mm* JH;r----":Vi-J-;",.-:!!.:'/. I'-«vV'3.2^1W.m,!« "V. . .1.-: Kiife';'.;:.- .1 :.*■'■*, •^I^.^jrvi'; ...■:■; •■■;• ^•#^',r-■•.,■• •■ ■..-■■■! *•>***?.*?■■•: •: ■'.■■•■■ ■ ■...' jm%..'^-.,- . ■■ ':".■'■ ■' ::.;.;;;»r;.t; ■'••'•::.r^;:' i'/;-»;T'l.'::' v ^ k v — y \ ^ —■ j NLM005547434 \,^ / CL^t$c\W6zi Clinical Lectures ON ABDOMINAL SURGERY AND OTHER SUBJECTS, BY CHARLES T. PAI of opium in a little warm water. It is, however, better to secure an evacuation of the bowels or the passage of gas before usino an opiate. Local Treatment. Should adhesive straps be applied to the abdomen after the stitches are removed? If the abdominal walls are loose and flabby and hence no tension upon the wound, their use may be dispensed with; if there is any likelihood of unusual tension upon the wound they should be used; in any case they are a source of additional safety and comfort. In fact it is my belief that some support should be given to the abdominal walls by this means or the use of bandages, for a month or more after the operation, especially if the patient is to travel any distance after leaving the surgeon's care. An accident from the lack of this precaution happened to a patient of mine. A very fat woman was operated upon for a large ovarian tumor. The case was normal and satisfactory in every way after the operation. Before the end of the third week she was compelled to go to her home in Nebraska; the wound seemed to be healed entirely. I received a letter from her doc- tor about a week after her departure, saying that the wound had opened from one end to the other through the skin and fat; while going from the depot to her home, five miles away, in a wagon, the severe jolting led to the occurrence of this accident. Strapping in that case would probably have avoided it. A serious complication sometimes arises from infection of the deep portion of the wound, even after the complete healing of its superficial edges. This is the formation of abscesses between the peritoneum and the abdominal walls, in the line of the wound; this condition should be recognized early and receive prompt and vigorous treatment. Their presence is indicated by hardening of the tissues in the rectus muscle on each side of the wound, by tenderness to the touch, and by nightly rise of tem- perature. The use of the hypodermic needle, to locate early the formation of pus, is suggested. If pus is found, the abscess should be freely opened, emptied and made aseptic. Irritation of the wound from this source, or that of stitch-hole abscesses, is allayed by the use of wet dressings, consisting of sterilized gauze moistened with a two per cent, solution of carbolic acid, and covered by an impervious dressing. 30 ABDOMINAL TUMORS. Tympanitis, occurring after the operation, is a very serious and troublesome complication and its presence almost invariably implies septic infection; it is difficult to relieve by treatment. If free catharsis can be obtained, it usually passes away. The use of the rectal tube relieves distention of the large intestine, and should be practiced. In extreme distention, with other efforts at relief failing, repeated puncture of the intestine through the abdominal walls, with a hypodermic needle, is recommended, and its practice has been followed by relief. Prolonged anaesthesia, from any agent used, is occasionally fol- lowed by persistent and troublesome vomiting; if this complica- tion follows the operation, the stomach should be kept entirely empty for 24 hours, or during its continuance. It is sometimes benefited by the use of ice pellets, or small quantities of very hot water, or hypodermic injections of morphia. Of course, after a severe operation, the patient should be kept perfectly quiet in bed; this does not mean absolute confinement to one position. Many patients are so desirous of assisting in every way towards recovery, that they will move scarcely a fin- ger, fearing harm as the result. The irksomeness and harmful- ness of one position should be avoided, by allowing the patient to change her position from time to time, or instructing the nurse to make such change. There is no "little thing" which can result in more harm, than an over anxious nurse to be constantly instructing her patient "not to move" or "not to stir," for fear harm would result from the patient's attempt to comfort herself by change in her position. There is no doubt in my mind that the patient should remain in bed for at least three weeks, to allow perfect union of the wound and safe repair in the pedicle; the larger the pedicle the greater the length of time that should be given for the heal- ing process. Ventral hernia would be less frequent in occurrence, if patients were kept in bed longer; besides, there are on record many cases which have passed through extreme danger from leaving the bed too early; even death has resulted from such haste. No doubt many cases of debility, pain in the pelvis, and other complica- tions arise from such cause. ABDOMINAL TUMORS. 31 Special Tumors—Ovarian, Par-Ovarian, Dermoid. Special management of these, or for that matter, any abdomi- nal tumor, is greatly influenced by the size of the growth. In this specimen is shown a small, multiple cyst of the right ovary, not larger than one's fist, the removal of which was attended with far greater difficulty and anxiety, and required a much longer incision, than the removal of this very large ovarian cyst containing 30 pints of fluid. The smaller one was fixed in the pelvis directly behind the uterus, was hard and non-fluctuating, and possessing many of the characteristics of a fibroid growth of the uterus; in fact there was much doubt as to its character from pelvic examination. The pain which the patient suffered was intense, and I determined to operate for its removal. The abominal section disclosed the pelvis filled with intes- tines, and they could not be gotten out of the way and the tumor removed, until the external incision had been prolonged to the umbilicus. The patient recovered. This larger tumor was uncovered by a three-inch incision, tapped, emptied and removed through this incision, no adhesion being present, and the intes- tines were not seen or touched during the operation. If there were a choice, my preference would be to attack large tumors, as being most easily managed. Dermoid cysts are apt to present a great number of difficulties in their removal, because of their sessile attachments, thin walls easily ruptured, deleterious contents and extensive adhesions. Adhesions should never be detached when the)' are out of sight, if it can possibly be avoided. After emptying the cyst, all adhesions should be brought under the inspection of the eye and the control of the fingers, before being divided. In my experience, the adhesions of an ovarian cyst, after it is emptied, can be safely managed in this way, no matter what may be their extent nor to what organ they may be attached. The length of the incision in the abdominal walls is of no conse- quence in comparison with the dangers attending the separation of adhesions through a short opening, without direct inspection and control. It is to be remembered, that in some cases the ante- rior surface of the ovarian cyst is so intimately adherent to the abdominal walls that no point of separation between them can be found. In such cases the sac should be emptied by a free incis- ion through its anterior walls, and as the posterior wall of the cyst is usually free from adhesions, this can be seized with the 32 A BD OML \ 'A L TUMORS. fingers, introduced through the anterior opening, and turned inside out, in this way peeling the sac off from behind forwards, safely and readily. Occasionally cases are met with so universally adherent in all directions, that the sac cannot be delivered; it should be thor- oughly and completely emptied of all its contents, the edges of the opening in it sewed to the abdominal incision, the cavity packed with iodoform gauze and the usual dressings applied. As the sac contracts, quantities of the gauze packing are taken out from time to time until all is removed. In these cases the sac collapses, heals by contraction and granulation, and recovery ensues, although the repair may be prolonged for many months. The contents of ovarian tumors vary greatly in consistency, color and other characteristics, depending upon the presence or absence of blood or pus. The contents of par-ovarian cysts are usually clear and limpid and easily removed. In the majority of ovarian cysts, single or multilocular, the contents are sufficiently fluid to be emptied through a trocar. The different compartments of the multiloc- ular variety, can usually be emptied through a single puncture of the trocar, by carrying it through the septa separating the different compartments through the cavity first emptied. If this procedure does not reduce the size of the tumor suf- ficiently to allow of its being withdrawn through the abdominal opening, this result can be accomplished in the following man- ner: Withdraw the trocar and make the opening in the cyst large enough to admit the hand into this cavity to break down the septa and remove the contents, all the time keeping the walls of the cyst in contact with the abdominal incision, to prevent debris from falling into the cavity. Ovarian cysts, with colloid contents, are many times difficult to manage, owing to the tenacity of the material filling them and the brittle condition of the cyst wall. If there are no adhe- sions, it is best to prolong the external incision and deliver the mass whole, as in cases of fibroid tumor, without attempting to empty it; if this cannot be done, they must be patiently removed piecemeal, great care being taken in cleaning the peritoneal cavity. Cysts with colloid contents, and papillomatous cysts, are apt to be thin walled and prone to rupture, especially the latter with dissemination of the included material and secretions into the peritoneal cavity. ABDOMINAL TUMORS. 33 The papillomata seldom reach great size, and early form adhe- sion to the walls of organs contained in the pelvis; they soon rupture and distend the abdomen with fluid, simulating closely, in their external manifestations, a case of ordinary ascites. The absence of any discoverable disease of the kidneys, heart or liver, together with the absence of anasarca, local or general, with rapid reaccumulation of the fluid, if tapping is practiced, will arouse suspicion as to the nature of the trouble. Careful examination of the pelvis, per vaginam, will determine the presence of the tumor, even if moderate in size. These tumors, owing to the existence of extensive adhesions many times present great difficulties in their removal, yet they can usually be turned out of their bed by enucleation. If the rupture has existed for some time they are peculiarly apt to inlect the general peritoneum with papilloma, so that many times count- less numbers of nodules of the disease are found scattered over the parietal peritoneum and the special organs of the abdomen and pelvis. Wrhen this condition is present, the patient is sel- dom, if ever permanently relieved by an operation. Sometimes solid tumors of the ovary are met with possessing all the characteristics of fibromata, showing a well defined pedicle and presenting complications in their removal. Fibroid Tumors or Mvomata of The Uterus. There are five methods of dealing with these tumors recog- nized and practiced by surgeons. First, removal of the ovaries and tubes. Second, the intra-abdominal method of removing the uterus cither with or without the formation of a stump. Third, extra-abdominal method, with the stump fixed in the lower end of the external wound, or turned into the vagina. Fourth, myomotomy, or enucleation of the tumor through the abdominal walls without opening the uterine cavity. Fifth, the use of electricity. There are certain general instructions which apply to the first three methods, and others which apply to the intra and extra- abdominal methods only, which are worthy of special considera- tion. In all three, particular attention must be directed to the control of hemorrhage, which will be very profuse primarily if the enlarged blood vessels are accidentally torn or opened, and certain to be fatal secondarily, if the means used for controlling the vessels after division, fail to remain absolutely secure during 34 ABDOMINAL TUMORS. the recovery from the operation. As vessels are in a state of great tension at the time of ligation, the tissues included in the ligature are apt to retract and the ligature slip off; or by diminu- tion in size of the vessel, the pressure of the ligature becomes insufficient, so that especially great care must be used in their application. Never approach the removal of a solid tumor of the uterus without having at hand every known means for the control, temporarily and permanently, of severe bleeding. If the extra or the intra-peritoneal method with a stump, is to be prac- ticed, special apparatus should be in readiness for temporary or permanent application, such as Kceberle's serre-nceud, or the rubber elastic cord. In all cases of removal of the uterus for myoma, the proxim- ity of the ureters to the cervix, in their course to the bladder, and the probability of the bladder being drawn up on the ante- rior surface of the tumor, should be borne in mind; and injury to either of these organs be avoided. In all cases in which the uterine cavity is opened, the espec- ially noxious character of the secretions of its mucous mem- brane, should be remembered; the danger of infection from this cavity is particularly imminent, and is probably the reason why so many of these cases are fatal from septic peritonitis. The instruments used in opening into this cavity should not be used again in the operation, before being specially cleaned; all other procedures in the operation should be stopped until this cavity has been rendered thoroughly aseptic, accomplished by the use of the actual cautery or by other satisfactory means. The removal of the ovaries and tubes for these tumors, is sup- posed to act, by the early establishment of the menopause, par- tially by cutting off some of the blood supply. Many cases seem to be followed by cessation of previously profuse menorrhagia, and gradual disappearance of the tumor. In the hands of Mr. Lawson Tait, this treatment has been eminently satisfactory. Occasionally this simpler operation has been attended with extreme difficulties in its performance, owing to the special adhesions of the ovaries, necessitating great care in the applica- tion of the ligature. All operation commenced with the intention of removing the tumor entire, require a long incision through the abdominal walls, the length depending upon the size of the growth; it always should be sufficient to admit of perfect freedom of manipulations in the pelvis. ABDOMINAL TUMORS. 