hemorrhoids; twenty-six.
   In sixteen  cases the method  of treatment em-
ployed was partial excision and ligation.  The results
were good.
   In six cases Whitehead's method was employed,
and in only the cases where primary union was obtained
were the results satisfactory.   Where primary union
failed there was more or less stricture.
   In four cases the cautery  was used with good re-
sults.
   (c.)  Carcinoma of the Rectum; four cases; with
four operations and one death.
   In one case the disease  returned  inside of six
months.  In the remaining three cases there was a sub-
stantial amelioration of their condition  In all the four
cases the method employed was that of rectal excis-
ion.   In the fatal case the severe and high operation
was performed.  In all the cases operated upon there
was a fair prospect of a complete removal of the dis-
ease.
    6 
82
A SYNOPSIS OF
   In  addition to the above there  were five other
cases upon which proctectomy was not deemed justi-
fiable,  the  tissues involved  being  too extensive.
In these cases the disease had extended through the
muscular coats and had apparently invaded the blad-
der, and prostate  or uterus in front, and was adher-
ent to the sacrum behind.  In these  cases colostomy
was advised, but rejected.
   The diseased part was generally about two inches
above the anus, and here the bowel was strictured.
The surface was nodular, hard to the touch, and  eas-
ily broken with the finger nail.  Of the  nine cases
there was only one form of the disease—adenoid carci-
noma.  In some of the cases the growth was present
for only a few months, and it was in  the youngest
patient (26) that  the growth returned after excision.
In this later case there was  a  history of heredity.
The  ages in the  cases operated upon were: 20, fe-
male; 40,  female; 38,  male; 41. female (fatal); non-
operative—41, male; 5(5, female; 49, female; 39, male;
44, female.  The  average time in the  hospital  was
thirty days.
   (d.)  Stricture of Rectum; two cases.
   (e.)  Ischio-rectal Abscesses; two cases.
   (/.)  Ulcer of Rectum; two cases. 
CLINICAL SURGERY.
83
 OPERATIONS ON THE GENITOURINARY ORGANS.

   (A.)   Male. — (a.)  Hydrocele;  twelve  cases;
twelve recoveries.
   Operation.   Von Bergmann's modification of Vol-
mann's.  Recovery was rapid in all cases; no compli-
cations.
   (b.)  Urethrotomy for Stricture of the Urethra;
ten  cases;  internal,  three; external and  internal,
seven, four of which were without  a guide.  The in-
ternal method was used  in those cases  where  the
stricture was situated in the pendulous portion of the
urethra.   Where the stricture was behind the bulbo-
membranous junction, and of a resilient  character,,
external perineal urethrotomy  was performed and a.
rubber tube was left in the bladder from thirty-six to-
seventy-two hours.  The urethra was  enlarged so as.
to easily allow the passage  of  a No.  30 steel sound
(F).  The bladder was  washed out with warm boric;
acid  solution at the close of the operation.
   After treatment.   After the third or fourth day,.
the sounds  were passed  every third day till the pa-
tient  left  the hospital, and was further  advised to
continue the passing of the sound.
   (c.)  Varicocele; four  cases; four  recoveries.
The  method employed  was sub-cutaneous  ligation
in all cases, and the results were satisfactory.
   (d.)   Congenital Phimosis; ten cases; ten recov-
eries.  Ether was given in most  cases, but chloro- 
84
A SYNOPSIS OF
form and cocaine were also used.   Circumcision  was
performed in all cases by the clamp method.
    (/.)  Miscellaneous, 13; recoveries, 13.
     1. Suprapubic; Lithotomy; two cases.
     2. Lateral Lithotomy; one case.
     3. Litholapaxy; two cases.
     4. Extravasation of urine; one case.
     5. Epithelioma of the penis and inguinal glands;
amputation of penis; one case.
     6. Tuberculosis of the testis; castration; one case.
     7. Hydrocele and cystic degeneration of the tes-
tis; castration; one case.
     8. Hematocele with hydrocele;  one case.
     9. Multilocular hydrocele; one case.
    10. Chronic cystitis; cystotomy;  one case.
    11. Rupture of urethra.
    Case I.  Vesical Calculus; Suprapubic Lithotomy; Re-
covery.—E. R., age 21; admitted June 15th.  Had symptoms
of irritation of the bladder  for thirteen years.  Examination
with a Thompson searcher easily detected a stone  which was
apparently about two inches in diameter.
    Operation.—The  urine was drawn off and the  bladder
filled  with twelve ounces of warm water.  A  Colpeurynter
was used to distend the rectum.  A vertical incision was made
above the  pubis, and the stone was quickly found, but ex-
tracted with  considerable  difficulty.   A  rubber tube was
placed in the bladder, the wound  healed by granulation, and
at the end  of seven  weeks all urine was passed by the ure-
thra.  The calculus  was found to  consist of  calcium oxalate
and earthy phosphates.  It was three and a half  inches in its
long diameter and two inches in its short. 
CLINICAL SURGERY.               85
 
86                   A SYNOPSIS OF
    Case II.  Vesical Calculus; Litholapaxy.—Charles A. C;
age 27.  For five years has had symptoms of irritation of the
bladder.  Examination with Thompson's searcher easily  de-
tected  a calculus, which  was  about  an inch  in diameter.
Litholapaxy was successfully performed.
    Case III.   Vesical Calculus; Litholapaxy.—B. A. C, age
56, for twelve years has had symptoms  of bladder irritation.
Examination with Thompson's searcher  easily detected a
small stone about one and one-half inch in diameter.  Lith-
olapaxy was successfully performed.
    Case IV.  Lateral Lithotomy for Removal of  Spruce
Gum from  the Bladder.—The staff was passed and feels the
foreign  body.  The usual  incision for  lateral lithotomy was
made and two pieces of spruce gum each about an inch long
were removed.   On  the introduction of the staff there was
considerable pain and blood passed in considerable quantities.
When  he entered the hospital the urine was filled  with
pus, fetid and poisonous, and a septic fever was raging.  The
case is important as showing  the importance of infection in
the production  of vesical  symptoms.  In this case there was
set up a high grade of cystitis by the presence of a piece of
soft spruce gum  introduced by the man himself only a few
days before.
    Case V.  Vesical  Calculus,   Suprapubic  Lithotomy;
Death.—Charles B., age 62, had suffered twelve years with
stone in the bladder.  On examination there was found a con-
siderable degree  of cystitis. The stone was of  large size, and
it was decided to perform suprapubic lithotomy. The patient
presented all the evidences of  advanced senile degeneration
and he was well nigh exhausted by the pain  and frequent mic-
turition from which he had suffered.  The stone was removed
by  the  high operation.  The patient  bore the anaesthetic
badly and on the second day became delirious  and died from
uragmia.  At the autopsy atheroma  of  the  vessels  was very
noticeable,  and  the kidneys  were  the  subjects of  advanced
pyo-nephrosis. 
CLINICAL SURGERY.
87
^m.-