35 In all such cases, the intestines, even if empty as the result of the previous preparation already mentioned, certainly if dis- tended, from any cause, will bulge into the abdominal incision and fill up the pelvis as soon as the tumor is withdrawn; they should be controlled and kept entirely out of the way by the usual methods already described. Intra-Abdominal Method. In the special technique of the intra-abdominal method with the formation of a stump after the tumor is delivered through the abdominal incision, the first procedure necessary is to exe- cute what is called "tying off" the broad ligaments, and this requires great care, in order to avoid opening any of the large veins and to enable one to apply ligatures to the broad ligament for the permanent closure of all the vessels included in its folds. It is done by seizing the broad ligament as close as possible to the uterus with the thumb and finger of the left hand at a point about half way down its lateral wall. With the right hand a pair of blunt pointed forceps are thrust through the ligaments between the fingers and the uterus and opened laterally; in this way a separation is made close to the uterus without opening any large vessels. Through this opening a needle armed with a long double thread is passed. As soon as it is drawn well through, a suffi- cient length of it is cut off to answer the purpose of tying that portion of the ligament which is left attached to the tumor and towards its top. This ligature is tied as close to the top of the tumor as it can be drawn, and prevents bleeding from the uter- ine side of the broad ligament. The needle is still threaded and lies inside of the outer portion of the ligament. The thread is drawn through the needle far enough to make a second double ligature. The needle is then carried through the remaining outer portion of the broad ligament, at a non-vascular point, and this portion is tied in halves, just as one would tie the pedicle of an ovarian tumor. In this way all the vessels are securely fastened, and as the stump of the broad ligament is bisected by the ligature, it is very secure and little likely to slip. This procedure is repeated in securing the broad ligament on the other side, and now the mass can be lifted out of the pelvis and we are ready to proceed to the next step of the operation 36 . IBDOMINAL TUMORS. which is to permanently close the vessels in the uterus and tumor previous to its separation. This is done by tying around the lower part of the tumor, as close as possible to the vaginal juncture of the cervix, a piece of rubber tubing. The rubber tube is as large as the middle finger, and when in position, should be drawn as tight as your strength will permit, its ends crossed once and secured temporarily at the point of crossing by a Nel- aton forceps or a knot. It is very essential to ascertain the position of the bladder before the rubber tube is fastened, in order to avoid including this viscus in its grasp. If the bladder is drawn upwards on the anterior surface of the tumor, it must be carefully dissected away from the tumor before the rubber is applied. In cutting away the tumor, the incision should be sufficiently far away from the rubber to leave tissue enough outside of it to prevent the rubber from slipping over the end of the stump. As soon as the rubber tube is in position, the tumor is removed by incisions through the uterine tissue anteriorly and posteriorly' in such direction as to leave a stump in the shape of an inverted cone, the apex of the cone being towards the vagina. The cer- vical canal must now be thoroughly disinfected either by the use of the Paqueline cautery or 95 per cent, carbolic acid. The walls of this conical cavity are then sewed tightly together by inter- rupted sutures of catgut, introduced in a series from below upwards. These sutures should include a considerable portion of the uterine tissue, and should be tied very tightly in order to entirely control bleeding from the divided surfaces. The last row should be so placed as to invert the peritoneal covering of the uterine stump, by applying the peritoneal surfaces together throughout the length of the incision in the stump, so shutting off its cavity entirely from the peritoneal cavity. As soon as these sutures are satisfactorily placed, the rubber tube should be removed. There should be no bleeding from the stump after the removal of the tube, if the manipulations have been rightly accomplished. After cleansing the peritoneal cav- ity, the abdominal incision is closed in the usual manner. If no stump is to be left, the procedures are the same as have already been described up to the point of tying off the broad ligaments. Then by separating the folds of the broad ligament the uterine arteries are located and temporarily secured with for- ceps, and subsequently ligated, or permanently secured at once by a catgut ligature, carried beneath them with a curved needle.. ABDOMINAL TUMORS. 37 After the uterine arteries are secured, the peritoneum, cover- ing the anterior surface of the tumor, is incised across this sur- face above the top of the bladder and is pushed off the surface of the cervix as low as the vaginal juncture. A similar incision is made through the peritoneum on the posterior suface of the tumor, and it is peeled off in the same way from this side as low down as the vaginal attachment. These detached folds of peri- toneum being held out of the way, the tumor is removed either by detaching it from the vagina entirely, or by dividing it through the lowest accessible point of the cervix. During these manipulations especial care must be taken to avoid injuring the uterus. To me, the method just described is the ideal operation for the removal of uterine myoma. It disposes entirely of the compli- cations, primary or remote, arising from the formation of a stump, either extra or intra-abdominal; and it certainly dimin- ishes the danger of infection from the uterine cavity, especially if the cervical canal has been curetted and rendered aseptic just previous to the operation. In the extra-abdominal method the stump is fixed in the lower end of the external wound; or, according to the plan practiced by Dr. H. T. Byford, of this city, is turned into the vagina through an opening in the anterior wall of that cavity. Fixing the stump in the external wound requires a long stump and hence a high division of the tumor. The technique of its performance is the same exactly as has already been described in the other methods as far as tying off the broad ligaments After this is accomplished, the rubber tube or cord is applied at the proper height on the tumor, so that when the abdomen is closed the rubber tube will be outside of the abdominal cavity without any tension on the stump. It is now in position and fas- tened so that the uterus can be divided and the tumor removed. In order to prevent the rubber cord from slipping it is proper to introduce a strong pin through the substance of the stump out- side the cord. Cases in which the tumor develops low down and implicates the cervix to such an extent as to prevent apparently the for- mation of a pedicle, can be managed safely in the following ninnner: First. Apply the rubber cord as low down as possible, near the vaginal juncture, to control hemorrhage temporarily. 38 ABDOMINAL TUMORS. Second. Remove the tumor by an incision through its sub- stance, without reference to its size, high enough to make the pedicle sufficiently long. Third. Enucleate from the stump all the separate myomata,, if there be any, or the myomatous tissue that may be found in it. In the plan practiced by Dr. Byford, after division of the tumor, the bladder is dissected off from the stump of the tumor and the anterior wall of the vagina for a sufficient distance, a small opening is made into this wall by the thrust of a pair of scissors; this opening is enlarged to correspond to the size of the stump by tearing the tissues with the fingers; the stump is then turned into the vagina and the opposed edges of the peri- toneal surfaces of the opening closed by the continuous catgut suture, thus leaving a perfectly clean peritoneal cavity. The stump is fixed in the vagina by a pair of forceps introduced through the external opening of this cavity. The operation of Myomotomy or enucleation of the tumor from the uterine walls, is applicable in moderate sized tumors. After the exposure and management of the growth as already described, bleeding is controlled temporarily by the application of the rub- ber cord around the broad ligaments and cervix. The tumor is exposed by a free division through its external investment of uterine tissue; as soon as this incision is made the tumor can be enucleated from its bed with the finger. If the uterine cavity is not opened, the walls of the cavity, left by the removal of the tumor, are brought in close approximation by a successive series of interrupted catgut sutures commenced at the bottom of the cavity. The peritoneal edges of the incision are inverted and closed by a continuous catgut suture; when this is accomplished, the constricting rubber is removed, and if there is no bleeding from the stump following the removal of this cord, the external wound is closed in the usual way. The use of electricity, according to the method advocated by Apostoli has quite a number of advocates and, in the hands of some surgeons, seems to certainly cause the disappearance of the mass. Success for this agent requires a special knowl- edge for its application according to the plans described by Apostoli. Its proper position in the relief of these growths has not as yet been positively determined. The sub-peritoneal fibroid growths with well defined pedicles are quite readily managed by treating the pedicle in the manner already described as perfectly safe in securing the pedicle of an ovarian tumor. ABDOMINAL TUMORS. 39 It is surprising to what an immense size these sub-peritoneal tumors will sometimes develop with a very slender attachment to the uterine wall. This specimen before you, weighing 42 pounds at the time of of its removal, was attached to the uterus by a pedicle of about four inches in width and half an inch in thickness. This other specimen, weighing sixteen pounds at the time of its removal, had a still more slender attachment to the posterior wall of the uterus. In neither case was the body of the uterus distended in any way, and the pedicles were managed in the manner just advised. Both patients recovered. The other specimen before you is a very interesting one; it is an instance of multiple fibroid degeneration of the uterus, which was successfully removed by the extra-abdominal method just described. It is especially interesting, because upon examina- tion you will notice that it is at the same time a pregnant uterus, the foetus having reached about the fifth month of development. The condition of pregnancy in this case was recognized by the attending physician and the condition was readily confirmed by examination after the case came under my care for operation. This large sub-peritoneal fibroid, almost detached from the rest of the tumor, occupied the pelvis and could net be displaced; in fact, it prevented me from determing the location of the cervix by any examination that could be made through the vagina. The operation was necessitated by the extreme suffering and evi- dent exhaustion of the patient. The child could not have been delivered through the natural passage, either before or after coming to full term, even if the condition of the patient had not appealed for immediate interference. Myomata, developed from the uterus, are frequently intra-lig- amentous, pushing their way between the folds of the broad lig- ament and filling the cavity of the pelvis in their growth. Such growths are very troublesome in their management; the ureters are difficult to locate and extremely likely to be injured, as the cervix is usually implicated in these growths. The best plan of removal to be adopted, is complete ablation. In these cases the uterine body is sometimes scarcely changed in size, and when the abdominal incision uncovers the tumor, the uterus is found carried up to the top of the mass. In one such case operated upon, the following plan was executed successfully and with recovery of the patient: The peritoneal covering of the mass was divided from one pelvic margin to the other, across the top of the tumor; the incision was deepened so as to open 40 ABDOMINAL TUMORS. up the cellular tissue bed investing the mass. The fingers and finally the hand were introduced into this loose tissue, from which the tumor was rapidly enucleated, turned out and severed from the cervix close to the vaginal juncture. The divided uter- ine and ovarian arteries were secured with forceps and subse- quently ligated; the edges of the investing peritoneum, after removing the tumor, were approximated easily and sewed together across the pelvis with a continuous catgut suture, leav- ing a perfectly clear peritoneal cavity. The recovery was with- out drawback. There was a special condition present in this case to which my attention had never been called previously. The tumor in its development so completely filled the pelvis and reached down- wards so far as to cause bulging of the perineum; it approxi- mated the walls of the vagina so perfectly that that channel was practically closed; the function was so disturbed that the patient could not urinate voluntarily, and just before the operation it was with the greatest difficulty that a catheter could be passed into the bladder. It is scarcely necessary that any special review shall be made of the technique of the operation called Oophorectomy, as the gen- eral directions already given must be carried out in any case in which the operation is supposed to be necessary for the relief of the patient. With non-adherent ovaries the operation presents no compli- cations in its performance and can be rapidly executed through a small abdominal incision and without an)- interference with, or exposure of the intestines. With displaced ovaries, bound down by adhesions, it may become an extremely hazardous and diffi- cult operation, requiring much patience and skill to carry it to a successful issue. Elevation of the uterus by means of pressure through the vagina, will sometimes render the necessary manipulations more easy of execution; adhesions are separated and managed in the manner already described, and the ligatures applied with the usual care. If the ovaries are removed at all, it is well to include as «reat a length as possible of the P'allopian tubes outside of the lio-ature. Operations upon the gall bladder are usually necessary for the relief of billiary colic caused by the passage of gall stones or for the removal of these concretions, which have caused an obstruc- tion of the ductus communis choledochus. ABDOMINAL TUMORS. 41 Two operations are commonly practiced: First. Cliolecystotomy, which is practically the formation of a temporary billiary fistula and the removal of the concretions from the gall bladder or the gall ducts, or the exposure of the gall bladder, opening into its cavity, removal of all gall stones and immediate closure of the wound in the viscus. Second. Cholecystectomy, or the removal of the entire viscus with its contents, forming a pedicle out of the cystic duct. Special means should be at hand, in both operations, to keep the intestines away from the field of operation and to prevent leakage into the peritoneal cavity, of the contents of the gall bladder. Attach strong silk threads to six small sea sponges to be used for this purpose by packing them around the gall blad- der when exposed; the strings are for the purpose of keeping control of the sponges after their introduction and to provide for their removal. There should be at hand and ready for use, an aspirator with which to withdraw the fluid accumulations found in the gall bladder. The best incision for the exposure of the gall bladder is the vertical one, carried from the margin of the costal cartilage on the right side directly over the center of the tumor, if a tumor be present. If no tumor be present, the incision should be made directly downwards from the tip of the ninth rib, and should be at least four inches in length; it should be carried for the same length by a free use of the knife, through all the tissues of the abdomen until the peritoneum is exposed at the bottom of the wound; all bleeding vessels should be secured in the usual man- ner before this membrane is opened, then the peritoneum is picked up between dissecting forceps, opened and incised to the same length as the abdominal opening. The small sponges should now be packed around the exposed gall bladder, pushing the intestines well out of the way, and so placed as to catch any leakage from the gall bladder after it is opened. Cases of retained gall stones which have existed for a longtime and have caused a good deal of distress with disease and distention of the gall bladder, are apt to have pus mingled with the contents from infection, hence these contents are quite sure to be deleterious and should be prevented from entering the peritoneal cavity. As soon as the gall bladder is exposed and protected with the sponges as directed, its fluid contents should be drawn off completel)' by the aspirator. As soon as the walls become flaccid from aspir- 42 ABDOMINAL TUMORS. ation, they are grasped with forceps on opposite sides of the addominal incision, and the viscus drawn out as far as possible into this opening. When the aspirator fails to evacuate any more fluid it is with- drawn and the walls opened between the forceps already grasping the cyst, by means of the knife or scissors; this opening in the gall bladder should have the same direction as the opening in the abdominal walls, and should be extensive enough to admit the finger with ease. The gall stones should now be removed by means of a pair of dressing forceps or the old-fashioned bullet forceps; it is to be remembered that gall stones are remarkably light and brittle, and if they are to be removed without break- age, they must be handled very carefully. Taking advantage of their lightness one can succeed in remov- ing a stone that eludes the forceps, by means of a forcible cur- rent of water thrown into the cavity of the bladder from an irrigator; the stone floats on the water and is lifted out of the opening in the over-flow. Billiary calculi are frequently found impacted in sacculi of the bladder walls, in the cystic duct or the common duct, and are very troublesome to remove; the tubes, dilated for their passage as they are forced onwards by accumulation and contraction behind them, fall together in their rear so that they may become fixed in their position and cannot be squeezed backwards into the gall bladder or onwards into the intestine. Sometimes they can be dislodged from their position in the grasp of the bladder or duct walls, by tearing these walls away from them with the pulp of the finger, so that they can be seized with forceps and removed; at other times they can be crushed in situ by being grasped through the abdominal cavity in forceps, the jaws of which are padded and prevented from doing harm to the invest- ing tissues by drawing sections of rubber tubing over these jaws. Being so very brittle, the application of slight force is sufficient to crush and pulverize them to such an extent that their debris is floated back into the gall bladder and discharged from the external opening; or their destruction having rendered the com- mon duct patulous, this debris is carried on into the duodenum. After the bladder is emptied of its contents and concretions the edges of the incision in the bladder walls are sewed to the peritoneum of the abdominal incision by a continuous catgut suture, thus shutting off the cavity of the gall bladder from the cavity of the abdomen. IBDOMINAL TUMORS. 