 
88
A SYNOPSIS OF
    Case VI.  Epithelioma of Penis and Inguinal Glands;
Amputation of Penis; Recovery.—A. B. S., age 47, was ad-
mitted September 20th.  His general health had always been
good and he had never had any venerial disease.  Three years
before a small  wart-like  growth appeared on the glans penis
near the corona.
    This had continued to grow till the time of the operation-
when it was about the size of a tangerine  orange.  The  sur-
face was entirely ulcerated  over  and the discharge profuse,
aided by frequent cauterizations.  The edges were indurated
and the glands in both inguinal regions were enlarged.
    Operation,  September 22nd.—The penis was amputated
three-quarters of an inch from the symphysis pubis and the
inguinal glands carefully dissected out. A catheter was al-
lowed to remain in the bladder the first 48 hours, after which
time micturition was voluntary and without  pain.  Both the
penis and inguinal glands were found  to be epitheliomatous.
    Case VII.  Traumatic Encysted Hydrocele of the Testis;
Castration.—H. J. M., age 30, while in the employment of the
R. G. W. Railroad as brakesman, on November 28,  1888, was
caught between the drawheads fracturing both thighs in the
upper one-third.  The testicles  were  also injured.  The  frac-
ture of both thighs was treated in this hospital with a good re-
sult, viz:
    1.  Firm bony union.
    2.  No angular deformity.
    3.  Both lower extremities of same length.
    4.  No undue deviation of feet.
    5.  No lameness.
    6.  Functions perfectly restored.
    Was again  admitted to  the hospital January 18, 1892, on
account of hydrocele.  His  father died at the  age of 50 of
tuberculosis pulmonalis.
    Present Ailment.—In June, 1890, he first noticed the in-
guinal glands swollen and very tender and  a  dull pain in the
groin, the right testicle was  swollen and painful.   No gonor-
rheal history.  The symptoms  subsided with the exception of
the testicle which remained tender and swollen. In the spring
of 1891 he first noticed a lump appearing on the right testicle 
CLINICAL SURGERY.
89
which gradually enlarged and spread about the testis to such
an extent that he could no longer feel the organ.  When he
entered the hospital, January 18, 1892,  there  was  a  large
hydrocele of the right side.
    Operation.—Von Bergmann's modification of Volkmann's
operation was performed and the cyst was found to be  con-
nected  with  the  testicle.  The  fluid was of a milky white
color  containing spermatozoa,  dead, and motionless.   The
tunic was found to be about an eighth of an inch in thickness.
There was caseous degeneration of the testis almost breaking
into an abscess at the  point where he first noticed the lump
two years previously.  The tunic was removed and the case-
ous matter was scraped out.  The scrotum  was  sutured and
drained at the most pendent portion.  The  wound  entirely
healed and the patient allowed to go about.
    February 8th, the skin broke down rapidly forming an
abscess.  February 10th, operation; castration.
    The testicle was  three times its normal size and the skin
adherent.  The right testis was  removed.  Speedy  recovery
followed.  The testis  was found to be the seat of a  well ad-
vanced tuberculosis.
    Case VIII. Hydrocele and  cystic degeneration of the
Testicle; Castration.—C. C. H.; age 23.   Received  an injury
to the right testicle one  year previous.
    Examination.—The scrotum was found pear-shaped, of
slow growth and translucent.  The testicle had been  the seat
of severe pain, all of which had subsided.
    Operation.—Von Bergmann's modification of Volkmann's.
The sac contained about one pint of straw-colored fluid.  Sec-
ondary cysts were  found in the  testicle.   Castration.  Speedy
recovery. The testicle was found to be of a cystic degenera-
tion.
    Case IX.  Hcematocele with Hydrocele.—F. J. B.;  aged
22.  While boxing was  hit severely on  the  scrotum. There
was a pre-existing hydrocele.  The tumor was swollen  to an
immense size, and came  on rapidly  after the  injury.  The
scrotum was black   and  violet-colored,  tense,  painful,  with
a  more or less evident feeling of fluctuation.   On  account
of the inflammation  imminent from the tension and the blood 
<J0
A SYNOPSIS  OF
in clots, an incision was made, the  clots turned out and the
cavity thoroughly washed.  The  bleeding points secured by
ligature.   The damaged and redundant portions of the tunica
vaginalis cut away.  The cavity was drained.  The testis was
apparently not injured, and the reaction following the opera-
tion was  rapid  and severe, but  only  part of  the  scrotum
sloughed.  He left the hospital in five weeks' time.
    Case X.  Multilocular Hydrocele.—R. W.L.;  age 3.  Was
injured in the  right testicle by  a  fall when two years old.
Was admitted to the hospital November 25th.  The scrotum
was pyriform and about  the size of a  tangerine orange, and
translucent.  Absence of pain.
    Operation.—Incision  and removal  of  tunica  vaginalis.
The tumor consisted of a  main sac filled with  a  pale yellow
fluid, at the bottom of which were several small cysts, the larg-
est about the size of a cherry, containing a dear, white fluid.
The usual mode of dressing and a speedy recovery followed.
    Case XI.  Extensive infiltration  of  Urine; Perineal
section; Recovery.—F. W.; age 48.   Was brought to the hos-
pital suffering from an extravasation of urine caused by  stric-
ture of the membranus portion of urethra. The infiltration was
extensive, distending the perineum, the scrotum and the con-
nective sub-cutaneous tissue of the penis, and also perforated
the deeper layer of the superficial perineal faecia and descended
upon the thigh.   The infiltrated  parts were oedematous and
emphysematous, marked here and there with dark spots, and
in some  places sloughs.   The constitutional symptoms were
those of shock,  a cold and  clammy skin; feeble, quick and
irregular pulse, hurried respiration, and a furred tongue.
    Operation.    Incisions were  made  over the  dusky area
through  into the sodden cellular  tissue.  The patient was
placed in the lithotomy position, and a  free incision was  made
deep in the middle line of the perineum till  the main source
was tapped.  The bladder was thoroughly drained; this was
found to be in a state of advanced cystitis,  The  bladder was
washed out with a warm  boric acid solution.   The  stricture
was divided externally and internally.  The patient recovered
slowly. 
CLINICAL SURGERY.
91
    Case XII. Cystotomy for Chronic Cystitis. L. W.; age 55.
Had suffered for several years with a chronic cystitis.  The
calls to urinate were frequent  and imperative by night and
day, with no feeling of relief. Pain of a heavy, burning char-
acter in the perineum, above  the pubis and in the loins and
back.  The urine contains pus, voided as a stringy mucus, and
blood;  alkaline in reaction.  Amorphous phosphates depos-
ited in excess. The expulsive power of the bladder is lost, the
viscus fills up and trickles passively away.  As soon as a cath-
eter is introduced, the urine does not  come in a spurt, but
drops down nearly perpendicular from the end of the instru-
ment (atony).
    Operation.—The bladder was drained by making a median
incision in the perineum, and a  soft rubber tube of  large size
introduced into the bladder and the latter irrigated with medi-
cated solutions.  The operation, while not resulting in a com-
plete cure yet produced a marked palliation of the symptoms.
    Case  XIII. Rupture of  Urethra; Extravasation of
urine;  External Perineal Urethrotomy; Recovery.—O. C;
age 19.  In attempting to mount his bicycle he fell astride the
rear wheel, rupturing the urethra.  The patient was brought
to the hospital on the following day, the scrotum enormously
swollen.  Urination impossible.  Slight hemorrhage from the
meatus.  Impossible to  introduce even a filiform bougie.
    External perineal  urethrotomy  was immediately  per-
formed.  The urethra was found to be completely severed at
the bulbo-membranous junction.  The proximal end of the
urethra was easily found, and a tube was introduced into the
bladder and allowed  to remain several  days.  In due time
the wound  healed and  full-sized sounds were introduced at
regular intervals.
    (B.)   Female.—(a.)  Lacerated  Cervix  Uteri;
six cases.   Emmet's operation was employed, silver
wire sutures being  used.   Sutures  were removed on
the eleventh day, and results were all satisfactory.
    (b.)   Lacerated Perineum;   five  cases.  Flap
splitting  operation.   Silver  wire  sutures.   Sutures
removed on the fourteenth  day;  union good. 
92
A SYNOPSIS OF
    Case I.  Hydatidiform Degeneration of the Chorion.—
Mrs. McG.,  age 42.  Has had  several miscarriages,  but no
children.  There is a history of syphilis.  She sought medical
advice  on account of  profuse watery and  sanguinous dis-
charge recurring with great frequency.   The first discharge
occurred about one month previously, attended by severe pain
in the abdomen, incessant vomiting, and dyspnoea, which have
reduced her to an extreme.   She was in her third month of
pregnancy.
    Examination.—The uterine tumor had been rapidly in-
creasing and was found to reach up to the umbilicus.  The san-
guinous discharge was profuse and portions of cysts, sometimes
in large  masses, were found mingled in the discharge.  As
soon as the diagnosis of cystic degeneration of the chorion was
established,  under chloroform,  the os being  widely  dilated,
the uterus was cleared of the cystic mass varying in size from
millet seeds  to grapes or even larger.  The hemorrhage after
the operation was severe but was easily controlled by packing
with iodoform gauze.
    Case II.  Uterine {Placental) Polypus.—Mrs.  K. C, age
36, four months prior to her admission to  the hospital had  a
miscarriage  at  about two months.  She had been subject to
hemorrhage, which at times  was very profuse and offensive,
and had labor pains now and then, which were usually very
painful and attended with profuse hemorrhage.
    Examination.—She was anaemic.  The uterus was sensitive
on pressure.  The  os was dilated and a polypus about the size
of a hen's egg was found in the cervix, whose pedicle could be
followed as far as the uterine wall.   On pressing the fundus
blood escaped from the external  os.   The tumor was drawn
down with forceps, detached from the uterine wall by twisting
and the base scraped with a sharp spoon.  The uterus washed
out with a three per cent, carbolic solution and ergot given for
several days. 
CLINICAL SURGERY.
93
                UPPER EXTREMITIES.