43 A large drainage tube, properly perforated, is introduced into the cavity of the gall bladder to allow of the easy exit of the extremely free flow of bile and serum which comes on immedi- ately. The sponges are removed and the abdominal incision closed in the usual manner. A very massive external dressing is required to absorb this discharge. The sutures in the abdominal walls are removed at the end of a week or ten days; the drainage tube is allowed to remain in the gall bladder until bile has resumed its normal course indi- cated by the color of the faeces, or the amount discharged through it has greatly diminished in quantity. At the end of two weeks the wound in all its parts will be firmly cicatrized and, if desirable, the tube can be removed. The fistula soon closes if the patulency of the common duct has been restored; if this latter result does not ensue, the fistula becomes a permanent one but it is of little consequence or annoyance to the patient as compared with the extreme suffering which the operation has relieved. In some cases in which the common duct is certainly patulous at the time of the operation, after the removal of the foreign bodies the opening in the gall bladder is immediately closed by inverting its edges and closely approximating its peritoneal sur- faces by means of continuous catgut suture. This method of procedure has been followed by success in some instances, in others the sutures in the gall bladder have given way, allowing bile to be discharged into the peritoneal cavity, causing a fatal peritonitis. The attachment of the bladder walls to the external opening is the safest method to adopt. In performing the operation for cholecystectomy, the tech- nique is exactly the same as that already described for chole- cystotomy, as far as the exposure of the gall bladder and the introduction of the sponges for its isolation. When this opera- tion is advisable, the viscus is usually found much contracted and diminished in size; it is entirely freed by separating it from the under surface of the liver and detaching any adhesions which may be present, by means of the finger, the knife or the scissors, until the narrow cystic duct is fully under control; this duct is then tied by throwing a silk ligature around it as far inwards from the gall bladder as possible; the duct is then divided out- side of the ligature and the gall bladder is removed. Some means to disinfect the stump of the divided cystic duct should be used, such as touching it with pure carbolic acid or tincture of iodine. 44 ABDOMINAL TUMORS The stump is inverted or covered by a few Lemhert stitches. The sponges are removed and the external incision closed. A strand of iodoform gauze is left in contact with the duct and car- ried out through the angle of the wound to act as a drain in case the ligature or duct should give way. Pancreatic Cysts. My experience in surgical operations for the relief of pancre- atic cysts, consists of the treatment of four cases; they were all of large size, and the technical procedure was the same in all cases. They all recovered and so far have had no manifestations of the return of the disease. As these cysts develop behind the peritoneal cavity the poste- rior layer of the peritoneum must be divided before the cyst wall is exposed. The abdominal incision in each case was vertical in direction and made over the center of the most prominent part of the tumor, and of sufficient length to give ready access to it; this incision was made in the manner already described for all abdominal incisions as far as the opening of the peritoneal cavity. The tumor presents in this opening, probably crossed by some portions of the intestinal tube and covered by layers of the mes- entery, through which are seen large mesenteric vessels. If pos- sible the intestines and mesentery are pushed off the surface of the tumor or so displaced, that its presenting surface is invested only by non-vascular tissue; this is incised sufficiently to allow the cyst wall to be brought in contact with the edges of the abdominal incision. The peritoneal edges of the abdominal incision are then fastened to the surface of the cyst to the neces- sary extent by a continuous suture; the remainder of the abdomi- nal incision not included in this attachment is then closed by interrupted sutures. By this procedure the cyst wall is attached to the abdominal wall and the peritoneal cavity entirely closed. The cyst is then opened and its contents discharged; if thought advisable the cyst cavity can be packed loosely with iodoform gauze, for the purpose of drainage. Perhaps the future care of the cyst cavity can be best provided for by the introduction into it of two large and long drainage tubes, one perforated and the other not perforated; these tubes will provide for the drainage and allow for thorough irrigation of the cavity in case it should become infected. The external ABDOMINAL TUMORS. 4." dressings will be the usual application of antiseptic gauze and borated cotton; the drainage tubes must be retained in position for a long time, as the cyst cavity is so slow in contracting and granulating, and the fluid should not be allowed to re-accumulate. Pyosalpinx. The accumulation of pus in the Fallopian tubes or ovaries, or both, sometimes complicated with rupture into the pelvis or the organs contained therein, often requires surgical operation for its relief. The communication between the pus cavity and the cav- ity of the vagina or rectum, especially the latter, adds much to the gravity of the operation and to the difficulties of operative technique. When rupture of the pus sac has occurred, extensive adhesions are usually found present; it is really surprising how readily such adhesions are peeled off the distended tube when the surgeon, taking the uterus as a guide, can insert his finger between them and the sac wall; free bleeding occurs during the separa- tion of such adhesions, but usually stops spontaneously or is readily controlled by sponge pressure. If the distended sac is free from attachments to the surround- ing organs, or can be isolated without rupture and a sufficient portion of the broad ligament exposed to form a good pedicle, a silk ligature is applied in the usual way, tied and the entire mass removed. Total removal of the diseased tube or ovary is the best treat- ment to aim at, and the attempt to execute it should be made, even when great risks attend it, or at first glance its per- formance seems impossible; by persistence and steady progress, one often succeeds satisfactorily in seemingly hopelessly bad cases. If the risk attending the entire removal seems too great, a portion of the highest part of the sac wall should be cleaned of investing tissue, it should then be emptied of its contents by the aspirator, after which the sac wall is sewed to the perito- neum of the edges of the abdominal incision by the continuous catgut suture. To shut off the peritoneal cavity the still open portions of the abdominal incision should be closed by inter- rupted sutures; then the pus cavity should be opened freely through its exposed portion and the interior thoroughly irri- gated with some antiseptic fluid. A glass drainage tube is intro- 4*i ABDOMINAL TUMORS. duced into the cavity of the sac, and a large external dressing applied. The drainage tube is kept in until the pus cavity is obliterated by contraction and granulation. Sometimes it is advised to make a counter-opening into the pus sac through the vagina in order to facilitate drainage and pro- vide means for perfect irrigation. My experience has not shown that this plan possesses any superior advantages; in fact it has seemed to me that the cases in which it has been tried, have not recovered as rapidly as those in which no opening was made into the vagina. It is especially necessary in all operations for the relief of pyosalpinx to draw the folds of the small intestine out of the pelvis, if they are found non-adherent, or after their separation, if adherent to the pus sac, and the use of sponges or pads made out of iodoform gauze placed around the field of operation to isolate the pelvis entirely from the rest of the abdominal cavity. These precautions are strenuously advised owing to the extreme likelihood of rupture of the distended sac walls and the dissemi- nation of foul pus contained in them into the pelvis, as well as to allow of free flushing of the pelvic cavity to get rid of it. This plan should always be carried out before the pus sacs are manipulated and before any adhesions are loosened. Many times the strict observance of the rules and practice of the pro- cedures advised, have carried particularly bad cases of the nature under consideration to a successful issue. In these cases, if anywhere, the adoption of free drainage seems to be impera- tively demanded. In many cases the bladder is so drawn out of position that it is extremely likely to be injured. Circumscribed accumulations of pus are certainly found in the pelvis at times with agglutinated folds of intestines, or other organs and tissues, for their walls, and without any determinable direct communication with the Fallopian tubes; they constitute the condition to which the name of pelvic abscess is applied. The amount of pus accumulation is sometimes very great. These abscesses do not infrequently make an external openino- for themselves, by means of adhesions or tissue necrosis, through some parts of the abdominal wall, oftenest in the inguinal region. Occasionally the surgeon is able to locate them rather early in their formation by abdominal section and cure them by carrying out the procedures already described for the management of cases of pyosalpinx in which adhesions cannot be separated and the sac removed entire. ABDOMINAL TUMORS. 47 When these accumulations of pus approach the surface at any point, as indicated by the presence of redness, cedema of the sur- face and perhaps fluctuation, they should be treated like any deep seated abscess. Of course it is understood that all minute details of operative manipulation, already passed in review in the consideration of the technique advisable in all abdominal operations, are to be observed in all the procedures applied to special cases or conditions. Extra-Uterine Pregnancy. Cases of extra-uterine pregnancy before term, with or without rupture, are referred to the surgeon for operation; the special manipulations necessary for their successful management demand of the surgeon well defined plans of procedure, in order that they may at any moment be put into rapid execution. The surgeon will never be confronted with operations calling for greater skill, promptness and readiness of action than the one which he must face when asked to relieve and surmount the imminent danger of immediate death attending many cases of ruptured Fallopian pregnane)*. It seems proper to look upon all cases of extra- uterine pregnancy as cases of dangerous tumor, and to consider the propriety of their removal in anticipation of hazardous com- plications or accidents threatening the life of the patient. As is well known, the rupture is most likely to take place about the second or third month of the term of development. If the site of rupture is towards the abdominal cavity, the hemor- rhage is sudden, profuse and often deadly. If the rupture is to- wards the broad ligament tissue, bleeding is not so profuse and is usually soon limited by the pressure of the distended folds of that ligament. Careful diagnosis having established the existence of an unrup- tured tubal pregnancy, the operative procedures for its removal present no complications. The abdominal incision, exposure of the tumor, ligation of its base and its excision are to be made with the same precautions and with the observance of the same rules as have been already indicated as necessary and sufficient to accomplish the removal of any small tumor situated in the abdomen. When the rupture has occurred on the free surface of the tube and the blood is rapidly flowing into the abdominal cavity, as indicated by the well defined symptoms always present 4S, ABDOMINAL TUMORS. in such an occurence, every manceuver of the surgeon must be executed with great rapidity and yet with great certainty. The abdominal opening is made quickly and as soon as the peri- toneal cavity is exposed the uterine end of the distended Fal- lopian tube is immediately seized with the fingers and included in a ligature passed under it by means of a curved needle, and securely tied. The tissues of the broad ligament towards the free ends of the Fallopian tubes are secured by a ligature applied in the same way; these ligatures stop the bleeding at once and thus get rid of the main element of danger. After this the mass of effused blood can be cleaned out of the way and the ruptured tube, with or without the fcetus, removed with deliberation and safety. The peritoneal cavity is thoroughly cleansed and the opening in the abdominal walls closed in the usual manner. No drainage is to be used if its use can be avoided; if such uncontrollable oozing of blood is present, the Mickulitz gauze drain should be introduced; its pressure will stop the oozing and its presence provide for the drainage; it can usually be removed safely by the third day. In bad cases the terrible effect of the great blood loss can be in part relieved by the injection of large quantities of solution of common salt, in the proportion of one teaspoonful of salt to a quart of sterilized water, into the cellular tissues of the back, or less quantities into some easily exposed vein. The abdominal incision is usually best made in the mid line, as giving more certain control of the Fallopian tubes when the diagnosis of which tube is the seat of pregnancy has not been made. I made the lateral incision in one successful case, directly over the most prominent part of the swelling, and the necessary manipulations were readily carried out through it. This is the specimen removed from the case, and on the surface of this mass of blood you will notice the body of the fcetus at the third month of development, rather firmly held in the lamina of the clot. More deliberation can be practiced in the cases of rupture into the broad ligament, as the loss of blood is not an element of so much concern. In another case of this variety of rupture, the following plan of manipulation was practiced: After opening the abdomen, clean- ing out much loose blood from the cavity and exposing the tumor, an incision was carried through the broad lio-ament invest- ing the top of the tumor, from the uterus to the lateral portion ABDOMINAL TUMORS. 