    Fractures and Dislocations; twelve cases.
    Case I.  Amputation at the shoulder joint for crush of
the arm; Recovery.—F. N.; age 28; brakeman in the employ
of the R. G.W. railroad.  While setting brakes fell between
the cars, and two cars passed over his right arm.   Was taken
to the hospital November 21st, and at midnight the arm was
amputated at the shoulder joint. The  humerus was crushed
and the  muscles of the  arm were lacerated and contused to
the shoulder joint and filled wTith dirt.  Hemorrhage was pro-
fuse, and when he reached the hospital was almost in a state
of collapse.
    Operation, November 21st, at midnight.—After compresses
were put about the arm,  a  circular incision was made two
inches below the head of the humerus and all bleeding points
secured.   A  second incision was made from the acromion
process,  perpendicular to  the circular incision, and the head
of the  humerus was removed.  Two rubber drainage  tubes
were used, which were taken out on the third day. He made
a good recovery.
    Case II.   Amputation  of lower one-third  of arm for
gunshot wound at elbow.—C. J., male; age 21.  Was accident-
ally shot through left elbow, December 10th, 1891; calibre 45.
He was first seen six weeks after the accident, when the entire
forearm was swollen and oedematous.  The gunshot wound was
suppurating freely, and several fragments of bone were re-
moved.  All the  symptoms of septic infection were present.
Amputation was advised and assented to.
    Operation.—Ether.  Amputation at  middle of  arm.   A
rubber drainage tube was used and taken  out on  the second
day. Primary union followed.
    Case III. Wiring of un-united fracture of Humerus with
secondary suture of Musculo-Spiral Nerve;  Partial success;
union of fracture.—A. B. D.; male;  age 35;  carpenter by 
94
A SYNOPSIS  OF
 trade.  Was admitted February  12th, 1891.  The patient, a
 strong, well developed man,  while  at  work was injured by a
 falling  derrick.  The injury  received was  a fracture of the
 humerus in its middle portion and fracture of the ulna of the
 same arm.  The injury was received three months prior to his
 admittance.   On examination  the  ulna was found united,
 while  the fracture of  the  humerus  remainsd ununited.
 There was also complete paralysis of the extensor muscles of
 the forearm with marked atrophy and symptoms of a divided
 nerve.
    Operation.—Ether.  An  incision three inches long was
 made over the site of  fracture on the posterior and outer as-
 pect of the arm.  The ends of the bones were made even, and,
 after three-quarters of an  inch  had been removed, they were
 brought into  apposition and held  in  place  by means  of  a
 strong  silver-wire  suture.  The  musculo-spiral  nerve was
 found divided and the ends separated half an  inch.  The
 upper end  with its bulbous  extremity was quite prominent;
 the lower end was closely adherent to  the surrounding callus
 and much  atrophied.  A section  of  the upper end was
 carried through the upper part of  the bulb close to the normal
 trunk; of the lower end only a small portion was cut off.  The
 ends were brought together and a small needle armed with  a
 catgut suture was passed completely through the nerve trunk
 at right angles to its long axis, about a quarter of an  inch
 from the cut surface in each end, and a second  suture was
 passed at right angles to the first.  These sutures were  drawn
 tight until the opposing cut  surfaces were brought into con-
 tact.  A small capillary drain was left in the wound, and the
 arm was placed in  a splint in  such a position as  to keep the
 injured nerve  in a  state of the least possible tension.  The
 dressings were not removed for four weeks, there being no in-
 dication to the contrary.  The wound healed by first intention.
 Six weeks  after the operation  there  was no return  of sen-
 sation or motion.
    Seven months after the operation the hand is much im-
 proved and there is firm  bony union.  The muscles  which
 were paralyzed and atrophied  have greatly  increased in bulk,
 but he has no power over them.   No reaction to galvanism or
faradism. 
CLINICAL SURGERY.
95
    November 12th, 1891.—A slight abscess formed and the sil-
ver wires were removed.  Galvanism and faradism have been
used twice a week. The hand is still improving.
    February 12th, 1892, one year after operation.—The re-
action to galvanism and faradism still  more improved,  while-
sensation has almost returned.
    June 21st, 1892.—Left the hospital, sensation having en-
tirely returned.   The muscles have still further increased in
bulk and he has good power over them.  The patient was seen
several months  later and  he was still  further improved,  but
was not yet able to work well as a carpenter.
    Case IV.  Amputation at both Wrists.—M. P., an Italian
laborer, while attempting to thaw out some giant  powder had
both hands blown off  and face badly  burned.  Was brought
to the hospital February 1st.  Amputation at both wrists was
performed the same day.   He made a good recovery.
    Case V.  Amputation of both Hands cd lower  one-third
Forearm.—A. F.  E.; male; age  52; miner.  In  a premature
explosion in the Mercur mine, both hands were torn off at the
wrists and both eyes destroyed.   Was brought to  the hospital
May 8th.
    Operation —Amputation of  both forearms  in  the lower
one-third, and  eneucleation of both eyes.  He was in great
shock, but rallied and improved. Three weeks later he was-
taken to his home.
    Case VI.  Compound Comminuted Gunshot  Fracture  of
Humerus: Re-section and wiring; Successful.
    Mrs. C, wife of a physician, on the night  of  May 17th,
was shot in  the lower one-third  of left arm by a burglar;  cali-
bre 38.  On  the  following morning she was removed to the
hospital and under ether an examination was made.   Several
large pieces of bone were removed.  The lower fragment was
found not to be fractured into the elbow joint and  it was de-
cided to resect the bone.
     Operation.—An incision three inches long was made  on
the outer side of the arm, and several more pieces of bone
 were removed.  The lower fragment was entact  three inches
 above the elbow  joint. The ends of the bones were made  even
 and after three and one-half inches of bone had been removed 
96
A SYNOPSIS OF
 they were brought into apposition and held in place by means
 of stout silver wire sutures.  A small drainage tube was left
 in the wound.
     Subsequent  Treatment and  Progress.—The  arm was
 dressed in a heavy antiseptic dressing and placed in a suitable
 firm splint.  At the end of the second day was dressed on ac-
 count  of a bloody discharge, at which time the tube was re-
 moved.  The next dressing was on the eighth  day. From now
 on there was no elevation of temperature and she went  on  to
 a rapid and  uneventful recovery.   Eleven months  after the
 operation she had good use of her arm and was able to attend
 to her household affairs.
     Case VII. Arthrotomy of Elbow Joint.—W. K., age 10,
 entered the hospital October 5th with a very  pronounced de-
 formity due  to  injury  of  elbow joint sustained six months
 prior to his admission.  The injury was received by a fall from
 a hay stack, striking upon his right elbow.  He was treated
 for dislocation of the radius and ulna backwards.  It was put
 in a  splint at  less than a right angle and left for six weeks.
 Flexion of the arm was painful, on which account the arm was
 kept in an extended position at about an angle of 180°.   Flex-
 ion  could be carried to about  110°.  The fore-arm was dis-
 placed outward and backward. Arthrotomy performed October
 7th revealed fracture of internal condyle and coronoid process.
 The  coronoid  process being loose  was removed and half of
 the  internal condyle, enough to permit flexion of the fore-
 arm.  The wound healed by primary union and at the  end of
 five  weeks passive motion was begun and continued for some-
 time.  A rubber drainage tube was left in the  wound and the
 arm  put up in the extended position with a heavy antiseptic
 dressing and a splint externally.  He left the hospital on De-
 cember 7th with a very useful joint.
    Case VIII.  Congenital Dislocation of the Radius Back-
 icard.—A. A., Female,  age 18.  Admitted July  7th.  The
 radius projected backward two inches.  Incision and removal
of projecting portion of radius.  Primary union.
    Case IX.  Arthrotomy of Elbow Joint.—P. J., Male, age
 19, fell down an embankment a distance of  twenty feet, strik-
ing  on the point of right elbow,  sustaining a comminuted 
CLINICAL SURGERY.
97
fracture  of  lower extremity of humerus.  Admitted to the
hospital May 12th.  It was impossible to put the arm up in a
flexed position on account of a tendency to  a backward dis-
placement of the ulna.  It was therefore treated in the ex-
tended position.   On removing the splints two months later it
was found that there was considerable anterior displacement
of the trochlear surface due to the interposition of callus be-
tween the fragments so that it was impossible to flex the arm.
Arthrotomy was  performed July 20th, when enough of the
anterior  trochlear surface  was removed  to permit flexion  of
the fore-arm.  The wound healed by first intention, and pas-
sive motion began in four weeks time, resulting in a useful joint.
    Case X.  Removal of Carpal Bones for Necrosis, Follow-
ing Gunshot Wound of the Wrist.—A. W. W., male, age 30,
was shot through the right wrist February 20th, the ball pass-
ing from within outwards.  When seen on February 29th ex-
tensive necrosis  of carpal bones had ensued.  A single free
incision  was made over  the dorsum of the wrist, extending
along the center of the meta-carpal bone  of the index finger
(Langenbeck's).   Through this opening the carpal  bones  were
readily turned out.  The bases of the  meta-carpal bones, and
the lower extremities of the radius and ulna were not excised.
The wound  healed  slowly and  passive movements  of the
fingers were performed at an early period after the operation.
He was discharged from the hospital with a good result.
    Case XI. Operation for Deformity just above the elbow
joint.—N. W.; female;  age 12. Fell from  a chair sustaining a
supra-condyloid fracture of left humerus.  When  she entered
the hospital ten months after the accident she was unable to
flex the arm beyond a right angle on account of the  anterior
displacement of the upper fragment.
    Operation.—An  incision was made over the epicondyle
(external) and the obstruction removed.  The wound healed
by primary union, but an annoying complication  set  in, con-
sisting of a  paralysis of the fore-arm and the hand.  This un-
toward event probably  was caused by the undue pressure, over
the nerves, of the rubber bandage used in producing artificial
anaemia.   Local  treatment of  paralysis  by  galvanism and
massage  re-established in three weeks time flexion and exten-
     7 
98
A SYNOPSIS OF
 sion of fore-arm and fingers.  The muscular power was fully
 restored and the function of the elbow became normal.
     Case  XII.  Amputation at the Shoulder Joint for Trau-
 matism and removal of Neck of Scapula, Acromion Process,
 and the outer portion of the Clavicle, for extensive Necrosis.
 —R. L. B.; male; age 31.  On August 8th, 1891, while running
 his saw mill, he accidentally fell on the circular saw, which at
 the  time  was running at a high rate of speed, receiving an
 incised  wound in the right axillary region, and fracturing the
 acromion  end of the clavicle, also the acromion process.  The
 excision extended  through the pectoral muscle into the axil-
 lary space.  The wound was sutured with no drainage.   Two
 weeks after the  injury profuse suppuration set in and bur-
 rowed into the axillary space and down the arm to the elbow,
 and also posteriorly under the scapula.  When the patient came
 to the hospital on the 23rd of January,  1892, he was greatly
 emaciated, and was suffering all the symptoms of a prolonged
 suppuration. January 25th, under ether, the acromion end
 of the clavicle and acromion process were removed.  There
 was found complete anchylosis  at the shoulder joint.  Thor-
 ough drainage was established. February 1st his condition
 was becoming worse, and amputation at the shoulder joint
 was performed,  and the coracoid process was also removed.
 The entire scapula was found necrosed, but the condition of
 the patient did not permit its removal.  He was placed in bed
 and stimulants administered.  He rallied, and for the  next
 few  days  seemed  to improve, but gradually sank and  died
 February  8th from prolonged suppuration.
    Miscellaneous cases; forty-eight.
    Case  I.  Injury to Brachial Plexus, with Complete Par-
 alysis in the Upper Extremity; Recovery.  J. D., female, age
 18, while coasting was thrown forward from her sled striking
 a tree on the left humerus.  The arm was badly swollen and
 contused,  and there was complete wrist drop.  She could flex
 the middle, ring and little fingers. The biceps, triceps, coraco-
 brachialis, brachialis-anticus, and the deltoid were paralyzed.
    Electrical Examination.—The  deltoid, biceps,  triceps,
brachialis-anticus,  coraco-brachialis, all the flexors  supplied
by the median nerve,  and all the extensors, do not react  at
all.   The  muscles  supplied by  the ulna nerve, the adductor 
CLINICAL SURGERY.
99
pollicis, the pronator radii teres, the lumbricales and interossei
act well to galvanism only.  There was anaesthesia of the skin
of the whole of the fore-arm except a small area on the ulna side.
    Treatment.—Daily galvanism was used and at the end of
three months time there was marked improvement.  In eight
months time all those muscles which  previously reacted to
galvanism alone now react to faradism  also.   Sensation nor-
mal.  In one year from the date of the injury she has as good
use of the arm as ever.
    Case II.  Tenosynovitis of the  Extensor Tendons of the
Hand {Tubercular?).—Operation, incision  and dissecting  out
of the tubercular sac.   Recovery.
    Case III.  Fracture of Humerus, Delayed Union,  Drill-
ing.—Captain W. was thrown from a buggy,  sustaining frac-
ture  of  humerus at  the junction of upper and middle one-
third.  The fracture was put up in the usual way and as soon
as the swelling had  subsided the arm was placed in  a plaster-
paris spika.  At the  end of  ten weeks time  there being no
union, irritation was attempted by  percussion.  This proved
ineffectual and at the end of three and  a half months,  under
ether, the ends of the bones were rubbed together.   This  was
again done three weeks later with no better result.   The ends
of the fragments were  now perforated at several points with
Brainard's drill.   The arm was put completely  at rest in ap-
propriate splints, and in six  weeks after the punctures  had
been made there was firm bony union.
    Case IV.  Varicose Aneurism of the Ring Finger; Am-
putation of Finger  at Meta-carpo-phalangeal Articu'ation;
Recovery.—N. M., female, age 24.
    Amputation of Fingers for Various Causes; thirty-four
cases.
    Cicatricial Contraction of Fingers; two cases.
    Cellulitis of Hand and Fore-Arm; eight cases.
    This diffuse inflammation  of the cellular tissue followed
injuries  of  the  most  varied description and in  each case
ended in suppuration and sloughing.   The local  treatment
consisted at first  of gentle  elastic compression with many
layers of moist cotton and the whole covered with oil-silk.  In
other cases incisions and thorough drainage were established.
    Osteoclasty for  Mal-union of Ulna; two cases. 
100
A SYNOPSIS OF
               LOWER EXTREMITIES.

    Fractures and Dislocations;  twelve cases.