49 of the brim of the pelvis, its course running parallel with that of the Fallopian tube; the fingers were introduced into this incision and the entire mass of blood clot, as you see it in this second specimen, enucleated from its bed between the folds of the broad ligament. No blood vessels required ligation. As there was some oozing of blood into the cavity left, that cavity was packed with strips of iodoform gauze, the ends of which were drawn out of the lower end of the abdominal incision and this incision closed by interrupted suture; the gauze packing was removed on the third day and the case went on to rapid recovery. Other cases of rupture into the broad ligament are best man- aged by the application of a ligature at both ends of the Fal- lopian tube and a removal of the diseased portion of the tube,. together with all the blood clots, in the manner already described for the control of cases of rupture on the free surface of the tube.. Many cases of successful termination, after operation for rup- tured extra-uterine pregnancy, have been reported. Nine cases have been operated upon by myself with recovery in all. Extra-Uterine Pregnancy, Near, At, or After Term. After safely passing through the extreme dangers attending rupture, in the earlier months of its development, an extra-uter- ine pregnancy may remain present in the patient so affected with symptoms of greater or less trouble for remarkably long periods of time, even for many years after the child has reached full term and died. Complications of one kind or another during any time of its existence, may happen and require surgical operation. The most certain necessity for such interference will follow as the result of purulent infection of the foetal sac or its contents,. after full term of development. Probably the most favorable time for operation in the majority of cases will be about the third month after the child has reached full term, and its death has occurred, accompanied with well marked symptoms of futile labor and been followed by diminution in the size of the tumor from absorption of the amniotic fluid. Probably, as well, at the end of this same period, partial sep- aration of the placenta will have occurred, or its blood vessels: have become so much contracted in size as to diminish or obvi- ate entirely one of the greatest dangers attending operation in 50 ABDOMINAL TUMORS. these cases, that is, primary or secondary hemorrhage following separation of the placenta. Aside from hemorrhage, the largest fatality has attended the operation in former years from septic peritonitis, which complication can now be almost certainly avoided by carrying out in detail, aseptic and antiseptic precau- tions and procedures before, during and after the operation. Spontaneous discharge of the fcetal contents and recovery, have not infrequently followed through the means of the forma- tion of adhesions, ulceration and rupture into the alimentary tract, uterine cavity, vagina, or through the abdominal walls, accompanied in most cases by severe pain, extreme exhaustion and prolonged periods of severe constitutional symptoms depend- ent upon the presence of the suppurative process. Operative procedure may be divided very properly into the minor and major, the latter having for its object the removal of the entire sac and its contents; the former accomplishing merely the removal of the fcetus and the attachment of the edge of the opening into the fcetal sac to the margins of the abdominal incis- ion, accompanied either with the removal of the placenta at the time of the operation, or the adoption of the plan of allowing it to remain for the gradual separation which follows contraction of the sac and its decomposition. The type of extra-uterine pregnancy, whether it be Fallopian or intra-ligamentous, exercises much influence upon the choice of the operation to be performed. It is scarcely probable that this condition can be accurately estimated previous to making abdominal incision. If after the abdomen is opened the tumor is found to be free from adhesions and pedunculated, as may be the case in the Fallopian or ovarian type, the major operation is the best one to adopt; the pedicle, if one is present, is ligated as for any tumor, and the mass removed; or if none be present, a pedicle is formed of the investing tissues by partial enucleation and treated as already described in controlling the pedicle and dur- ing the subsequent details incidental to the care of the case. If no pedicle is present and it is not possible to form one, or if the adhe- sions are insurmountable or the case is of the intra-ligamentous type, it is best to perform the minor operation, which consists in fastening the surface of the fcetal tumor into the abdominal incis- ion by a continuous catgut suture. As soon as this is accom- plished and isolation from the peritoneal cavity made perfect, the fcetal sac is opened by a free incision and the child delivered through it. ABDOMINAL TUMORS. 51 If the placenta is to be delivered at once, the blood vessels leading into it should be ligated by means of deeply applied silk sutures before any attempt is made at its separation. Otherwise, the cavity of the fcetal sac is best packed with iodoform gauze and kept free from septic infection until the contraction of the sac has separated the placenta and cast it loose. Both in the intra-ligamentous and other varieties, the anterior surface of the fcetal sac is sometimes blended intimately with the abdominal walls from adhesions so that they are practically con- tinuous tissues. If this condition is present, no attempt is made to separate these adhesions, but the incision through the abdom- inal walls is carried directly into the cavity of the foetal sac; the child is delivered, the cavity filled with iodoform gauze and the separation of the placenta awaited. In all cases in which the cavity is filled with the gauze, this material is withdrawn and replaced often enough to secure an aseptic condition of the cav- ity. As soon as the placenta is entirely detached and removed, the sac contracts and granulates rapidly and the patient goes on uninterruptedly to complete recovery. Anticipating by a few days the futile labor which marks the full term of development in the child, or by selecting the time of this occurrence itself, operative interference will be rewarded with the delivery of a living child. In these cases the danger from primary hemorrhage, attending any attempt to separate the placenta should lead to the avoidance of any active interference to accomplish this result. It is best to practice delay of separa- tion of the placenta and to make use of the gauze packing, unless a pedicle can be formed and the entire sac removed. C-esarian Section. The very formidable operation of Caesarian section of late years has been attended with remarkably favorable results, owing to the avoidance of septic infection and a more perfect recognition of the minute details necessary for its successful performance. There is recognizable in the cases reported, a well defined line of demarkation between two varieties presented for operative interference. First, those which are under control of the surgeon previous to the commencement of labor, which are very likely to be free from septic complications and hence recover. Sec- ond, those in which the operation is resorted to some time after 2 ABDOMINAL TUMORS. labor has commenced, and especially those in which attempts have been made to deliver the child through the natural passage, which cases are very likely to develop septic complication lead- ing to death. In the latter variety, it must be always remem- bered that there are two sources from which sepsis may arise. First, through the abdominal wound and its environs; second, through the certainly infected uterine cavity. The first source of danger from sepsis belongs to both varieties of cases. While the precautions must be assiduously carried out to pre- vent infection through the abdominal wound in both classes, in those in which the uterine cavity has been opened and interfered with previous to the operation, the surgeon is called upon to practice extreme care in the disinfection of this cavity. After carrying out all the antiseptic precautions previous to making the abdominal incision, the vagina should be thor- oughly irrigated with some antiseptic fluid. Labor having commenced previous to the operation and pro- ceeded so far as to partial or complete dilation of the cervix, the membranes are ruptured and the amniotic fluid allowed to drain away. If this fluid has already escaped without dilation of the cervix, this dilation should be secured by means of Barnes' dilators, or other well known methods. Incision. The incision through the abominal walls should at once be made long enough to admit of easy delivery of the distended uterus and will require prolongation above the umbilicus to meet this necessity. All bleeding from the wound should be con- trolled permanently before the peritoneum is opened. After the peritoneum is divided to the extent of the external incision, the uterus and contents should be extruded from the wound by means of pressure through the abdominal walls over its posterior surface; as soon as it is delivered the intestines should be protected by the introduction into the abdominal cav- ity of large, flat sponges. The uterine wall should be then incised to a sufficient length to allow the delivery of the child; it should be made vertical and in the mid line of the anterior surface, if possible not including the ABDOMINAL TUMORS. 53 tissues of the cervix at its lower end. During its performance, hemorrhage is very free and should be controlled as much as pos- sible by sponge pressure. Some care must be used while dividing the uterine mucosa to avoid wounding the child. Just before opening the uterine cavity the edges of the abdom- inal incision should be made to constrict the uterine body in order to prevent any of the contents of the uterus from flowing into the abdominal cavity A rubber tube should be placed around the cervix in the hands of an assistant who will tie tightly after the uterus has been incised in case of severe hemorrhage. When the incision through the uterine walls is sufficiently free to allow of easy extraction of the child, this should then be seized and rapidly delivered; the umbilical cord should then be caught with two pairs of forceps and divided between them and the child handed to an assistant, with instructions to practice immediate artificial respiration and other means of resuscitation, if it does not cry lustily immediately upon being withdrawn. The surgeon should now practice free ablution of his hands. The bulk of the uterine mass diminishes rapidly by contraction of its muscular walls after delivery of the child. During all this time the assistants are directed by means of compression, to limit as much as possible the loss of blood and to prevent the entrance of any deleterious material into the pel- vic cavity. The placenta is separated from its attachments to the uterus with the finger, and with attached membranes slowly and care- fully drawn out of the opening. If the contractions of the uterine muscle are normal and strong, the tumor soon becomes reduced to a small size, hard and firm, the incision in its walls becomes remarkably shortened and the blood flow stopped. This condition can be expedited, or in cases of atony induced, by the hypodermic injections of twenty- drop doses of fluid extract of ergot; or by douching its cavity with hot sterilized water. If the uterine cavity has been opened and rendered septic before the operation, it should be thoroughly washed out with some antiseptic fluid, such as hot Thiersch's fluid, or hot solution of 1-5000 bi-chloride of mercury, followed by sterilized water. The water flows out readily through the dilated cervix and makes its exit through the vagina. 54 ABDOMINAL TUMORS. All blood and other material should now be sponged away from the uterus and surrounding parts. Before closing the uterine incision a strand of iodoform gauze as thick as a finger should be carried through the uterine cavity into the vagina. The uterine incision is closed by means of three rows of inter- rupted silk sutures, the first row. passed through the muscularis of the uterine walls, just outside of the mucous membrane; these sutures should be more than half an inch apart. The second row should bring together the middle portion of the muscular wall of the uterine incision, and the third row should include the outer layer of this muscular wall. The edges of the peritoneum should be brought together over all, by means of the continuous catgut suture, so applied as to invert its edges and bring free peritoneal surfaces in contact with each other throughout the length of the incision. If these sutures are all satisfactorily applied, there will be no bleeding from the wound after their introduction. The peritoneal cavity is properly cleaned, the external wound closed by interrupted sutures and the patient cared for in every way, as after any other severe laparotomy. Porro's Operation. Any severe operation upon a patient requiring a complete abla- tion of the pregnant uterus, such as is contemplated and practiced in the performance of Porro's operation, should be preceded by all the special and general preparations of the patient, to prevent the occurrence of sepsis, which have already been described. The surgeon should previously have prepared several rubber bands or a Koeberle's serrenoeud or other clamp, with which to compress the stump and control hemorrhage. The cervix should be partially dilated, membranes punctured and the amniotic fluid allowed to drain away, if this has not already occurred. The abdominal incision must be long enough to admit of the easy delivery of the entire tumor, and made in the same manner as the similarincision in making a Caesarian section. The deliv- ery of the uterus and contents, as also the control of the intestines and protection of the abdominal cavity, should be man- aged as already mentioned. ABDOMINAL TUMORS. 0-) After the delivery of the tumor the broad ligaments are "tied off" in the same manner as has been minutely described dur- ing the performance of the operation for ablation of a fibroid of the uterus. As soon as this is accomplished the cervix is surrounded by the rubber cord, which is drawn tightly enough to control all bleeding, tied once and temporarily secured with a Nelaton for- ceps. The uterus is then opened, the child and the placenta with its membranes delivered. After this the uterus is severed and removed. The uterine canal should now be disinfected by the use of strong carbolic acid or the actual cautery, and then packed with a small strand of iodoform gauze. The incision through the uterus, for its ablation, should be sufficiently far away from the rubber tube to prevent the tissues of the stump from being drawn through that tube; the stump should be cut long enough to allow of its being fastened in the lower end of the incision without dragging on the vagina. Jf the rubber cord is not high enough on the stump to come outside of the abdominal cavity, a second rubber cord should be applied in such position as will accomplish this result, drawn sufficiently tight to control bleeding, tied and permanently fastened by silk sutures introduced through its knot. If the rubber tube is not to be used as the permanent means of constriction of the stump, then Koeberle's serrenoeud or some other clamp, is applied in such position as to be outside of the abdominal cavity, fastened securely and the temporary rub- ber tube removed. In both instances, my partiality is for the use of the rubber tube; its action is constant and persistent, does not necessitate repeated disturbance of dressings, such as is necessary in order to tighten the clamp to accommodate it to the constantly diminishing size of the stump tissue contained in its grasp. When the stump is satisfactorily controlled, by either of the methods above mentioned, it is secured in the lower end of the abdominal incision, by attaching the peritoneum of the stump to the parietal peritoneum by means of a continuous catgut suture carried around the entire circumference, thus shutting off the abdominal cavity completely. During all these manipulations much care should be taken to avoid injuring the bladder. The protecting sponges should now be withdrawn, the peri- toneal cavity cleansed and the abdominal incision closed by interrupted sutures. The free end of the stump is cauterized with the actual cautery or mummified by being covered with a 56 ABDOMINAL TUMORS. thick layer of iodoform powder and the usual external dressings are applied. The subsequent management of the case should be in accord- ance with the rules already given in describing the technique of a case of myoma of the uterus, treated according to the extra- peritoneal method. In cases in which the uterine cavity is pre- sumably septic this method is much safer than the one described above. Obstruction of The Bowel. Laparotomy for the relief of obstruction of the alimentary tract from any of its many causes, is an operation of not infre- quent necessity and quite hazardous in its nature. It seems proper to recommend' the choice of the mid line of the abdomen for the primary incision in all such operations, as this median incision gives the most perfect command of all por- tions of the abdominal cavity; and hence secures greater cer- tainty for at once reaching and properly managing the source of obstruction. As many of these cases, when operation is required, are accom- panied with extreme tympanitis from gaseous distention of the intestinal tube above the point of strangulation, their difficulty of management is immensely enhanced by the existence of this complication. As the folds of the distended intestine are forced into close contact with the abdominal walls, the incision which finally opens the abdomen should be made with great care in order to avoid injury to them. If there is not much gaseous distention, as soon as the abdominal incision is completed, folds of collapsed intes- tine should be sought for and followed upwards till the point and cause of the obstruction is reached. In the majority of cases the point of obstruction will be found in the right iliac region. The cause of the obstruction is very often found to be narrow and tense bands of adhesions, and they should be divided and the intestine released. Sometimes it is caused by a fold of intes- tine slipping beneath the vermiform appendix, which has become adherent by its free extremity only; if the intestine cannot be withdrawn from the loop thus formed, the appendix should be divided between two ligatures and special precaution taken to avoid infection from its cavity. ABDOMINAL TUMORS. o I Sometimes the strangulation is due to an internal hernia of a loop of the intestine through some abnormal opening in the mes- entery or omentum. This opening should be enlarged and the intestine withdrawn and the abnormal opening closed by sutures. Again, the strangulation is due to the presence of a twist of the intestinal tube or volvulus, oftenest occurring at the site of the sigmoid flexure. The axis of the tube must be restored to its normal position by untwisting the coils concerned in the forma- tion of the volvulus. If the obstruction is due to the presence of a malignant growth in the intestinal tube, two operations are at the choice of the surgeon for the relief of the patient. First, the establishment of an anastomosis between portions of the tube above and below the site of the constriction. Second, the entire removal of the tumor through an enterectomy, performed by severing the bowel through healthy portions above and below the tumor and restor- ing the continuity in the intestinal tube by suturing together the ends just made If the obstruction is due to an intussusception of rather recent occurrence, the tumor thus found is drawn out of the abdominal incision and the intussusception overcome by pressure upon the invaginated contents from below rather than from any forcible dragging upon the invaginated tube from above. If adhesions have formed between the folds of the intussusception and are sufficiently firm to prevent its reduction in the manner just indi- cated, the surgeon will be compelled to consider the propriety of making an entire resection of intussuscepted mass, and the sub- sequent restoration of the continuity of the alimentary tract by rejoining the resected ends by suture, or the propriety of the establishment of an anastomosis between the small intestines above and the large intestines below the invaginated portion. Neither operation presents much prospect of successful relief as an encouragement for its performance. If the existence of great gaseous distention of the tube presents any obstacle to the suc- cessful execution of the procedures indicated as necessary to overcome the obstruction, this complication must be relieved by some special procedure. It is said that repeated washing out of the stomach by means of the stomach tube previous to the laparotomy tends to relieve the distention. As this is a simple procedure and can be easily carried out, it should be practiced in all proper cases. After the abdominal incision is made the distended coils of 58 ABDOMINAL TUMORS. intestines may be withdrawn through the external opening, held out of the way and protected by towels wrung out of hot aseptic solution. As soon as the constriction is relieved the accumu- lated gas will flow into the previously undisturbed portion and allow of their easy return into the abdominal cavity. When the distension is so extreme as to prevent the adoption of any other method for its relief, the coils of intestine must be punctured at non-vascular portions by means of a. hypodermic needle and the accumulated gas allowed to escape. Cases of obstruction which have reached the condition of extreme exhaustion, almost collapse, with excessive distention, can sometimes be quickly relieved temporarily and time secured for the performance of subsequent operation for permanent relief, by a simple operation. A moderate incision is made through the abdominal walls and the first fold of intestine met with, seized and brought through the external incision; its walls are fastened to the edges of the external incision and its cavity opened, thus establishing a faecal fistula, out of which the con- tents of the tube can flow, and thus the immediate symptoms will be relieved. During all these procedures the intestines must be handled with extreme care, as their thin walls, weakened from inflamma- tion and distention, are particularly liable to tear under even slight pressure. After accomplishing the relief of the obstruc- tion the external wound is closed in the ordinary manner and the usual antiseptic dresssings applied. Appendicitis—Peri-Typhlitis—Peri-Cecal Abscess. Operative interference through the abdominal walls, for the relief of the diseased conditions of the vermiform appendix, has of late assumed considerable prominence and has been practiced with a corresponding frequency. When determined upon for the relief of disease unaccompanied with the presence of adhesive peritonitis or the formation of pus, the technical manipulations are comparatively easy of execution. On the other hand, when infection has taken place in or around the appendix, together with gangrene or rupture of its walls, accompanied with more or less peritonitis and extensive adhesions between coils of intes- tine, the means of relief are extremely difficult to carry out and haazrdous in their nature. ABDOMINAL TUMORS. 59 The region of operative interference, in either case, is properly exposed and the appendix is most readily uncovered by means of a vertical incision carried through the abdominal walls, about two inches to the inner side of the anterior superior spinous process of the ilium; the middle point of the incision should be directly opposite to the spine. All bleeding vessels should be secured before the peritoneum is opened, after which, this mem- brane is divided to the full length of the incision. As soon as the abdominal cavity is opened, provided infection has not taken place or abscess formed, coils of intestine will push into the wound, and should be held out of the way by placing sponges or pads of iodoform gauze so as to restrain their exit and yet leave the caecum fully exposed to view. The vermiform appendix is then sought and is usually easily recognized by its well known shape and characteristics; if non-adherent, its mesentery is ligated and detached until perfectly free at its origin from the bowel. The appendix is then ligated firmly by a silk suture close to its origin and detached by an incision sufficiently far away from the point of application of the ligature. The mucous membrane is then destroyed and rendered absolutely aseptic by touching it with 95 per cent, solution of carbolic acid applied by means of a silver probe; any superabundancy of the acid can easily be shaken off this probe, and yet after being well shaken enough of the acid adheres to its surface to accomplish the purpose desired without any danger from the caustic action of the medicine extending beyond the immediate point of its application. It has never seemed necessary to me, to resort to the more prolonged procedure of inverting the stump of the appendix into the cavity of the caecum, and uniting opposed surfaces of the caecum over the invaginated stump, as is recommended by some operators, at least in the several operations done by myself for the removal of this organ, the simpler procedure mentioned has given rise to no complications. Faecal fistulae have been attrib- uted to the fact that this precaution was not carried out, but it is quite likely that they were caused by an injury to the caecum during the operation; none of my cases were followed by forma- tion of fistula. When the previous inflammation has led to the formation of many adhesions and to abscess, after the abdomen is opened according to the plan directed, the appendix is often very diffi- cult to find, or to be freed entirely so as to be safely removed, even after the careful and prolonged manipulations required to 60 ABDOMINAL TUMORS. separate the adhesions. The danger of breaking through the adherent intestine is very great. Not infrequently, when considerable pus is present, the appen- dix is found greatly enlarged and more or less softened and gangrenous, but free in the cavity of the abscess. In both varie- ties it is frequently found closely adherent throughout its entire length and is freed with great difficulty. In one of my cases its mesentery was found so infiltrated and softened by exudate and inflammation that the tissues would not hold a ligature, and the spurting arteries could not be secured thereby; they were caught in a pair of haemostatic forceps and these were left in the wound until the second day, when they were removed, restrain- ing hemorrhage perfectly; the patient made a rapid recovery. In pus cases the main abdominal cavity should be completely isolated from the site of the abscess by means of iodoform gauze pads before the latter is opened, and the pus thoroughly cleaned away by means of flushing with sterilized water. In all cases, the appendix, when separated, can be satisfactorily removed according to the method already given. Great care should be used in cleansing the entire wound, after which, a strip of iodoform gauze may be carried to the stump of the appendix and out of the lower end of the abdominal incision, to act as a drain; after which the external wound is closed in the ordinary manner and the proper dressings applied. Abdominal Nephrectomy. The external incision for this operation is made through the linea semi-lunaris in the usual manner common to all operations which open the peritoneal cavity. The intestines are pushed out of the way by means of a large flat sponge. As the tumor is behind the posterior layer of the peritoneum, this layer, too, must be incised before the tumor is exposed. The colon, in these cases, usually lies on the top of the tumor and the incision which opens the posterior layer of the peritoneum should be made some distance away from the outer edge of the colon and parallel to it. It must be of sufficient length to allow the operator to have complete control of the tumor, and to provide for its easy removal. The sponge is then withdrawn and the inner edge of the incision of the posterior layer of the peritoneum sewed securely to the inner edge of the incision through the ABDOMINAL TUMORS. 61 abdominal walls; in this way shutting off completely the peri- toneal cavity from the field of operation. The blood vessels entering the tumor are now sought and ligated. The ureter is found and secured temporarily by forceps, the tumor separated from its attachments and removed. It is just as well if the tumor is rather large and the space limited, to secure the blood vessels temporarily by long jawed forceps, as they can be ligated inside of these after the removal of the tumor. It seems best to always provide for drainage through the posterior lumbar region; this can be done easily and without fear of hemorrhage by thrusting a pair of scissors directly backwards to the interval between the last rib and the crest of the ilium and expanding their blades to make an opening through which a large drainage tube can be readily drawn. After the removal of the organ, the ureter may be managed in either of two ways. Its free end is made thoroughly asceptic by the application of the actual, cautery or pure carbolic acid, and it is drawn out and fastened to the most dependent part of the external wound; or its extremity may be inverted into its lumen, like the finger of a glove, and the peritoneal edges fastened by suture. After the tumor is removed and the manipulations mentioned satisfactorily carried out, the edges of the posterior layer of the peritoneum which was sewed to the abdominal wound is unfas- tened by snipping the sutures. The sponge is again used to keep the intestines out of the way while the incision in the posterior layer of the peritoneum is secured closely by means of the con- tinuous catgut suture, thus perfectly isolating the peritoneal cavity from the large space recently occupied by the tumor. The abdominal wound is sutured in the usual manner, the sponge removed, and the external wound closed. Faecal Fistula. Abdominal section for the relief of faecal fistula is the final resort in cases of that unfortunate complication. After the abdominal incision is made in the usual manner and with the usual precautions, the fold of the intestine implicated in the formation of the fistula is freed entirely from its adhesions to the abdominal walls and if necessary from surrounding folds of 62 ABDOMINAL TUMORS. intestine; the opening in it is then closed accurately by means of Lembert's intestinal stitch, which inverts the opening into the lumen of the bowel and approximates opposed surfaces over it. The fistula through the abdominal walls is then freely abraded and united by suture. It is well to place a strand of iodoform gauze in contact with the intestine at the seat of operation and carry it out through the abdominal wound. This will act as a guide in case the stitches should give way and will prevent the occurrence of general peritonitis in that event. Cholostomy. The operation for the production of a temporary or permanent fistula into the large intestine through the anterior abdominal walls, may be done either over the course of the descending or ascending colon. The opening in the bowel is usually made near the end of the descending colon and is termed Maydls' opera- tion; it is best executed according to the following plan: an incision three inches in length is carried through the abdominal walls in the direction of the external oblique muscle over the well known course of the bowel and at its lower part in the left inguinal region. When the opening through the abdominal walls is completed, the peritoneum is sewed accurately to the skin throughout the entire circumference of the wound by means of the continuous catgut suture. After the abdomen is opened, the colon is easily recognized by its sacculated formation and striae of longitudinal muscular fibres; the colon is seized and drawn into the external wound, its meso-colon is transfixed with a glass or a hard rubber rod covered with iodoform gauze. This rod is allowed to project over the edges of the abdominal wound on each side. This prevents the intestine from falling back into the abdominal cavity or making traction on the suture. The surface of the intestine is attached to the edges of the circumference of the abdominal wound, throughout their entire extent, by means of the continuous suture applied so as only to take up its peri- toneal and muscular coats. It can now be opened freely and the edges of the opening turned back and attached to the external wound by interrupted sutures; its contents can be washed out by irrigation and the usual dressings applied. Some operators think it best not to open the bowel until after the lapse of several days has made the adhesions between the ABDOMINAL TUMORS. 