    Case I.  Re-section of Femur for Mal-union; Recovery.—
B. B., male, age 22, was knocked down by  a  runaway team,
sustaining a fracture of the left femur at the junction of the
middle and upper one-third.  He  entered the hospital seven
months  after the accident, with mal-union, marked  angular
deformity, and  evident over-lapping of the fragments.   The
shortening was three and a half inches.
    Operation, June 12th.—Ether.  An incision  four inches
long was made over the outer aspect of the thigh, in the re-
gion of  the  fracture.  On exposing the bone  the  two
fragments were found  over-lapping  about  three  and  a
half inches, and  muscular tissue  intervening.  The lower
fragment  projected   upward  and  backwards,  and  the
upper,  downwards and forwards.   There  was considerable
formation of  new bone on the ends of the fragments.  Not
until one-quarter of an inch had been removed from the upper
fragment and three inches from the lower fragment could the
ends of the bones be brought into  apposition.  Good  position
having been secured, the ends of the bones  were held in place
by stout silver wire.  The thigh and leg were  immobilized by
means  of heavy wire-gauze  splints.  The wound  was not
dressed  till the end of four weeks, and it was found nearly
healed.  The  position was good and  union fairly firm.  In
four months time the union was firm.  The  shortening was
three and a half inches.  No deformity.
    Case II.  Re-section of the Femur for Mal-union; Recov-
ery.—B. B., male, age 15, was admitted August 10th.  He had
received a fracture of the right femur  four months previously
by direct violence.  At the time of  his admission there was a
two-inch shortening of the right leg and well marked  signs of
an old fracture at the juncture of the  middle  and lower one- 
CLINICAL SURGERY.
101
third  of  the right femur, with evident over-lapping of the
fragments,  and marked angular  deformity.  The  union was
not firm and he was  unable to walk  without the aid of
crutches.
    Operation, August  15th.—An incision  four inches long
was made over the seat of the fracture on the outer aspect of
the thigh.  The fragments were found over-lapping about two
inches, the  lower pointing upward and  outward.  The bones
were held  together  with moderate firmness by considerable
formation  of new bone, and were  forcibly  separated and
brought  into apposition by the removal from each end of an
inch of bone.  They were held in place by  stout  silver wire
sutures.   The  leg,  thigh and pelvis were immobilized  by
means of a heavy splint.  The wound was not dressed for
three and a half weeks, when it was found entirely healed.
    October 15th.—The position was good and union firm, with
two inches  shortening.  He went about on  crutches, but the
limb was still kept in splints.  He went  home  December 1st
with a useful leg.
    Case III.  Un-united Fracture  of both Bones of Leg;
Wiring; Recovery.--William M.; age 27.   Had  received a
fracture of  both bones of the left leg in the lower one-third, by
direct violence, three months previous to his admission to the
hospital. At the time of his admission there was  no  union.
The shortening was an inch and a half.  Under ether the ends
were rubbed together and the position maintained by splints
and  extension. At  the end of seven weeks there was no
union.
    Operation, September 12th.—An incision three inches long
was made over  the fracture on the anterior surface.  The line
of fracture was  oblique, running  from  within  outwards.
About one-quarter  of  an  inch was  taken  off of the  upper
fragment of the fibula and three-quarters of an inch off the
upper fragment of the tibia, one-quarter of an inch was taken
off the lower fragment of the tibia and three-quarters of an
inch off the  lower fragment of the fibula.   The bones were
held in place by stout silver wire sutures.  The  leg  and thigh
were immobilized by a heavy plaster splint.  The wound was
not dressed for six weeks, when it was found healed and union 
102
A SYNOPSIS OF
firm.  Shortening, one and a half inches.  At the end of three
months' time he left the hospital with firm bony union and
a useful leg.
    Amputation Middle One-Third of Femur for Compound
Comminuted Fracture.—H. M. N, male, age 30, was admitted
April 25th.   On March 13th was run over by a heavily loaded
wagon, sustaining a  compound  comminuted  fracture of left
femur in the lower one-third.  When he was first seen at the
hospital the  thigh  was greatly swollen and pus was oozing
from several tracts, and all the symptoms of septic  infection
were present.  He had been injured while crossing the desert
lying west  of the Great Salt Lake and had had no medical
aid.
    Operation,  April 26th;  Ether.—Amputation was  per-
formed  at  the middle of the thigh.   Rubber drainage tubes
were used and a moist bi-chloride dressing 1 to 5,000 applied.
Tube removed on fourth day.  Temperature rose on the sixth
day to 102°  F., but there was  no evidence of trouble  in the
stump.  The  bowels  had been severely confined for several
days. A brisk cathartic was administered and the tempera-
ture was normal the  next  morning.  The  wound healed  by
primary union and he was discharged cured July 21st.
    Case V.  Amputation Middle of Leg;  Recovery.—S. H.,
male, age 69.  August 7th was kicked by a horse, sustaining a
compound  comminuted  fracture of right  leg.  On the fifth
day  after the accident  the  wound was suppurating freely.
When he was admitted  to the  hospital the  leg was tense,
swollen, and suppurating freely.  Fragments of bone were re-
moved and  the wound drained.  No betterment.
    Operation, 14th;  Ether.—Amputation in middle one-third
of right leg. Rubber  drain. The flaps sloughed and the
wound healed by granulation.  Secondary operation, Septem-
ber 21st, re-amputation, primary  union.
    Case VI.—Amputation  Lower One-Tliird  of Leg for
Crush.—M. J., male,  age 22, was run  over  by an electric  car
crushing lower part  of  leg.   He was  brought to the hospital
on the night of September 26th.  The foot  and  lower part of
leg were crushed  and filled  with  dirt.  The same night the
leg was amputated at the junction of the middle and lower 
CLINICAL SURGERY.
103
one-third.  Rubber drainage tube was used  and removed on
the third day; primary union.
    Case VII.  Osteoclasty for Mal-union of  Tibia.—M. G.
P.,  male, age 25, was admitted September 28th, ten weeks
after receiving fracture of the right tibia.  There was consid-
erable deformity and the union was quite firm.  He was given
ether and the tibia refractured, straightened, and put up in co-
aptation splints, which were taken off October 20th.  There was
firm bony union and no deformity.  Discharged cured Novem-
ber 1st.
    Case VIII.  Amputation  Upper  One-Third  of Leg.-~
P. J. T., male,   age 20, was  run over by  an  electric  car,
sustaining  a compound comminuted fracture of ankle joint;
was brought to the hospital  October  28th. The ankle was
found  crushed  and filled with dirt.   Amputation lower  one-
third of leg was performed four hours later.  Primary union.
    Case IX.  Amputation  Upper  One-Third of Thigh;
Death.—T. L. P., age 16,  sheepherder.  Was  herding his
sheep and on going down a steep hill fell, throwing his gun in
front of  him, which  discharged, the ball  passing through
the lower part of the femur, producing a compound comminu-
ted fracture of the femur; calibre 45.   He lay for twelve hours
where  the accident happened  before he received any assist-
ance.  He was taken home and two  days later, October 1st,
was brought to the hospital. The femur was found splintered
high up.
    Operation,  October 2nd;  Ether.—Amputation was per-
formed at  the upper  one-third of the thigh. He was in bad
condition at the time of the operation.  He never rallied and
died ten hours later from shock.
    Case X.  Amputation  Lower One-Third of Thigh for
Gunshot Wound; Death.—M.  A. B., male, age  13, while out
hunting was accidentally shot through the right knee; calibre
38.   Admitted  to  the hospital November  5th.  There was
found a compound comminuted gunshot fracture of lower ex-
tremity of left femur, the ball passing through  the  condyles.
Amputation in the lower one-third of thigh was performed
twelve hours after the injury.  He never rallied and died four-
teen hours later from shock. 
104
A SYNOPSIS OF
    Case  XI.   Gunshot Wound  of Leg, Gangrene; Amputa-
tion Lower One-Third of Thigh; Death from Tetanus on the
Tenth Day.—C. L. D., male, age  20, while duck-hunting acci-
dentally shot himself in the right leg.  The entire charge of
shot was discharged into the  right leg, tearing  away almost
the  entire outer  muscular part of  the leg.  The fibula was
comminuted and the flesh was terribly lacerated on the outer
side  of foot  and  ankle.  The  entire  wound was powder
burned.  Shot, wadding, and bits of clothing, as much  as
could  be,  were removed from the ankle joint and the tarsal
articulations.  The  wound was dressed with heavy antiseptic
dressing and kept moist in a solution of bi-chloride 1 to 2.000.
Gangrene set in on the second day, and on the sixth day  the
limb  was amputated in lower  one-third of thigh.  On the
eighth day symptoms of tetanus  set in.  He first complained
of sore throat, with inability of opening mouth  to its full  ex-
tent.   Mastication and deglutition became difficult.  Rapidly
the painful  contraction and  the rigidity  extended to other
muscles near.  The  lips were drawn apart  (risus sardonicus),
and the neck drawn back.  The thorax became rigid; respira-
tion rapid and shallow; pulse small and feeble and the whole
face expressed the most intense suffering and anxiety.
    As the disease advanced all the muscles of the trunk  be-
came hard and rigid.
    The paroxysmal attacks came on  every  few  minutes with
the most  violent  contractions, twisting his body into incon-
ceivable positions, till death resulted from asphyxia, two days
from the onset of the attack.  He was conscious to the last.

                     (b.)  NEOPLASM.

    Case  I.  Sarcoma of the Fibula; Amputation  at Knee
Joint; Recovery.—M. S., male, age 39; farmer by occupation;
admitted December 20th.  General health has always been good
until recently.   When about  17  years old he first noticed a
lump on the upper  and outer surface of the left leg.  This
lump remained about the size of an  orange till about  three
years prior to his admission, when it  increased rapidly in size
and became painful, so much so that  he  was unable to attend
to his occupation.  When he entered  the hospital he was suf- 
CLINICAL SURGERY.
10
Anterior. 
106
A SYNOPSIS OF
Posterior. 
CLINICAL SURGERY.
107
fering considerable pain and was using a cane.   Examination
showed a large, hard, nodular tumor on the outer  aspect of
the left leg,  just below  the  knee.  Very  tender on  pressure,
and  in  some places showed areas of softening.  There was
marked atrophy of muscles  of thigh.  No glandular enlarge-
ments.
    Operation, December  23rd.—Ether.   Stephen Smith's
method of amputation at knee  joint was performed.  Drain-
age  tubes were used, and  were removed on the  fourth day.
The wound healed by first intention and he was discharged,
cured, January 25th, 1892.
    Pathologisfs Report.—The tumor sprang from the upper
one-third (outer aspect) of  fibula.  Was nodular,  with evi-
dences of softening, and measured, in circumference, twenty-
six inches.  Round  and  spindle-celled sarcoma.

                 (C.)  TUBERCULAR DISEASE.

    Case I.   Tubercular Synovitis of the Knee; Arthrotomy;
Recovery.—A. T. B., male, age 24, was admitted March 27th,
with a tubercular history on the father's side.  One  year be-
fore his admission his right knee began to swell, and when he
entered the hospital there was a marked redness and tender-
ness, and was four and one-half inches larger in circumference
than the other.  The movements of the joint were limited and
very painful.
    Operation, March 30th.—Two longitudinal  incisions  were
made on each side of  the patella, opening the joint.  The syn-
ovial membrane, being found in an advanced state of  tuber-
cular disease, was removed.   The articular  ends of the  bone
did not seem to be involved.   Recovery was rapid and he left
the  hospital  with the functions  of the joint fully  restored.
He was heard from  eight months later and had had no return
of the  trouble.
    Case II.  Amputation of the Lower One-Third  of Thigh
for  Tubercular Arthritis of the Knee;  Recovery.—M. T.,
male, age 21, admitted October  22d.  His general health had
always been good, but with tubercular history on his mother's
side.  No evidence of tubercular deposit in lungs.   Two and
a half years  ago  received a  slight  injury  to the knee, since 
108
A SYNOPSIS OF
which time the joint has gradully increased in size, attended
with pain and tenderness.  He was  treated in Chicago by
parenchymatous  and intra-articular  injections of  iodoform.
He was discharged as cured.  He came to this territory, where
he lived for the next six months, apparently free from the dis-
ease, when the trouble broke out anew.  When he entered the
hospital the knee joint was  enormously swollen, accompanied
by great pain and tenderness.  Mobility was entirely gone and
the  leg  was fixed at  angle of about 150°.  Fluctuation was
present.  Patella slightly movable.
    Operation, October 23rd; Ether.—A transverse incision was
made through the middle  of the patella opening the joint.
The disease had so much invaded the lower end of the femur
and the  articular end of the tibia that  excision was impossi-
ble, and  amputation was at once performed.  It was found
necessary to make a section of the femur at the junction of
the  middle and lower one-third.  Drainage tubes  were used,
but on  the second day  secondary hemorrhage set in, which
necessitated the opening of the flaps, when it was found  that
there was profuse oozing from the bone.  The end of the bone
was packed  with  styptic cotton, but the hemorrhage was not
entirely  controlled for several  days.   The wound healed by
granulation, and on December 20th re-amputation was done,
at which time two inches of the bone was removed. Primary
union followed.  The pathologist reports a typical  tubercular
disease of the joint.
    Case III. Tuberculosis of Ankle Joint; Atypical re-sec-
tion; Subsequent Amputation in Lower One-Third of Leg.—
L. P., female, age 20.  Mother and father both living and in good
health.  An uncle on  mother's  side died of phthisis pulmon-
alis.  Two sisters  and six brothers living and in good health.
    Previous History.—When seven years old she sprained her
right ankle, which gave her no trouble till  July, 1889, when
the joint became stiff and painful, and she was unable to walk
for  some time.  In July, 1890, there was a repetition of the
same trouble, and  when she was admitted to the hospital,
January, 1891, the ankle  was swollen,  painful and discharging
on the inside of the ankle just below the joint.  There was no
history  of  having sprained the ankle  the  second time.  In 
CLINICAL SURGERY.
109
January, 1891, atypical resection of the ankle joint was per-
formed through two lateral incisions for osteo-tuberculosis.
The operation consisted in the extirpation of the tubercular
capsule and of the removal of tubercular foci in the epiphysial
extremity of the tibia and the external malleolus.   Deeply-
seated osseous foci were found in the articular surface of the
astragalus, which were thoroughly scraped out by the free use
of the sharp spoon.  After iodoformization the incisions were
closed with drainage.  Foot placed on splint  and retained  by
wire-gauze.  At the end of twenty days union good except at
points of drainage. With exception of a small connective-tissue
abscess,  recovery  was  uninterrupted;  patient walked  on
crutches at the end of the third month, and left  the  hospital
four weeks later greatly improved in general health, and with
good motion of the ankle joint.  In the following December
the ankle and leg became greatly swollen  and painful, when
she returned to the hospital. The previous incisions were open
and discharging freely.
     Operation, January 15, i8#2.—Amputation  in lower one-
third of leg; primary union; discharged March 25th cured.
     Case IV.  Anchylosis of Knee Joint; Amputation Lower
One-Third of Thigh; Recovery.—A. D., male,  age 24.  Ad-
mitted  August 20th.  Both parents tubercular.   Has had re-
peated  attacks of inflammation  of right knee  and since the
last attack one year previous to his admission, the knee has
been anchylosed at a right angle.  His general health has not
 been the best.  The affected knee was enlarged  three inches.
Amputation just  above the condyles was performed, rather
than excision of the  knee, because the patient  preferred the
 use of an artificial appliance rather than a  stiff leg, in fact
 would submit to the former operation only.
     Operation, August  22nd.—Amputation of  femur three
 and a half inches above the knee, as  the  most suitable place
for artificial  appliance.  Tubes removed on third day; primary
 union;  discharged August, cured.  Eight months after leav-
 ing the hospital was wearing the  appliance and attending to
 his duties.
     Case V.  Excision of the Knee Joint for Tubercular Ar-
 thritis: Recovery.—M.. B.. female, age 28.  and mother of three 
110
A SYNOPSIS  OF
 children; admitted April 27th. Tubercular history on mother's
 side.   One  year  prior  to her  admission  she received  a
 slight injury to her  right knee.  Some stiffness in the joint
 remained, which was followed by a painless  enlargement of
 the joint, but for two  months the pain had been constant,
 and when she  entered  the hospital, the knee  was greatly
 swollen.  Temperature, 103° F.; pulse, 110; fluctuation present.
     Operation, April 29th.—A transverse incision was made
 through  the  middle  of  the patella,  followed by escape  of
 tubercular pus.  The ends of the bones were excised and held
 in place by stout silver wires.  Drainage tubes were inserted
 and the wound dressed with heavy antiseptic dressing, and a
 stout wire-gauze splint applied externally.  She made an un-
 eventful recovery and was discharged June 15th.
     Case  VI.  Excision  of Knee  Joint for  Tubercular Ar-
 thritis.—A. B. S., male, age 29.  A strong, healthy-appearing
 man, with no family history of tuberculosis.  Had for the last
 three and a half years suffered from  knee joint  trouble.  On
 admission to the hospital, November 1st.  there was found  a
 uniform enlargement  of the joint, together with fluctuation.
 His temperature was 101%° F.; pulse, 105.
     Operation.—Complete re-section of  the knee joint, includ-
 ing  patella.    On  section  of  the femur  the  bone  appeared
 highly osteoporotic.   On  the inner condyle  was found  a
 small sequestrum surrounded by granulation  tissue, and cor-
 responding to this, a caseous deposit was found on the inner
 tuberosity of the tibia.  Both articular extremities were sawn
 across  and removed, together  with the  synovial membrane
 and ligaments of the joints.   After thorough iodoformization
 of the wound the  bones were brought together and  wired.
 Drainage tubes were inserted, and a copious anti-septic dress-
 ing was applied  and retained  by a  wire-gauze  splint. The
 limb was kept in an elevated position for ten days.  The tem-
 perature never rose above 100.5° F., and  at the first dressing.
 on the twentieth day, union was complete except at the  points
 of drainage.   Examination  at the end  of the eighth week
 showed consolidation well advanced, with an inch and a quar-
 ter shortening. At the end of  three  months he  was able to
get about  without any inconvenience. 
CLINICAL SURGERY.
Ill
    Case VII.  Excision at Knee for Tubercular Arthritis,.
with subsequent amputation at Lower One-Third of Thigh.
—T. B. C;  male:  age 36.  Was admitted into the  hospital
April 1st with the following history:  At an early age  he fell>
injuring his right knee.  Some stiffness of the joint remained
but did not cause him much inconvenience until about a year
and a half ago, when he received a second injury to the same
knee, followed by  an  enlargement of the  joint and attended
with almost constant pain.  No history of tuberculosis in his
family.
    Present Condition.—Patient anaemic; knee anchylosed and
enlarged, with the point of fluctuation on the outer side of the
patella tendon,  likewise  the  point  of  greatest  tenderness.
The pulse is small  and weak, and there is a slight rise in tem-
perature at  night, attended with profuse sweating.  He  has a
slight cough and a tubercular deposit in  the left lung.
    Operation.—Complete re-section of the knee joint, includ-
ing the patella.  The articular surfaces were found to be the
seat of a well advanced tuberculosis.  After performing a
typical re-section  of  the  joint, and iodoformization  of the
wound, the  bones were brought together and wired.   Drain-
age tubes were inserted and the usual dressing applied.  The
temperature continued high for a number of days, being as
much as 105° F. on the tenth  day.  The wound  was  suppur-
ating freely and the patient's  condition  was becoming worse.
Amputation of the lower  one-third  of the  thigh was per-
formed on  the fifteenth day, with an immediate betterment
of his symptoms.   The wound healed by primary union, and
he was discharged cured.
    Case VIII.   Tuberculosis of Hip  Joint; Resection of
Hip Joint, and subsequent amputation at Hip.—W. D., male,
age 20.  Was  admitted March 24th  with well  marked, ad-
vanced tubercular disease of the hip joint, of  three years' du-
ration.  There were several sinuses from which pus was flow-
ing freely.
    Operation, March 26th.—Re-section of  the  head of the
femur;  three weeks' later amputation  at the hip was per-
formed.  The wound continued to discharge for some time.
He was rapidly becoming emaciated from the hectic fever and 
112
A SYNOPSIS  OF
profuse purulent  discharge.  The acetabulum was freely ex-
posed and scraped.  The wound healed slowly and he left the
hospital much improved in his general condition.
    Case IX.   Tuberculosis  of  Hip Joint; Re-section; Re-
covery.—M. L., female, age 9,  admitted March 7th with well
advanced  tubercular  disease of hip.  Resection  of  head of
femur  was performed  March 10th.  The wound healed slowly'
and she left the hospital June 10th much improved in health
and with a useful joint.
    Case X.   Tuberculosis  of  Hip Joint;  Excision;  Re-
covery.—W. G., age 10; female.   The operation consisted in
the removal of the head  and neck of femur; healed slowly.
    Case XI.   Tuberculosis  of Hip Joint;  Excision;  Re-
covery.—M. D., female, age 12;  admitted  September 18th.
Excision of head of femur only;  healed  slowly.
    Case XII.  Tubercidosis  of Ankle Joint; Amputation at
Lower One-Third of Leg; Recovery.—A.  D.: female; age 18.
                    (d) INFLAMMATORY.
    Case I.  Gangrene; Amputation  Upper  One-Third  of
Thigh; Recovery.—H. H, male, age 23, was  admitted to the
hospital January 10th, complaining of intense pain in left leg.
He gives the  following  history:  Father and  mother living
and in good health. During his early childhood was always
sickly, and at about ten  years old began to suffer with severe
sick headaches.  When  20  years old he received a severe in-
jury to the abdomen  just above the pubes, and passed what
seemed to be pure blood, with a great and frequent desire to
urinate.  He recovered from the injury and was perfectly well
up to four or five weeks previous, when he was attacked with a
severe  headache attended  with severe pain in the umbilical
region, which lasted for three or four days. The pain on leav-
ing the abdomen  was felt most severe in the right leg, with
numbness of the  foot.  The pain in  the calf of the leg was
most intense, especially on pressure. There is no specific his-
tory.  On examination a localized  indurated spot about the
size of  a silver dollar was found in the  calf of the  leg in the
soleus muscle, exquisitively tender  on pressure. There were
evidences of dementia.  January  13th  an incision was made
over the indurated spot and not even one drop of blood was 
CLINICAL SURGERY.
113
present, venous or otherwise.  The pulsation of either femoral
could not be made out,  although  the radial pulse was felt
strong, and regular.  The right leg  was also  numb.  The in-
durated muscle was abnormally friable,  semi-opaque,  pale,
slightly lustrous, and of a redish grey color.  The appearance
of a coagulated necrosis.  January 17th process of gangrene
has set in from the point  of incision and is extending in all
directions; toes are beginning to be discolored, numbness be-
ginning in the toes of the right foot, temperature 104.5°, pulse
140, pulsation of either femoral can  not be felt, but the pulsa-
tion of abdominal aorta is distinctly felt.  January 18th the
line  of demarcation not established.  January 20th amputa-
tion in upper  one-third  of thigh.  The flaps sloughed and
amputation at hip was performed.  Primary  union.  The
arteries were found hard and thick and the lumen almost ob
literated.  He was discharged cured February 27th.
    Case  II.  Bursitis Praepetallaris.—J. G. F., male, age 54,
miner  by  occupation, was admitted in  June. About a year
previous first noticed, just below the knee, a swelling, attended
with very little or no pain, which increased till about four
inches in length, extending up over the  patella.  He gives the
following history:  Had been a miner for about sixteen years,
where the work very often, especially in small places, required
the men to work on their knees.
    Operation.—Ether.  An incision was made over the fluc-
tuating swelling, and the sac, the walls of  which were found
very dense and thick, was dissected out.   The cavity was dis-
tended with a clear and serous fluid.  The interior was rough
and  irregular, covered with warty  nodules, and traversed
by thickened  bands.  There were  also definite  peduncilated
outgrowths  with  floating  cartilaginous ends.  The incision
was closed with drainage  and recovery was rapid and perfect.
                   (e) MISCELLANEOUS.
    Lisfranc's Operation for Frost-Bite;  four cases.
    Choparts Amputation for Frost-Bite; two cases.
    Syme's Operation for Crushed Foot; one case.
    Foreign  Body in Knee Joint;  two  cases.  In the
first  case  cocaine was used and the floating body re-
     8 
114
A SYNOPSIS OF
moved through a small incision.  In the second case
the operation was performed under ether, and an in-
cision made to the  outer  side of the patella  tendon.
Two large pieces of floating cartilage were  removed.
Primary union followed in both cases.
    Re-amputation for Painful and Adherent Cica-
trices; ten cases.
    Amputation of Toes  for  various causes; fifteen
cases. 
CLINICAL SURGERY.
115
             OPERATIONS ON BONES.
   For Necrosis.—In this operation it was custom-
ary to make a free incision so that the diseased bone
could be both seen and felt;  chisels, curettes, gouges,
and trephines were employed to obtain a thorough
removal of all diseased bone.  Where  the operation
was not extensive, the limb was rendered bloodless
by elevation for four or five minutes, but in any case
of magnitude Esmarch's bandage was employed.  The
after treatment consisted in filling the cavity  with
iodoform gauze and covering the wound with a large
antiseptic dressing.  The majority of the cases were
of tubercular origin, and in these general measures
were adopted in addition.
    Tibia.—Nine cases of  necrosis of the tibia were
treated.
    In  one of these there was  a total central  ne-
crosis  of the shaft,  and in another  there was al-
most total central necrosis of the shaft.  In operat-
ing the  periosteum was  spared and the entire canal
of the bone was opened, and a sequestrum, almost  a
perfect cast of the interior of  the bone, together with
a portion of the involucrum, were removed. Healing
was slow and sinuses remained for weeks, but recov-
ery was finally perfect.
    In  three  of the  cases  there was  simply acute
osteitis,  where  an incision  was made down to tli«
bone and drilled, thus relieving the tension. 
116               A SYNOPSIS OF
   In  one case there was  found  some thickening
and hardening at the upper end of the tibia, attend-
ed  with a persistent  gnawing, boring pain, worse
at night.  An  opening  was made with gouge and
chisel, and a focus of tubercular softening about the
size of a cherry, was discovered.  This was curetted,
with relief of symptoms.
   In two other cases injuries to the bone had been
received several years previous, followed by osteo-per-
iostitis and some superficial  caries.  This was treated
by an incision and scraping  of the diseased bone.
   In another case there  was necrosis following a
compound fracture.  Incision for removal of the dis-
eased bone.
   Foot and Ankle.—There were four cases in which
the disease affected  the lower extremities of the tibia,
fibula and astragulus.  These all  recovered, and,
though the range  of  motion  in the ankle  was im-
paired, yet the joint was a useful one.
   Fibula.—There were two cases of necrosis of the
fibula following gunshot wounds.  Incision and re-
moval of dead bone.
   Femur.—Ten cases of  necrosis of femur were
operated upon.
   In  one  case there  was   necrosis of  the dia-
physis  following acute  osteo-myelitis, complicated
with spontaneous fracture.   The limb was amputated
at the hip, using Wyeth's method of applying tourni-
quet.  It was found that the disease had extended to
the acetabulum and ilium,  the latter were curetted.
The wound was slow in healing and sinuses persisted
for a long time.
   Four cases were for  necrosis following gunshot 
CLINICAL SURGERY.
117
wounds; incision and curetting; recovery was prompt.
   Three cases  for  necrosis  following compound
fractures; incision and curetting;  recovery prompt.
   Two of the cases were post-typhoidal.
   Humerus.—Two cases were  operated upon for
necrosis  affecting the  humerus.   The patients both
recovered with a strong arm.
   Maxilla.—Four cases of necrosis of the lower jaw,
and three of the upper jaw, were all due to infection
of organisms of  suppuration through carious teeth.
In one case the half of the lower jaw  was removed.
They all made a satisfactory recovery.
   Ribs and Sternum.—Three cases  were operated
upon for necrosis of  the  sternum, and  four  for
necrosis  of the ribs, all were post-typhoidal. Recovery
in each case satisfactory.
   Fingers.—Ten cases for necrosis of the phalanges
and meta-carpal bones.   Result satisfactory.
   Necrosis  (tubercular?) of tuberosity of ischium.
Incision and curetting.   Improved. 
118
A SYNOPSIS OF
                   ORTHOPEDIC.