63 bowel and the abdominal wound absolutely secure. Other oper- ators pursue the plan of shutting off that portion of the colon which is below the point of the formation of the artificial anus. If this operation is practiced, a portion of the colon is withdrawn from the external wound sufficient in length to freely expose its meso-colon; the contents are displaced from this exposed portion of the intestine, and kept out of the way entirely by including the upper part of the colon in a constricting band of one kind or another; the opening in the abdominal walls is then protected by sponges, or iodoform gauze pads applied between it and the bowel which is to be divided; the colon is then severed entirely and the meso-colon detached from the bowel for a proper distance; the bleeding vessels being permanently secured at once by ligation. The upper end of the lower portion of the divided intestine is then invaginated for a safe distance and permanently closed by means of the continuous suture, bringing its opposed peritoneal surfaces in close approximation with each other. After being thoroughly cleansed it is dropped into the peritoneal cavity. The upper end of the divided colon is then brought into the external wound and accurately united to the edges of that wound by suture; the constricting band is removed, the peritoneal cav- ity thoroughly cleansed and closed by sutures. Intestinal Anastomosis. The following plan of making an anastomosis between differ- ent portions of the intestinal tube, has proven in my experience, eminently satisfactory and successful both in experimentation on the lower animals and in application to the human being. The contents of the folds of the intestine to be the seat of the anas- tomosis, are carefully displaced for some distance away and kept from interfering with the operation by the application of con- stricting bands firmly fastened about the tube, or by means of properly protected forceps. The opposed surfaces of the intes- tinal tube to be united are then fastened together for the dis- tance of an inch by the continuous silk suture applied at some distance below the point at which the incision is to be made into the bowel. The incision is then made into the bowel, three-quar- ters of an inch in length, through that portion of the intestine which is directly opposite the mesenteric attachment to the bowel. A cross incision is made into the bowel one-half inch in 64 ABDOMINAL TUMORS. length, at each end of the longitudinal incision; the middle of this cross incision being at the point of termination of the longi- tudinal incision. This procedure is carried out on both of the surfaces of the intestine which are to be applied to each other, making two flaps of the intestinal wall on each side, which can be folded into the lumen of each intestine and fastened by suture, thus forming a permanent opening between the cavities of the opposed folds of intestine, three-quarters of an inch long and half an inch wide. The lower edges of the wounds thus made are then sutured together with the same needle and thread which has already made the first line of attachment between the folds of intestine. While these sutures are being introduced the lower flaps of both openings are turned into the cavity of the corre- sponding intestine, thus allowing of the ready and accurate apposition of the peritoneal surfaces; they are carried through the surface of opposed intestine for some little distance below the lowest point of the opening into the bowel, fastening together peritoneal surfaces until the upper edge of the bowel is reached, when the intestinal flaps at that point are also turned into the cavity of their corresponding intestine and united by the same thread and in the same manner as in the lower edge, throughout their entire length. Finally, the opposed walls of the intestine above the opening in the bowel are united at some little distance beyond the opening, by means of the same continuous suture. Any seemingly weak points in the circumference of attachment are now secured by separate suture. The constricting band or forceps are removed, all foreign material cleared away, and the bowel returned into the abdominal cavity, the opening in which is closed in the usual manner. The intestinal flaps made in the way described, not only secure an immediate and permanent opening between the folds of the intestine united together, but also support and protect the applied surfaces of the intestinal walls. The entire procedure is executed with the same needle and thread, and can be carried out with great rapidity. The needle used is the fine, round English sewing needle, curved slightly towards its point; the best suture is very fine but strong silk. In restoring the continuity of the alimentary tract after any operation which requires the removal of a portion of the small intestine, as well as of the large intestine, and necessitates the rejoining of these unequally sized parts of the alimentary tract, the following method is most satisfactory. The free ends of both ABDOMINAL TUMORS. 65 the divided small and large intestine are invaginated into their respective tubes and permanently closed by bringing their peri- toneal edges accurately together with the continuous suture, after which the small intestine is applied to the large intestine and a lateral anastomosis is established in the manner already described. This plan of forming an anastomosis is also safely applicable to the execution of the operation called gastroenter- ostomy, or the establishment of a permanent fistula between the stomach and the small intestine. In the latter operation the external incision through the abdominal walls is made above the umbilicus over the neighborhood of the stomach, and its course may be either in the line of the linea alba or oblique in direc- tion, and parallel with the edges of the costal cartilages, depend- ing upon the choice of the operator. It should not be forgotten, while contemplating the propriety of adopting or the success attending innovations upon estab- lished operations, that it is always proper to give due and just consideration to the older plans of operation; accordingly it is well to remember that the vast majority of wounds upon the small intestine, either produced by accident or design, have been repaired by the surgeon and the patients carried to recov- ery with the use only of the silk or catgut thread, practicing the well known method of a double row of sutures, advised by Prof. Czerny, of Heidelburg, and without the aid of any special appar- atus or incision. Hydatids. Tumors developing in the abdomen as the result of the growth of the parasite termed echinococcus, require surgical operation for their relief. Many times the parasite can be killed and' recovery ensue by a single aspiration of its serous contents; this result will usually follow only when the cyst is single and when suppuration has not occurred, provided the situation of the tumor is such as to allow of the introduction of the aspirator needle directly into the cavity of the cyst, without puncturing any other hollow organ or large vessel or excretory duct. Its success will depend on the complete emptying of the contents of the cyst. This method will fail, as it has in my hands, if the main cyst is full of loose daughter cysts which will be drawn into the needle and occlude its lumen. The danger attending aspiration is in 66 ABDOMINAL TUMORS. not emptying the sac completely, so that the contents, subjected as they are to great pressure, are forced through even small openings like the needle puncture into the general peritoneal cavity, causing fatal peritonitis or inoculation of the parasite into the peritoneal cavity. Death has resulted while attempting to aspirate hydatid cysts from puncture of the hepatic veins, with sudden dissemination of the contents of the cyst into the general circulation through these channels; still many cases of perfect recovery from hydatid cysts are recorded as having followed a single aspiration of the contents. When the suppurative process has been established, open incision will be required. When laparotomy is necessary for the removal of the tumor thus formed, two operations are open for adoption; the first contem- plates immediate incision of the sac and evacuation of the contents; the second proposes the performance of an operation for the purpose of establishing adhesions between the tumor and the abdominal walls, and after a lapse of sufficient length of time for their foimation, to open the sac and empty out its contents. The first method of treatment is as follows: The tumor is exposed by an incision through the abdominal walls over its most prominent portion, made in accordance with the rules already given; if found non-adherent, the walls of the cyst are attached to the edges of the incision by the use of the continuous suture. The peritoneal cavity is closed entirely by means of the usual interrupted suture, introduced at such points as remain open after the attachment of the cyst to the external wound. The cyst is then opened freely and the contents evacu- ated and proper antiseptic dressings applied to prevent septic infection of this cavity, after satisfactory means of drainage have been introduced into the cyst cavity, either by the use of drainage tubes or strips of iodoform gauze. This method of primary incision is mainly applicable to cases in which adhesions have already formed between the cyst wall and the abdominal walls, or in those cases in which the cyst occupies a considerable por- tion of the abdominal cavity, displacing the contents thereof, and its walls thereby rather closely applied to the internal sur- face of the abdominal walls. It has been used safely in hydatids developing in the substance of the liver and still having at the time of the operation, a thin layer of liver tissue between the cyst and the abdominal walls. In such cases the external surface of the liver is attached to the edges of the external abdominal incision by means of sutures, previous to incising the cvst. After ABDOMINAL TUMORS. 67 this incision is made, the treatment of the cavity is similar to that just suggested. In the second method of operation, the proper incision is made through the abdominal walls to expose the surface of the cyst or the organ in which it is developed; the wound is then packed with iodoform gauze, covered with the usual external antiseptic dressing and left for several days. The presence of the packing in the wound soon leads to the establishment of firm adhesions between the surface of the cyst and the parietal peritoneum. When these are formed the dressings and packing are removed and the cyst cavity opened freely, emptied, drained and such external dressings used as have been described. Firm adhesions will usually be found between the cyst and the abdominal walls if the suppurative process has occurred previous to the operation, and the latter is attended with correspondingly less danger. With pus present, free irrigation of the cavity of the cyst is indicated. Gastrostomy. Immediate starvation is avoided in a patient by the establish- ment of a permanent fistula between the stomach and the abdominal walls, and is practiced for the relief of otherwise irremediable stricture of the oesophagus as the result of the devel- ment therein of malignant disease or cicatricial contraction. The abdominal cavity is opened by an incision, three inches in length, carried through its walls, oblique in direction, parallel to the edges of the costal cartilages of the seventh, eighth and ninth ribs on the left side and three-fourths of an inch away from the costal margin. This opening being made, the middle portion of the anterior surface of the stomach is drawn well into it and attached to its edges by silk sutures. It is necessary to avoid entering the cavity of the stomach with the sutures passed through its walls. W7hen this attachment is satisfactorily made the still open portions of the abdominal incision are closed by sutures. A silk suture is passed through the serous and muscular layer of the exposed portion of the stomach and left long to mark the position for the formation of the fistula. If the patient's condition will allow, the fistula should not be made into the stomach until firm adhesions are formed between 68 ABDOMINAL TUMORS. the stomach and the abdominal walls; at the end of 24 hours this will have occurred and the danger of peritonitis attending the entrance of the contents of the stomach into the peritoneal cavity avoided. If the patient's condition, from absence of food, will not allow of any delay being practiced, the opening into the stomach can be made at once, or milk can be injected into the stomach by the use of a hypodermic needle which is inserted through the portion exposed in the incision. This opening into the cavity of the stomach should always be small, sufficient to admit of the introduction of a No. 10 English catheter into the stomach cavity; if made larger than this there is likelihood of the occur- rence of constant overflow of gastric juice producing annoying excoriation of the surrounding integument. As soon as the fistula is well established the patient can be fed by means of a tube passed through it. In one case under my charge, a permanent tube, improvised from an aluminum trache- otomy tube, was used satisfactorily; the external opening was kept closed by a well fitting cork. The aluminum tracheotomy tube was shortened sufficiently and its free end worked into the shape of a flange, which, after the tube was introduced into the stomach, retained it in position; it was light and did not cor- rode. In cases of cicatricial stricture of the oesophagus dilata- tion can often be accomplished by carrying a bougie through the stricture from the opening in the stomach. After the stricture has been dilated sufficiently the opening in the stomach may be per- mitted to heal. Stenosis of The Pylorus. Impermeability of the pyloric extremity of the stomach as the result of cicatricial contractions or the development of malig- nant growth, has been relieved by means of three operations. First, Loretta's operation for cicatricial stenosis, which is practic- ally a divulsion or a forcible dilation of an inflammatory stricture of the pylorus. It is accomplished in the following manner: The stomach is exposed by an incision through the abdominal walls in the mid line, made after the usual manner and with the usual precautions. The anterior wall of the stomach is brought into the abdominal incision and opened to such an extent as will allow of the easy introduction of two fingers through this opening into ts cavity; the stricture is then dilated by passing the finger into ABDOMINAL TUMORS. 69 it; first one and then two, followed by a separation of the two fingers in the stricture until the pyloric lumen is of satisfactory size. The wound in the stomach walls is then accurately closed by the Lembert suture, applied in two rows as recommended by Prof. Czerny; the first row introduced close to the incision in the stomach walls and the second row bringing peritoneal surfaces together, at least one-fourth of an inch away from this incision. The abdominal wound is closed by sutures and proper dressings applied. It should always be borne in mind that in all operations in the abdominal cavity in which the stomach is opened, if the oesoph- agus is patulous, it is imperatively necessary to wash out the stomach repeatedly with some mild antiseptic fluid such as one- half per cent, solution of table salt, in order that contact with any of the deleterious contents of the viscus may not imperil the success of the operation. Second, free vertical division of the stricture and pylorus, with subsequent transverse suturing of the wound, thus made. In this operation the pyloric extremity of the stomach is exposed to view by means of the usual incision through the abdominal walls and the pylorus drawn well out of the wound; the vertical incision is then made over the center of the pylorus, opposite to its attached margin; it should be sufficiently long to divide the entire length of the contracted portion; the centers of the opposite edges of the incision are then seized with proper forceps and drawn away from each other until the wound through the pylorus is made to assume a transverse direction, in which position the edges are accurately united by sutures and the pylo- rus is returned to the abdominal cavity, the external wound closed and proper dressings applied. When the pylorus is the seat of a malignant growth, Pylorec- tomy, or complete excision of the tumor is practiced for its relief. The tumor in the pylorus is exposed by the usual abdominal incision, made either in the mid line or over the course of the tumor. When the tumor is exposed, it is sufficiently freed by a separation of adhesions or attachments, to be brought well through or into the abdominal opening. The cavity of the abdomen is protected from the entrance of deleterious material, during the excision of the mass, by the proper application of sponges or other material around and beneath the exposed tumor. The detachment of the tumor is made by a division through the stomach walls and duodenum, through healthy tis- 70 ABDOMINAL TUMORS. sue; the necessary incisions are made slowly and carefully. All bleeding vessels in the walls of the viscera, or their mesenteric attachments, are permanently closed by ligature as soon as divided. After the removal of the tumor the large opening in the stomach is diminished to correspond in size with the lumen of the duodenum, by closely approximating the edges of the opening in the stomach by means of silk suture. The continu- ity of the alimentary tract is then restored by attaching the free extremity of the duodenum to the properly reduced opening in the stomach, by means of a double row of silk sutures; the first row applied close to the edge of the opposed openings and car- ried around the entire circumference of the intestinal tube; the second row applied at least one-fourth of an inch away from the first row, and also encircling the intestinal tube. If the inter- rupted suture is used, they should not be introduced at a greater distance than one-fourth of an inch apart. The abdominal cav- ity is thoroughly cleaned and the external opening closed with sutures and dry external antiseptic dressings used. Gastro enter- ostomy is rather more satisfactory and less dangerous than pylorectomy and is usually practiced in preference. Super-pubic Cystotomy. The bladder is rendered as nearly aseptic as possible by re- peated irrigation with 3 per cent, solution of boric acid in water and the administration of 5 grains of boric acid internally every tour hours for a few days preceding the operation. The incision for exposing the bladder above the pubis should be three inches in length and made accurately in the mid line, there is usually no difficulty in following this line as the pyra- midalis muscles form an easy guide to be followed; the deeper portion of the incision should reach the pubis at its lower end as it is carried down to the transversalis fascia. All bleeding ves- sels are secured. If possible the bladder is distended by forcing into its cavity ten or twelve ounces of a four per cent, solution of boric acid in water. This distention of the bladder brings its fundus well above the pubis and as a rule the reflection of the peritoneum above the external incision. As soon as the external incision has reached the fascia covering over the anterior wall of the distended bladder, this fascia, together with the peritoneum, is pushed up to the extreme upper end of the external incision ABDOMINAL TUMORS. 