   Talipes;  thirty-six  cases.
   In  twelve  of  the  cases  the   feet  could  be
brought  into proper  position.   These were treated
by immobilization  of  the foot and leg, by plaster of
paris, the parts being protected by cotton and carried
sufficiently high up to prevent its ready displacement,
necessitating  frequent  removals and reapplication
of the plaster.
   In two aggravated cases of long standing in which
mark change in the shape of the bones, in the length
and position of the ligaments, and in the connective
tissue of the foot, rectification was brought about in
one  case by free incision made through all  the soft
parts of the sole of the foot.  In the other case cunei-
form osteotomy was performed in addition to the free
incision  through all the soft parts of the sole of the
foot.
   In  talipes  equinus and  equino-varus,  compris-
ing  the  rest of the cases, the tendons were divided,
frequently the plantar fascia also.   The  foot was
forcibly carried to a little beyond the normal  position,
and was maintained in place by the application of a
plaster of paris bandage.
   All of  these cases ran  the customary   afebrile
aseptic  course.  In  several weeks' time in  various
cases the patient was  given a  club foot shoe and in-
structed to walk. 
CLINICAL SURGERY.
119
   Pes Planus;  one case.  Treatment consisted in
hygienic measures, and locally, a  steel artificial arch
under  the sole with an internal lateral offshoot.   In
a short time he was able  to  attend  to his  duties as
policeman.
   Hallux Valgus; five cases.  The displacement of
the great-toe in each case was extreme  and trouble-
some, and associated with  bunion.   The  treatment
consisted in each case of complete ex-section of the
joint.
   Hammer-Toe; two cases.   In one case the toe
was removed and in the other  the joint excised. 
120
A SYNOPSIS OF
            OPERATIONS ON NERVES.
   Excision of Meckel's Ganglion, and Neurectomy
of the Inferior Dental Nerve; success.   The patient
was a man of 40, who had up to five years ago enjoyed
good health, at which time he began to suffer from neu-
ralgia  of right side of the face.   The cause of which
was unknown.  The pain would begin with a jerk in
the upper jaw, extending over the face,  would  shoot
down through the lower jaw to the chin and along
the right side of the tongue  At other times it would
begin by a sharp darting pain under the  eye, which
could some times be started by  touching the part or
washing the face in cold water.  The pain at first in-
termittent had now become almost constant, and was
worse in stormy weather.  At another time the pain
would be felt in the temporal fossa, in the lower eye-
lid, at the side of the nose and in the upper lip.  The
eye would water and the tears stream down his face.
The pain was often so great that it would  waken him
from his sleep.  He gradually lost flesh, appetite and
sleep, and was unable to eat solid food owing to the
pain  induced  by  movements of the jaws.  Medical
treatment of all kinds had been  tried without  avail.
Meckel's  ganglion was  removed by modification of
Carnochan's operation, as follows:  An  incision was
made in the cheek  with its center opposite the infra-
orbital canal.   A portion of  the anterior wall of the
antrum was removed with  a  half-inch trephine.   A 
CLINICAL SURGERY.
121
slender probe was passed as a guide along the infra-
orbital canal, and the floor of the latter was carfully
cut away from below  with bone scissors until the
posterior wall of the antrum was reached, care being
taken not to divide the nerve.  A portion of  the pos-
terior wall of the antrum was removed by chisel and
mallet.   The ganglion was easily found by tracing
the nerve back.   With a pair of curved scissors the
ganglion was separated from its other branches and
removed.  The hemorrhage after the posterior wall
of the antrum  had been removed was troublesome,
but  was  controlled  by pressure.   Great care  was
taken not to lacerate the tissues posterior to the antrum
by the chisel and mallet.   The deeper part  of the
operation was  rendered easier by aid of a reflecting
light. After removal of Meckel's ganglion, neurectomy
of the inferior dental nerve was performed as follows:
The mouth being opened as widely as possible, an inci-
sion was carried along the anterior border of the ramus
of the lower jaw, extending from the last upper molar
to the corresponding tooth in the inferior maxilla; the
mucus membrane being divided the  finger was in-
serted between the internal pterygoid and the ramus
of the jaw, feeling  for the sharp spike of bone, the
orifice of the inferior dental canal.  The nerve was
caught up by a curved aneurism needle as  it enters
the foramen and about an inch of  it  removed.  Ten
days after the operation the patient was free from
pain and was  able  to eat solid food without incon-
venience.  His appetite came back and he slept well.
On  testing sensation  several  months later  it was
found that on the  affected  side there  was diminution
of sensibility on the side of the nose, the lower eyelid, 
122
A SYNOPSIS OF
and  the  right portion of the  upper lip.   Fourteen
months after the operation he remained well and has
had no return of the pain.
   Nerve Stretching; there were five cases of sciatica
treated by nerve stretching.   All of these were invet-
erate cases which resisted every form of conservative
treatment.   Four were entirely cured by  the opera-
tion, and one experienced marked relief. The method
pursued  was as follows:   Under an anaesthetic the
thigh was  flexed on the abdomen and the leg kept
extended upon the thigh.  The sciatic nerve together
with all the tissues on the back of the thigh were put
on the  stretch.   In this bloodless stretching of the
nerve the results  are often  quite  as  satisfactory  as
those obtained by  making  an incision down to the
nerve before endeavoring to stretch it.  The patients
were kept in bed a couple of weeks  and then allowed
to go about. 
CLINICAL SURGERY.
123
             MISCELLANEOUS CASES.

   Case I.   Lipoma of  Back.—Excision and  re-
moval of a large fatty tumor.
   Case II.  Lupus  Vulgaris of Forehead,  about
the size of a  quarter  dollar.—Elliptical  incision;
primary union.
   Case III. Ungual Exostosis.—A large outgrowth
on the distal phalanx of the great toe.  Operation; re-
moval of growth, and the base well leveled down to the
bone and scooped out.  The outgrowth returned sev-
eral months afterwards and the toe was amputated at
the last joint.
   Case IV.  Coccygodynia.—H. P.,female, age 35,
a typical neurasthenic. She had been  subjected to a
number  of  gynaecological operations.   She  com-
plained of a constant pain in  the coccyx, aggravated
by sitting down.  There were  no local  signs of in-
flammation, no evidence of displacement.  The coccyx
was removed and the wound closed without drain-
age.  Primary union.   There was marked  improve-
ment in her condition.
   Case V.   Hypospadias, of the Peno-Scrotal Va-
riety.—Treated by Duplay's method. The first step in
the operation consisted in freeing the penis and divid-
ing the  band which  curves  the organ  downwards.
After healing from this operation the  glans was tun-
nelled, and a new urethra was formed.  Improved.
   Psoas Abscess.—Seven cases. Incision and drain- 
124
A SYNOPSIS OF
age.   One of these cases was bi-lateral, and drainage
at each side was effected by trephining through the
ilium.
   Lumbar Abscess.—Seven cases.    Incision  and
drainage.
   Cellulitis of Foot and Leg.—Twelve cases.
   Cystitis.—There  were  thirteen  patients  treated
for  chronic cystitis.   The treatment  consisted in
overcoming the mechanical interference, with  com-
plete  evacuation of the bladder, by  a  mechanical
treatment or operation as the nature  of the case de-
manded.  The  tenesmus was treated  by injections of
nitrate of silver to the prostato-vesical region.   The
solution was repeated every second  or third  day, at
first very dilute, and its strength gradually increased
to ten per  cent.  The  bladder was irrigated  with
warm antiseptic solutions.   Of these the most fre-
quently used was nitrate of silver, five to ten grains
to the ounce.   An attempt  was made to render the
urine sterile by the use of salol and boric acid per os.
Counter irritation and the judicious use of salines
were also found of use, and the patients were put on
milk  diet.   Large  improvement  invariably  took
place.
   Pott's  Disease of the  Spine.—Six cases.  Each
treated by  the suspension of the patient and a plas-
ter jacket applied.
   Wounds.—A great number of  wounds (113) were
successfully treated in accordance with modern meth-
ods.
   Removal of Superfluous Hair   by Electrolosis;
five cases. 
CLINICAL SURGERY.
125
         FRACTURES AND DISLOCATIONS.
                   (a) FRACTURES.
   In the following cases of fractures, no case of non-
union has occurred.  In every case the patient has
recovered without appreciable deformity  and with
perfect restoration of function, with the exception of
an intra-capsular fracture, and a fracture of the twelfth
dorsal vertebra.   The seat of fracture and  the dress-
ings were as follows:
   Acromion Process; one case.   Velpeau bandage.
   Clavicle; twelve  cases.  A Velpeau bandage was
applied to five of the cases;  Sayre's apparatus to three
of the cases, and  S. W. Smith's apparatus to four of
the  cases.  At  the end of three or four weeks the
bones were firmly united and in good position.
   Femur; eleven cases.   Three of these were intra-
capsular.  Extension was made by means of a stirrup
to which was attached a cord  passing through a pul-
ley  placed at the foot of  the bed and bearing  the
weight at the other extremity.  The adhesive straps
forming the stirrup were carried up as far as the upper
end  of the lower  fragment, and applied to the limb
by a roller bandage.   Lateral support was obtained
by  means of a  long side splint, reaching to  the
axilla.   A roller  bandage was then applied to  the
limb and long side splint.  The  amount  of weight
employed  depended upon the degree  of shorten-
ing,   beginning  with  a  moderate  weight.   The
limb was measured  from  day to  day, and  weight 
12(5
A. SYNOPSIS OF
gradually added to the extension, till  the  shorten-
ing was  overcome.  The patients were  treated  on a
hard mattress with the foot of the bed elevated.   In
no case was the shortening after recovery greater than
three-quarters of an inch.
   The intra-capsular fractures were treated  by the
application  of  a  plaster paris spika  extending from
the toes.   The results were all that could be desired.
   Fibula;  nine cases.   Limb was fixed in a fracture
box in four cases, and in five cases in plaster paris.
   Humerus;  eight cases.   Dressed  on  internal
right angle splints.
   Maxilla {inferior); six cases.
   Maxilla (Superior); three cases.   There was no
displacement, consequently no dressing required.
   Patella; three cases.  Agnew's  splint was applied.
   Radius and Ulna; five cases.  Anterior and  pos-
terior co-aptation splints, the hand being held  in  the
semi-prone position.
   Radius  (Colles); eight  cases.  Anteroposterior
co-aptation straight splints were  applied, extending
from  the elbow joint to the middle  of the carpus.
Results were satisfactory in all cases.
   Tibia; four cases.    The limb was fixed for  the
first  few  days in a fracture box, and then placed in
plaster paris.
   Tibia and Fibula; ten cases.   When possible, ex-
tension was applied and the limb  fixed in a  fracture
box.
   Ribs; twelve cases.   The affected side was  immo-
bilized by broad bandages.
   Vertebra (Twelfth Dorsal): one  case.   The  pa-
tient was paraplegic. 
CLINICAL SURGERY.             127
                  (5) DISLOCATIONS.
   Dislocation of the Shoulder; six; four subglenoid,
and two subcoracoid, were reduced under ether.  The
cases were  recent  and reduction was accomplished
without difficulty.
   Dislocation of the Scapula;  caused by direct vio-
lence to  the shoulder.   In  this  case  the aromion
process of the scapula was forced beneath the  clav-
icle.   The treatment consisted in drawing  the elbow
well  backwards and applying a pad over the  clavicle,
the pad and elbow being fixed in  position by means
of a  bandage passed over the clavicle and around the
elbow.
   Dislocation of  the Hi}); seven cases were reduced
under ether.  These cases were all recent and reduc-
tion  by manipulation was accomplished without  diffi-
culty.
   Dislocation of  the Knee; one case.    This con-
sisted of dislocation of the  head of the tibia back-
ward.   Dislocation was complete, the crucial  liga-
ments were torn and  the parts about the joint  suf-
fered extensive injury from  laceration.   Reduction
was  accomplished  with the application of extending
force. 
128
A SYNOPSIS OF
                  AMPUTATIONS.
   The following 104 cases of amputations have been
recorded just as they occurred, either for injury or
disease, and the salient features of each are given in
a tabulated form below.  The flaps were made as  fol-
lows:
   For the leg,  Sedillot's method,  or the circular
method with periosteal reflection (Bryant, J. D.); for
the knee, Stephen Smith's lateral flap method; for the
thigh, antero-posterior, modified circular and musculo-
cutaneous flaps; for the hip, Wyeth's bloodless method;
for the  fore-arm, antero-posterior musculo-cutaneous
flaps, made from without inward; for the arm, modi-
fied circular flaps;  for the elbow, circular method; for
the shoulder, circular method; for the foot, Lisfranc's,
Chopart's and Syme's amputation.
   In  several  cases  in which amputation was per-
formed for  injury, it was impossible  to  secure  the
usual flaps  on account of the destruction of the integ-
ument.  In these cases it was necessary to modify the
plan, using  what tissue was available.  The vessels
were tied high above any perforating branch, and  the
nerves pulled down and cut off high  up.   In no case
was  there secondary  hemorrhage.  Strands of ster-
ilized cat-gut or fenestrated rubber tubing were used
for drainage, which  were  generally  removed  at  the
end of 48 hours.   Healing was usually complete at
the end of two or three weeks.  In those cases where
healing was by granulation the cicatrix together with
a V-shaped  piece was taken out, and if necessary  the
end of  the bone removed.   Primary  union following
in each case. 
NO.	SEX.	AGE.	C'.U'SE.	PART AMPUTATED.	ULTIMATE RESULTS AND BEMABKS.
1.	M.	19.	Co. com. fracture of foot-Railroad accident.	Lower one-third of leg. Cir-cular method with periosteal reflection, and oblique coapt-ation of the flaps. (Bryant, J. D.)	Recovered Symmetrically tapering, and exceptionally serviceable stump. Artifi-cial appliance worn.
2.	M.	75.	Epithelioma of foot.	(1) Ankle joint. Syme's amputation. (2) Amputa-tion at the knee joint. Lat-ualfl-vp method. (Stephen Smith's operation.)	(1) The growth returned in less than two month's time, and the leg was (2) amputat-ed at the knee. Primary union followed, and he left the hospital. The disease re-turned, and he died in three months from date of second operation from exhaustion.
3.	M	45. Necrosis of stump. 1		Middle of leg. S<5diUot's method.	Primary union. _ Serviceable stamp. Artificial appliance worn.
4.	M.	40.	Co. com. fracture of leg. Foot and leg crus-hed in a mine.	Middle of leg. Circular method with periosteal re-flection. (Bryant, J. D.)	Drainage. Primary union. Serviceable stump. Artifi-cial appliance worn.
5.	M.	6.	Co. com. gunshot fracture of femur.	Hip joint. Wjeth's blood-less method.	Died two hours later from shock.
 
35.
29.
Co. com. fracture  of tibia
et  fibula.    Foot  and leg
crushed by large boulder.
Gangrene following  frost-
bite of feet.
Co. com.  fracture  tibia et
fibula.  Run over by cars.
Extensive necrosis  of hu-
merus following injury.
Co. fracture of ankle-joint.
A  steel rail falling on the
ankle.
PART AMPr/TATED
Knee  joint.   Lateral  flap
method.   (Stephen Smith.)
Amputation  at  left  knee.
Lateral  flaps.    (Stephen
Smith).
Right leg at middle portion.
Circular method with reflec-
tion of periosteum. (Bryant,
J. D.)
Upper one-third leg. Double
antero-posterior flap method.
Shoulder joint. Amputation
by  circular  incision  at a
point corresponding to  the
insertion  of  deltoid, and a
longitudinal  incision  from
the anterior  border of  the
acromion process the whole
length of the stump.
Lower one-third of leg.  Cir-
cular method.with periosteal
reflection.  (Bryant, J. D. )
ULTIMATE RESULTS AND
       REMARKS.
Primary union.
Die1 24 days after operation,
from exhaustion. Left hem-
iplegia.  Bed  sores.  Flaps
sloughed.
Primary union.
o
Primary union.   A  stump
with  a marked  degree  of
firmness.
Primary union. 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
11.	M.	50.	Tubercular arthritis of ankle-joint.	Middle of leg. S6diUot's method.	Primary union.
12.	M.	29.	Tuberculosis of shoulder-joint.	Amputation at _ shoulder-joint by circular incision.	The scapula and clavicle were involved in the disease, which were removed after recovery from the amputa-tion at the shoulder. The wounds healed slowly,and ne was discharged from the hos-pital improved. He died 2V2 years later from general tu-berculosis.
13.	M.	19.	Tuberculosis of knee joint.	Middle of thigh. Circular integumentary flap method.	Primary union except at point of drainage.
11.	M.	21.	Gunshot fracture lower ex-tremity of femur.	Middle of thigh. Circular integumentary flap method.	Primary union.
15.	M.	35.	Co. fracture of ankle joint. Wheel passed over ankle.	Middle of leg. Double an-tero-posterior flap method.	Flaps sloughed. Secondary union. Re-amputation and removal of adherent cicatrix.
10.	M.	42.	Co. com. fracture of hand and fore-arm. Caught in machinery.	Middle of fore-arm. Antero-posterior musculo-cutane-ous flaps.	Primary union.
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
17.	M.	25.	Extensive necrosis of femur foUowing injury.	Upper one-third of thigh. Modified circular operation.	Drainage. Primary union.
18.	M.	19.	Necrosis of tibia.	Middle one-third leg. Cir-cular flap method with peri-osteal reflection (Bryant, J. D.)	Primary union.
19.	M.	17.	Extensive necrosis of femur. Tubercular.	Hip joint. Wyeth's blood-less method.	Suppuration and subsequent curetting of acetabulum. The disease had been in pro-gress many years. Recovery slow.
20.	M.	35.	Osteo-tuberculosis of lower extremity of tibia and ankle.	Middle one-third of leg. Circular method with perios-teal reflection (Bryant, J. D.)	Primary union. Artificial appliance worn.
21.	M.	55.	Co. com. fracture of elbow joint. Railroad accident.	Lower one-third of arm. Circular-flap method.	Primary union.
22.	M.	50.	Co. dislocation of ankle joint. Fell 40 ft. down shaft of mine.	Lower one-third of leg. Circular method with perios-teal reflection. (Bryant, J .D )	Primary union. Good serv-icable stump. Artificial ap-pliance worn.
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
23.	M.	29.	Co. fracture of leg. Caved on in a mine.	Middle of leg. S6dillot's method	Primary union. Serviceable stump.
24.	M.	21. 65.	Tubercular elbow joint.	Lower one-third of arm. Cir-cular flap method.	Primary union. The usual methods prior to operation had been tried with no avail.
25.	M.		Spontaneous fractureof tibia following infiltration of that bone from a long in-dolent ulceration which had undergone a malignant change.	Knee joint. Lateral flap method (Stephen Smith's.)	Improved.
26.	M.	30.	Necrosis of carpus. Tuber-cular.	Lower one-third of fore-arm. Antero-posterior musculo-cutaneous flaps.	Primary union.
27.	M.	37.	Co. fracture of leg. Rail-road injury.	Middle of leg. Sedillot's method.	Not seen till twelve days after injury, when suppura-tion had set in. The flaps sloughed and re-amputation was performed, followed by primary union.
28.	M.	34.	Hand torn from fore-arm and co. fracture of fore-arm. Injured in blasting.	Middle of arm. Double an-tero-posterior flaps.	The tissues were greatly con-tused and lacerated. Prim-ary union.
 
NO	SEX.	AGE.	1 CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
29.	M. M.	38. 38.	Sarcoma of lower end of femur.	Middle of thigh. Circular integumentary flap method.	Primary union.
30.			Caries of carpus. Tuber-cular.	Lower one-third of fore-arm. Antero-posterior musculo-cutaneous flaps.	Primary union.
31.	M.	29.	Co. com. fracture of ankle. Railroad injury.	Lower one-third of Leg. Cir-cular method with perios-teal reflection. (Bryant.J.D.)	Primary union.
32.	31.	38.	Com. gunshot fracture of femur. Calibre, 45.	Upper one-third of thigh. Circular integumentary flaps.	Primary union.
33.	31.	42.	Long indolent ulcer of leg, foUowing scald.	Middle of leg. Circular method with periosteal re-flection. (Bryant, J. D.)	Primary union.
34.	M.	40. 17.	Co. com. fracture of ankle. Foot and ankle crushed by a large boulder.	Lower one-third of leg. Cir-cular method with periosteal reflection. (Bryant)	Primary union. Artificial limb worn.
35.	M.		Extensive necrosis of femur and hip. Tubercular.	Hip joint. Dieffenbach's cir-cular method.	No primary union. Wound healed by granulation.
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
36.	M.	40.	Co. com. fracture of foot and ankle. Crushed in rail-road accident.	Lower one-third of leg. Cir-cular method.	Primary union.
37.	M.	52.	Co. com. fracture of arm and fore-arm. Railroad injury.	Middle of arm. Circular flap.	Primary union.
38.	F.	14.	Extensive necrosis of femur, following injury.	Upper one-third of thigh. Circular integumentary flap.	Primary union.
39.	M.	22.	Co. fracture of elbow. FeU 20 feet from a scaffold.	Elbow joint. Circular method.	Primary union.
40.	M	16.	Co. fracture of leg. Kick of a horse.	Middle of leg. S6dillot's.	Primary union.
41.	M.	26.	Crush of foot. Electric car passed over foot.	Lower one-third of leg. Cir-cular method with periosteal reflection. (Bryant, J.D. I	Primary union.
42.	F.	27.	Periosteal sarcoma of tibia.	Lower one-third of thigh. Circular integumentary flap.	Primary union.
43.	M.	23.	Frost-bite of foot.	Lisfranc's operation. i Primary union.	
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
44.	M.	40.	Frost-bite of foot.	Chopart's amputation.	Died. Septic infection.
45.	M.	43.	Co. fracture arm and fore-arm. Fell thirty feet in shaft of mine.	Upper one-third of arm. Circular flap.	Primary union.
46.	M.	25.	Co. fracture tibia, followed by extensive necrosis.	U pper one-third of leg. Sed-illot's method.	Primary union.
47.	F.	13.	Tuberculosis, knee joint.	Upper one-third thigh. Cir-cular integumentary flap.	No primary union. Wound healed by granulation.
48.	F.	18.	Tuberculosis, knee joint.	Upper one-third of thigh. Circular integumentary flap.	Primary union. Excision of the joint had been per-formed.
49.	M.	25.	Com. gunshot fracture, tibia.	Knee joint. Lateral flap method. (Stephen Smith.)	Primary union.
50.	M.	30.	Hand blown from fore-arm in explosion.	Lower one-third fore-arm. Circular amputation.	Primary union.
51.	M.	45. |	Co. fracture elbow joint. Railroad accident.	Lower one-third arm. Cir-cular flap.	Primary union.
 