71 by the index finger of the left hand. The anterior wall of the bladder is then fully exposed to view by dividing the fascia cov- ering it. The anterior bladder wall having been uncovered, a curved needle armed with a silk ligature is introduced through its walls on each side, opposite to the middle of the externa'. incision. The needle used for this purpose should take up half an inch of the bladder wall; these sutures are cut long and their ends tied together and are used for the purpose of controlling the bladder walls and the incision made into this cavity; they should be handled carefully to avoid tearing the bladder tissue included in them. The incision through the bladder walls into its cavity, is made by thrusting a knife into that cavity through them, with the back of the knife turned upwards; the incision is extended downwards as far as is necessary to accomplish the purposes of the operation, and this length will depend upon the size of the calculus which is to be removed or the tumor to be treated and which size has been somewhat accurately estimated before the operation is begun. As soon as the opening into the bladder is made the water which distended it will rapidly flow away; the edges of the incis- ion in its walls can then be held up into the external opening by means of the stay stitches already introduced, and thus avoid losing the opening into the bladder or the greater danger of undue separation of the investing tissues of the bladder by unnecessary manipulation. Any foreign bod)' present can be removed by the fingers or forceps introduced into the cavity of the bladder. If the operation is done for the treatment of tumors or other diseases requiring its performance, the necessary manipulations can be executed through this opening in the bladder. The next procedure depends upon whether the patient's urine has been shown by previous examination of it, to be healthy and inoffensive in character or foul and deleterious in nature from the presence of cystitis. If the urine is healthy and the urethra normal in size, the wound in the bladder is closed immediately by bringing its edges in accurate apposition by means of closely applied interrupted sutures; this can easily be accomplished even in the presence of thick abdominal walls, as the stay stitches will enable the operator to hold the wound in the bladder under per- fect control. The external wound is then accurately closed after the removal of the stay stitches, with the exception of its lower end, at which a rubber drainage tube is introduced to the bottom ABDOMINAL TUMORS. of the cavity. The drainage tube is left in position for two days, to provide against the accident of leakage through the bladder wound; if no leakage occurs at the end of that time and the urine is passed normally, it can be withdrawn. Dry antiseptic dressings are applied to the external wound. When cystitis is present in the case and the urine thus ren- dered foul and offensive, it is best not to make any attempt to close the bladder wound; after accomplishing the purpose for which the operation was undertaken, through the incision in the bladder walls, its cavity is thoroughly irrigated with some mild antiseptic solution and a fair sized drainage tube, properly per- forated, introduced well into its cavity and brought out of the lower end of the abdominal opening. Perhaps it is better to introduce two drainage tubes of moderate size into the cavity of the bladder, one of them being perforated, the better to provide for future irrigation of the viscus. The stay stitches are then removed and proper external antiseptic dressings applied. Many plans are in use to successfully overcome the annoy- ance attending the overflow of urine in such cases as must be left open. No plan, in my experience, has answered so well as the application of masses of cheese cloth, moderately moistened with a two per cent, solution of carbolic acid. These moist pads absorb the urine and when changed often enough the patient can be kept quite dry. It has not been my experience during the performance of quite a number of super-pubic cystotomies to meet with hemorrhage of any consequence following the division of the blood vessels coursing through the fatty tissue investing the anterior surface of the bladder. It is my belief that their importance and the danger attending their division has been greatly magnified. On several occasions after the usual external incision was made, the bladder was safely reached and successfully opened by myself, when undistended, and without the introduction of the sound as a guide, by separating the tissues covering the bladder close behind the pubis with the finger, until its anterior wall was uncovered well down on that surface; holding the finger in con- tact with the uncovered bladder wall the knife is introduced along the finger as a guide, and the thrust made which opens its cavity. When the urethra is patulous a sound can be introduced into the bladder and the anterior wall lifted on the point of it into the external opening, after which the necessary incision into the ABDOMINAL TUMORS. 73 bladder cavity can be made on to the projecting point of the sound after the introduction of the stay stitches, the use of which has been recommended. Splenectomy, or complete extirpation of the spleen for enlarge- ment, the result of the disease termed leucocythemia, is attended with such an overwhelming mortality, that its performance can scarcely be justified. For one reason or another, the surgeon is tempted to perform splenectomy with the hope of giving relief in these lamentable cases. This should be done only for condi- tions not complicated with leucocythemia. The incision through the abdominal walls to uncover the tumor should be made in the left lines semi-lunaris, and should be made long enough to make subsequent manipulations easy. If free from adhesions and the organ has a sufficiently long pedi- cle to allow of its ready extraction through the abdominal incis- ion, this pedicle, made up of blood vessels and peritoneum, is carefully bisected, ligated in halves and divided, after the pedicle is secured for subsequent inspection by the application of a pair of forceps outside of the ligature. If many adhesions are pres- ent to the diaphragm or other organs, their separation is attended with great loss of blood, even if the vessels separated are not large, because the condition of the blood in these cases is such as not to be accompanied with the phenomena of coagulation. The majority of such cases die from hemorrhage very shortly after the removal of the tumor. Cysts of the spleen are more amenable to relief, their removal being attended with the subsequent restoration of the patient to health. The incision to uncover these is the lateral one men- tioned. Their complete removal, even if attended with that of the unenlarged spleen, has shown favorable results. If the cyst is in such condition as to preclude its entire extir- pation, it should be attached to the incision in the abdominal wall, incised, emptied and treated as already directed for the care of an irremovable cyst of any abdominal organ. In all condi- tions the external incision is managed according to the rules already given. The vessels entering the spleen are normally very large and are increased enormously in size in many of these tumors under consideration, so that the utmost care must be practiced in the means used in the control and prevention of bleeding from them. 74 ABDOMINAL TUMORS. Fifty Successive Cases of Ovariotomy* In presenting for your consideration a tabulated list of my first fifty cases of operation done in succession for ovarian tumor, it will be my object to call attention to those only which seem to me to possess somewhat special characteristics, or have shown some- thing unusual in their course. Not but what I believe that every case is of special interest to the operator, in so far as it furnishes him individually with useful experience and something new to cogitate over, and from which to elucidate improvements in future cases coming under his care. To mention all these cir- cumstances would become monotonous. In the final summing up I shall attempt to group together, in a somewhat practical way, the deductions which come to my mind as the outgrowth of this amount of work. My work in this field commenced rather early in my profes- sional career, and whatever success may have attended my efforts could not have been, and was not, the outcome of any special preparation. The first half-dozen operations were done before ever having witnessed the operation performed by any other operator. In 1878 it was my privilege to see considerable of this kind of work executed by the attendants at the Samaritan Hospital, Lon- don, and other surgeons. Since then, I have felt more at my ease in this labor, and could speak more emphatically as well as encouragingly to my patients. Before then the work had associated with it a large expenditure of force, both mental and physical, on the part of the operator, and I am free to admit that, as a rule, the patients did not get along as easily and smoothly as they have since. Still it has been my good luck not to have a very large percentage of mor- tality. The table shows that the second and thirty-seventh cases died as the result of circumstances attending the operation. Two out of fifty—it is not a bad showing. If it is my good fortune to equal this percentage in the second fifty, no complaints will be heard from me. Case I.—This lady is still living in this city. She has never borne any children. The operation was done during the third year after my graduation, and is chosen for remark, first, because the case furnishes a good illustration of the impudence and * Read before the Gynaecological Society of Chicago, Friday, April 20, 1888. ABDOMINAL TUMORS. 75 assumption sometimes displayed by young and ambitious prac- titioners, and which causes them at times to run where angels would fear to step even slowly. I believe I invited to be present at the operation Professors Freer, Gunn and Powell, Jackson, Bogue. and some others, and they were all on hand. It has always been a mystery to me how that operation was carried on, or finished; perhaps some who were present might be able to tell; it is impossible for me to do so. However, it is clear in my mind that there was no encouragement to me in their prognosti- cations as to the result. They were unanimous in the assertion that the issue would be fatal. But it was not, although the patient had a hard time of it for awhile. Secondly, the case is of interest in the condition which made her recovery slow and full of hazard. The fourth or fifth day showed evidences of pro- found septic infection. An abscess was at last discovered in the cul-de-sac of Douglas. After opening and washing it out and draining thoroughly, she passed on rapidly to a full recovery. This latter inflammation may have so changed the remaining tube or ovary as to account for the subsequent sterility. No antiseptic precautions were adopted in this case. Case II.—This case was one of double ovarian tumor. The right cyst was free, non-adherent, and easily removed. The left was universally adherent to the left side of the abdomen, to the small intestines, spleen and stomach. Its contents were so gela- tinous that they were scooped out with the hands, and the cyst- wall was so thin that it broke down in many places during these manipulations, allowing the contents to become disseminated about and around the abdominal organs. The oozing was very free from the extensive surfaces of adhesions, and there was used a solution of persulphate of iron to check it. This remedy is a very unpleasant one to employ; this was the first and last case in which I have made use of it. The abdomen was washed and cleaned, as I thought, thoroughly. A large sized rubber drain was carried to the bottom of Douglas' cul-de-sac. The outer end of it was connected with a long rubber tube, carried outside of the bed and beneath it, and submerged in a solution of carbolic acid. The patient died on the third day of acute septicemia. The drain, carried to the bot- tom of the receptacle, gave exit to about two ounces of the con- tents of the cyst. It is fair to think that this case could be managed better to-day. No special antiseptic measures were adopted. 76 ABDOMINAL TUMORS. Case IX.—This case was the first tumor with purely colloid con- tents which I had come across. It was with the utmost difficulty that its contents could be emptied out of the rather small incis- ion which exposed the tumor. Still by persevering effort, it was all dug out, and, as few and recent adhesions only were found, the empty sac was pressed out and rather easily removed. I have seen such cases treated by enlarging the abdominal incis- ion in order to turn the mass out entirely. It has struck me that this method was not as good as emptying the cyst through the small incision. As all the cases turned out en masse have died, that fact may have influenced the formation of the opinion expressed. The cause of death may have been something else. Case XXVI.—This case was [the youngest person upon whom I have operated. Owing to the great size of the tumor, as com- pared with the size of the body, she presented a very odd appearance. In order to maintain an equlibrium while in the erect position, the shoulders were thrown far back—a plumb thrown from the shoulders touched the floor six inches behind the heels. The tumor was a dry one, and before it could be extruded the abdominal incision was prolonged above the umbilicus. For such a massive tumor the pedicle was very small as well as elongated. The weight of the tumor was fourteen pounds. The case was to me, particularly interesting because it was the only one of the series in which any attempt was made to carry out in full all the details of a Listerian operation, including the spray. Notwithstanding all this an abscess formed in the left iliac fossa, which delayed the recovery for weeks and placed her life in great danger, especially as, even after it was opened exter- nally, it seemed to empty internally into the bladder; large quantities of pus were passed from that viscus. At the end of six weeks she had entirely recovered. This was the only case in which I have been haunted with the fear that I might have left some foreign body in the abdominal cavity, such as a sponge or a pair of forceps. The sequelae showed it to be a groundless fear, fortunately. The subsequent history of this case is also interesting. At the end of two years she again came under my care with the abdomen distended with a large growth. This secondary growth commenced in the upper zone of the cavity, and in its development increased downward. It was diag- nosed to be post-peritoneal, on account of the crackling which IBDOMINAL TUMORS. 