NO.	SEX.	AGE. CAUSE. 1		PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
52.	M.	50.	Crush of right leg by falling between the cars.	Lower one-third thigh. Cir-cular integumentary flap.	Died eight hours after opera-tion from shock.
53. 54.	M.	10.	Tuberculosis of hip.	Hip joint. Dieffenbach's circular method.	Healed by granulation.
	M. 31.	48.	Gangrene, fore-arm and hand.	Upper one-third fore-arm. Circular method.	Healed by granulation.
55.		10.	Necrosis of humerus. Tuber-cular .	Shoulder joint. Amputation by circular incision.	Healed by granulation.
56.	M.	20.	Com gunshot fracture elbow joint.	Upper one-third arm. Un-equal donble-flap method.	Primary union.
57.	M.	43.	Extensive necrosis femur. Spontaneous fracture.	Hip joint Wyeth's blood-less method.	Died ten hours after opera-tion from shock.
58.	M.	21.	Gangrene of leg.	Middle of thigh. Circular integumentary flap.	Primary union.
59.	31.	19.	Co. com. fracture leg and thigh. Railroad accident.	Middle of thigh. Circular flap.	Died twenty hours after op-eration from shock.
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
60.	31.	17.	Co fracture foot. Crushed in mine.	Lower one-third leg. Circu-lar method with periosteal reflection. (Bryant, J. D.)	Primary union.
61.	31.	30.	Co. com. fracture tibia et fibula. Run over by wagon.	Middle of leg. S6dillot's method.	Primary union.
62.	31	43.	Necrosis of stump. Re-am-putation .	Lower one third of leg. Cir cular method.	Primary union.
63.	M.	24.	Comp. com. fracture of hu-merus, and comp. com. fract-ure tibia et fibula. Fell be-tween the cars.	Upper one-third of arm, cir-cular method. Knee joint, lateral flaps,(Stephen Smith).	Died three hours after oper-ation. Shock
64.	M.	25.	Co. com. fracture leg. Leg crushed in stone quarry.	Lower one-third thigh. An-tero-posterior musculo-in-tegumentary flaps.	Primary union.
65.	M.	32.	Extensive necrosis of tibia et fibula.	Lower one-third of thigh. t ircular integumentary flaps.	Primary union.
66.	M.	22.	Gangrene of foot. Frost-bite.	Lower one-third of leg. Cir-cular method. (Bryant, J.D.)	1 Primary union.
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
67.	M.	28.	Re-amputation. Railroad injury.	Lower one-third of thigh. Circular integumentary flaps.	Primary union.
68.	M.	22.	Gangrene of leg.	Knee joint. Lateral flaps, (Stephen Smith.)	Primary union.
69.	M.	25.	Co. com. fracture of foot, Crushed in a mine.	Lower one-third of leg. Ci r-cular method. (Bryant, J.D.)	Primary union.
70.	M.	42.	Co. com. fracture of foot. Caught between drawheads of cars.	Lower one-third of leg. Cir-cular method.	Primary union.
71.	M.	19.	Co. com. fracture of toes. Crushed by heavy steel rail.	Lisfranc's.	Primary union.
72.	M.	32.	Com. gunshot fracture of leg.	Middle one-third of leg, Circular method.	Primary union.
73.	M.	45.	Tuberculosis of shoulder.	Shoulder joint. Amputation by circular incision.	Healed by granulation.
74.	F.	20.	Tuberculosis of ankle joint.	Lower one-third of leg. Cir-cular method. (Bryant, J.D.)	Primary union.
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
75.	M.	38.	Necrosis of shoulder,foRow-ing injury and suppuration.	Shoulder joint. Amputation by circular incision.	Recovered from the opera-tion but died three weeks later from prolonged sup-puration.
76.	M.	38.	Co. com. fracture of tibia, involving knee joint. Gun-shot wound.	Lower one-third of thigh. Circular integumentary flaps.	Died 17 hours later from shock.
77.	U	29.	Gangrene of the leg. Endar-teritis.	Middle of thigh. Antero-posterior musculo - cutane-ous flaps.	Healed by granulation.
78.	31.	38.	Co. com. fracture of elbow. FeU 90 feet down a shoot.	Lower one-third of arm. Cir-cular method.	Greatly mangled and con-tused. Hemorrhage had been excessive. Died six hours after operation.
79.	M.	42.	Frost-bite of foot.	Chopart's amputation.	Primary union.
80.	31.	40.	Extensive necrosis of femur.	Upper one-third of thigh. Circular method.	Healed by granulation.
81.	M.	17.	Co. com. fracture of femur.	Upper one-third of thigh. Circular method.	The thigh had been suppur-ating for two or three weeks prior to amputation. Healed by granulation
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
82.	M.	50.	Both hands blown off in ex-plosion, and both eyes blown out.	Hands, lower part of fore-arms; eneucleation of both eyes.	Recovered from operation, wounds healing by granula-tion. Died three months after leaving hospital.
83.	F.	13.	Extensive necrosis of tibia.	Lower one-third of thigh. Circular integumentary flaps.	Primary union.
84.	M.	20.	Gunshot wound of leg. Gan-grene	Lower one-third of thigh. Circular integumentary flaps.	Died from tetanus on tenth day.
85.	M.	28.	Painful stump. Adherent cicatrix. Neuromata.	Upper one - third of leg. Sedillot's method.	Primary union.
86.	M.	13.	Gunshot wound of knee.	Lower one-third of thigh. Antero-posterior musculo-integumentary flaps.	Died two days later from shock.
87.	M.	52.	Both hands blown off, and both eyes blown out. Pre-mature explosion.	Lower one-third of fore-arms. (1) circular method. (2) Anterio-posterior mus-culo-cutaneous flaps. Eneucleation of both eyes.	Recovered. Healing by gran-ulation .
88.	F.	18.	Tuberculosis of ankle joint.	Lower one-third of leg. Cir-cularmethod. (Bryant, J.D.)	Primary union.
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
89.	M.	24.	Anchylosis of knee joint at right angle. Result of injury.	Lower one-third of thigh. Circular integumentary flap.	Primary union. Artificial appliance.
90.	M.	17.	Re-amputation for painful stump.	Lower one-third of leg. Cir-cular method. (Bryant, J.D.)	Primary union.
91.	M.	16.	Com. gunshot fracture of femur.	Upper one-third of thigh. Antero - posterior musculo-integumentary flaps.	Died nine hours later from shock.
92.	M.	42.	Extensive necrosis of femur.	Hip joint. Wyeth's blood-less method.	Healed by granulation.
93.	M.	39.	Sarcoma of fibula.	Knee joint. Lateral flap method. (Stephen Smith.) Lower one-third of leg. Cir-cularmethod. (Bryant, J.D.)	Primary union.
94.	M.	20.	Co. com. fracture of ankle, Run over by cars in mine.		Primary union.
95.	M.	69.	Co. com. fracture of tibia et fibula. Kicked by a horse.	Middle of leg. Circular method. (Bryant, J.D)	Healed by granulation. Sub-sequent re-amputation,prim-ary union.
96.	M.	22.	Co. com. fracture of tibia et fibula. Fell under electric car.	Lower one-third of leg. Cir-cular method. (Bryant, J.D.)	Primary union.
 
NO.	SEX.	AGE.	CAUSE.	PART AMPUTATED.	ULTIMATE RESULTS AND REMARKS.
97.	31.	21.	Tuberculosis, knee joint.	Middle of thigh. Circular integumentary flap method.	Healed by granulation. Sub-sequent removal of wedge-shaped piece from cicatrix.
98.	31.	28.	Co. com. fracture of hum-erus. Railroad accident.	Shoulder joint. Circular in-cision.	Healed by granulation.
99.	31	21.	Gunshot fracture of elbow joint.	Lower one-third of arm. Circular method.	Primary union.
100.	31.	30.	Frost-bite of foot.	Lisfranc's operation.	Primary union.
101.	F.	26.	Co. com. fracture fore-arm. Thrown from runaway team.	Upper one-third of arm. Circular method.	Healed by granulation. Sub-sequent re-amputation,prim-ary union.
102.	31. 25. i		Tuberculosis of ankle.	Lower one-third of leg. Cir-cular method. (Bryant, J.D.)	Primary union.
103.	M.	31.	Frost-bite of foot.	Chopart's amputation.	Primary union.
104.	M.	9.	Tuberculosis, knee joint.	Middle of thigh. Circular integumentary flap.	Primary union.
 
144
A SYNOPSIS OF
   The 104 amputations performed were distributed
as follows:
   Fore-Arm, 7.—Three  for explosion, in two both
hands were blown off, making two  double operations,
two for tubercular caries of carpus,  one crushed by
machinery, and one for gangrene following frost-bite.
   Arm, 10.—Four for railroad injuries, two for gun-
shot wounds, one for tubercular arthritis, three for
accidents.
   Elbow,  1.—Accident.
   Shoulder  Joint,  6.—Two for  accident,  two  for
tubercular  arthritis, two for  extensive necrosis  of
humerus.
   Hip, 6.—Two for tubercular arthritis,  three  for
extensive necrosis of  femur, one for gunshot wound.
   Thigh, 26.—Two for sarcoma,  five for tubercular
arthritis, six for gunshot  wound, two  for gangrene,
five for extensive necrosis, and six for accident.
   Knee, 6.—Two for  epithelioma of  foot, one  for
sarcoma of  fibula, one for accident, and two for gan-
grene, one of which was a double operation.
   Leg, 35.—Four  for  necrosis,  one  for  gunshot
wound, one for frost-bite, two for painful stump, five
for tubercular arthritis and twenty-two  for accident.
   Lisfranc's, 3.—For frost-bite.
   Choparts, 3.—Two  for  frost-bite   and  one  for
crush.
   Syme's,  1.—For crush.
   There were  ten  deaths, or  a mortality of 9.6 per
cent.   One died from septic infection following gan-
grene of feet as the result of frost-bite; two died from
shock  after amputation  at hip  joint, one was a boy
six  years old, result of a gunshot wound of femur 
CLINICAL SURGERY.
145
and  the  other for  extensive necrosis of the femur,
in which symptoms  of septic infection were very
pronounced,  and the  patient  in  extremis.   Five
following amputation  of the thigh, four of  which
were from shock following  severe  injuries, and one
died from tetanus on the tenth day.
   One from shock following a severe crush between
the cars, in which a double amputation was performed
at the knee, and upper one-third of the arm.
   One died  from exhaustion following amputation
at left knee and right leg for gangrene resulting from
frost-bite.  Left hemiplegia. 
 
A  SYNOPSIS      /»
                    3. Q. O.
OF
CLINICAL  SURGERY
       •  DURING THE SERVICE OF

 SAMUEL H. PINKERTON, M. D,
    Surgeon to the Holy Cross Hospital,
by
FRANKLIN A. MEACHAM, A. B., M. D.,
   ASSISTANT SURGEON TO THE HOLY
       CROSS HOSPITAL,


SALT LAKE  CITY, UTAH,


      For the Year 1892.    ^___






      SALT LAKE CITY :      llxl^"i
   Tribune Job Printing Company.
          1893. 
«"v*. %A Jt. 'v, 
£
5

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