77 could be produced by manipulation in circumscribed spots over the surface of the tumor. The noise was evidently produced by the displacement of intestinal gases over limited spaces. Upon opening the abdomen the mass was found entirely behind the peritoneum, which was opened posterially and the tumor easily enucleated. As far as could be determined, the mass grew from the lesser end of the pancreas. She did not survive the shock of the operation but a few hours. The mass proved to be sarcomatous. A post-mortem examina- tion showed no traces of even the stump of the first tumor. Dr. Fenger was present at the first operation and pronounced the tumor to be a heterologous growth. With an entire absence of any remnants or signs of the pri- mary tumor, it seems rather difficult to trace any connection between it and the secondary manifestation. Case XXXV.—This was a case of double papillomatous ova- rian cyst, in which the tumors had become intimately adherent, filled up the pelvis entirely, so as to absolutely conceal the womb and bladder. The cysts had ruptured so that in themselves they were small. The abdomen was distended with an immense quan- tity of free fluid. They were freely enucleated from their bed and from the surface of the uterus and bladder and removed. There was left as the result of this extensive peeling a surface coequal in size with the capacity of the pelvic basin. After secur- ing the pedicles and a few spurting arteries, the bleeding was easily stanched and showed no disposition to return after the introduction of a large drainage tube to the bottom of the cav- ity and closing of the abdomen. I have never seen a larger flow of serum from a drainage tube than followed in this case for sev- eral days. Fortunately, no infection of the general peritoneal surface had occurred, so that the lady recovered very rapidly and is well and strong to-day. The free drainage in this case, I have no doubt, contributed very greatly to the easy recovery. With- out it I believe the patient would have been suffocated by accu- mulation of serum; certainly no powers of elimination could have removed the amount of fluid drained. Case XXXVII.—This case was certainly the worst I ever met with so far as extent and firmness of adhesions go. It was uni- versally adherent to the abdominal walls, the small intestines, the bladder, the uterus, the under surface of the liver, and to the stomach. In fact, at only one place was a space as large as the surface of the hand untrammeled by adhesions. This was around 78 ABDOMINAL TUMORS. and about the pedicle. After separating the attachments to the abdominal walls down to this space on the right side, the pedicle was ligated and divided. It seemed impossible to reach the lim- its of the tumor from the anterior surface upward, so after secur- ing the pedicle the sac was turned upward, and the separation of the adhesions carried on from behind. It was a very slow and tedious piece of work, separating coil after coil of small intes- tine. When the stomach was reached, the adhesions were found so firm and extensive that it was deemed best to leave a large piece of the external layer of the sac wall attached thereto, rather than to try to separate them. This was accordingly done. All of the tumor except the piece left on the stomach was finally removed. There was not an excessive amount of bleeding, and the abdominal cavity was readily cleansed and a drain put in. The operation was done in Nebraska, and I had to leave the patient within two hours after the operation was finished. She was then in good condition. She died on the sixth day, as the doctor in charge wrote me, with all the symptoms of unrelieved obstruction of the bowels. Perhaps if the abdomen had been re- opened early in the manifestations of these symptoms, the obstruction might have been overcome, but this can only be a supposition, this was the second and last death in the series of fifty cases. Case XXXVIII.—The tumor in this case was accidentally dis- covered while operating upon a growth developed in the abdom- inal walls over the neighborhood of the gall bladder, and from which there was removed a gall stone of considerable size. Some months after the recovery from this operation, laparotomy was done for the small tumors which filled the pelvis and were developed from both ovaries—the right one much larger than the left, but both small. They proved to be ruptured cysts, show- ing papillomatous degeneration. Some six weeks after this operation, after the wound had united well and recovery seemed established, she developed increasing symptoms of bowel obstruc- tion. Examination of the rectum revealed a cancerous mass at the upper end of the rectum, probably also involving the sig- moid flexure. She was anaesthetized and the narrowed channel well dilated, sufficiently at least to relieve the accumulated con- tents. Still, the patient gradually emaciated, and at the end of a week or ten days succumbed to the effects of the complication. Case XLI is only remarkable from the age of the patient—78 years old—and the perfectly uneventful recovery after the oper- ABDOMINAL TUMORS. 79 ation. Looking back at the case, I remember the impression made upon me at the time was that she was the most contented patient ever under my care. No anxiety or worry of any kind was manifested. Everything done was good enough for her and gracefully accepted. The querulousness and disposition to be exacting sometimes supposed to go with old age was never displayed. I am quite sure her peaceful disposition had much to do with her speedy and happy recovery. I have since operated on a lady 68 years old for an ovarian cyst, and the results were nearly alike. So far as these two cases are of account, nothing whatever occurred that would make quite old age militate against the performance of the oper- ation. The shock did not seem so great as in many other easier cases in younger patients, and the reaction was quite as prompt and harmless. The case under consideration was a large multilocular cyst with thick walls and septa. The previous tappings had not apparently left any unfavorable conditions in their wake. The adhesion present gave no noticeable trouble. Case XLII.—This was my first case of twisted pedicle. The inflammatory symptoms—peritonitis—high fever, and extreme prostration had existed several days before the patient came under my care. Operation was advised and done immediately. The bad symptoms subsided at once, and the recovery was uneventful. There followed in due course quite a large ventral hernia, although primary union occurred in the wound, at least in the skin. It is possible that the usual care in picking up surely each layer of the abdominal wall was not followed in closing the incis- ion, but I was not aware of leaving anything undone in that respect at the time of the operation. The diagnosis of twisted pedicle was based upon the previous existence of the tumor, its sud- den and rather rapid enlargement, extreme tenderness of the tumor, followed by the usual symptons of peritonitis and constitutional manifestations of early and severe character. There was present also a free flow of dark blood from the uterus, commencing with the first symptoms and persisting. Case XLV was the second tumor removed having very thick colloid contents. It was perfectly symmetrical and free from adhesions of any importance. The contents were extremely tenacious, and their removal to 80 ABDOMINAL TUMORS. diminish the size of the cyst was attended with extreme diffi- culty. The cyst was held very carefully against the edges of the abdominal incision during these efforts, in order to avoid the entrance of any of the stuff into the peritoneal cavity. It is much easier to keep it out entirely than it is to get it out after it has once gained admission into the cavity. On two occasions the leaving of a very little of this material in the cavity inadvertently has given rise to serious complications in my experience. Case LX.—This case was also one of twisted pedicle; the symptoms of rapid increase in size, tenderness, and uterine hem- orrhage coming on suddenly and persisting, with developing peritonitis, were plainly present in the case, and early operation advised. Consent to operate was not obtained readily, and when the incision was made the cyst and pedicle were found black. Ulceration between the living and dead portion of the pedicle had well advanced at the site of the twist lowest down on the pedicle. Its complete separation was unattended with hemor- rhage. The case did well from the very first day. Remarks. It has always been my aim to do every one of the operations here recorded with closer and closer attention to absolute clean- liness of person, assistants, patient, and of appliances. As time passed along more experience gained, and complicating difficulties traced to their cause, after suffering manifold mental worry over them, this aim has been better and more certainly attained, with a corresponding increase in confidence in myself and ability to make assurances to the patient with an abiding faith in their fulfillment. There is no doubt in my mind whatever about the good done a patient by relieving her mind of doubts and nervous dread pre- ceding the operation, as can be done by confident assertion. The success attained in ovariotomy of late years warrants an indul gence in very strong assurances on the side of recovery in all classes of cases. The attempts to secure asepsis—to surely save one's patient from the dangers of fermentation, suppuration, and decomposi- tion of wound secretions—brooks no neglect of any kind in the items already mentioned. It is not a pleasant thought to be ABDOMINAL TUMORS. 81 forced to the conviction that you have rewarded the confidence and faith reposed in you by carrying to the afflicted one the ele- ments which, once developed, so often destroy life, especially if the misfortune be the result of carelessness or over confidence. So nothing that is used or brought in contact with the patient should be allowed to pass without the closest inspection by the operator himself. The patient puts her life in the operator's hands, not in those of an assistant, and is entitled to the former's own care and attention to the smallest detail in the preparation of needles, forceps, and instruments of all kinds, ligatures, sponges, and dressings. It is my conviction that sponges should not be used the second time in abdominal operations, no matter how well they are cleaned. They are so difficult to free abso- lutely from the contamination of blood and secretions, that one can scarcely be sure of them. Besides, the operation is so well paid for in most instances, and the material so cheap, that there seems no excuse to run any danger whatever. The greatest diligence should be observed in keeping every- thing harmful out of the peritoneal cavity. Reference is made not so much to foreign bodies of large or small size, although such ought never to occur, as to the escape of the contents of the cyst into the cavity. To me it has always been a very difficult undertaking to clear out any such secretions, especially if they are from a cyst with sticky contents. In two cases I worked for fully an hour in my desire to be sure that all particles had been removed, and yet in both cases an abscess subsequently formed, accompanied with a formidable temperature and general exhaus- tion. These accumulations were fortunately found and opened. Their contents showed more or less of the same material that filled the cyst, and the trouble was evidently dependent upon its presence in the cavity. The stuff will not flow through a drain easily, so that I am not sure its use would have overcome the difficulty. The contents can usually be kept out of the peritoneal sac by making the cyst constantly expand the edges of the abdominal incision during the necessary manipulations, by careful pressure against the tumor by an assistant. The ligatures used have always been of carbolized silk, and they have never given rise to any trouble. In the greatest num- ber of cases the pedicle has been clamped, the tumor removed, and the stump thoroughly cauterized down even with the clamp. Then the pedicle was sufficiently subdivided just below the clamp 82 ABDOMINAL TUMORS. and ligated with silk, after which the clamp was removed and the stump dropped. I have never had, following this method, any bleeding, or been called upon to reapply the ligature, or fish up a stump out of the pelvis after it had been dropped, to stay hemorrhage. It is the method used by Dr. Homan, of Boston. Accidents such as indicated have happened to me when using other methods, and I have seen them occur in the hands of other operators. Perhaps I may be pardoned for uttering a warning against using the ends of a ligature just tied for the purpose of bringing the tied tissue into view for inspection, especially against using them to in any way steady or lift the pedicle. This latter should always be fixed and manipulated with a pair of forceps fixed to its edge below the site of ligation. On more than one occasion traction on the ligature, apparently slight, has destroyed its com- pression and induced bleeding, or even torn it entirely loose, necessitating a tedious search for the lost stump in order to re-tie it; and one never feels as certain of the security against hemorrhage after such an accident, aside from the delay and annoyance caused. My experience confirms the great worth of, and necessity for, the drainage tube in many cases. Cases with many vascular adhesions leaving extensive oozing surfaces seem to always require the drain. Many cases would undoubtedly do better with it, even in which the raw surface is not large. One is more apt to err on the side of leaving it out than of making use of it too frequently. It takes but little over-weight of absorption and elimination of even not badly contaminated fluids to upset a patient's easy recovery, which might have all been obviated by the use of a drain for twenty-four or forty-eight hours. I have not noticed much difference in its workings, whether it be of glass or rubber; I have used both and the object aimed at was accomplished by either equally well. The abdominal wound has always been closed with the silk suture passed carefully and carried through the different layers of the abdominal walls, including the peritoneum. It does not seem that any more satisfactory method has been advanced. It is quickly executed and absolutely trustworthy in the vast major- ity of cases. Two of my cases have had ventral hernia follow; but I am inclined to think other things had something to do with the occurrence of the complication, such as too early assumption of the erect position, too free motion, and discarding the abdom- ABDOMINAL TUMORS. 83 inal support too soon. Very few of the cases have shown any suppuration in the track of the sutures, or other complication in the line of the incision; certainly no more than six gave any trouble whatever. In very thick, fat walls, the use of three or four button-stay sutures, introduced well away from the edges of the incision, is of great advantage in maintaining the parts in close apposition and conducing to early and firm union. In the after-treatment of the earlier cases it was the rule to use the catheter to empty the bladder six hours after operating. Quite a number of the cases developed a troublesome cystitis, and in some cases a urethritis, no matter what care was taken with the instrument or in its introduction. Of late it is not used unless absolutely required. The patient is induced to make earnest efforts at self-relief, and strccess generally follows these efforts, and cystitis has ceased to be a complication. It has become my habit not to feel concerned about a tempera- ture up to ioi degrees Fahr., coming during the first three or four days after an operation, if it be unaccompanied with unusual pain, headache, or anorexia. By securing a free action from the bowels by the administration of 5 grains of hydrarg., submur., followed in due time by some saline cathartic, and urging the patient to partake freely of water, the temperature ordinarily drops to about nor- mal in twenty-four hours. If, with a nearly normal temperature for several days after operation, it suddenly mounts to 100 degrees or more, some complication is impending, and it must be sought for with great care. Laterally it has been a surprise to me how many of the cases go on to a safe recovery without the administration of any medicine. If sepsis is avoided, the indi- vidual's own powers of repair seem entirely competent to com- bat other complications with the simplest of assistance. When pain is a complication, rectal injection of the tr. opii deodorata, in full, free doses (30 drops or more), has always seemed to cause the least disturbance and accomplish the best results. In none of these cases did there arise any necessity for reopen- ing the abdominal wound, Tne highest temperature recorded occurred in the twenty-sixth case, in which 104 degrees was present for several days. The abscess was found and opened and the girl got well. Cases one 'and nine, forty-five and forty-seven, also had abscess collections, with high temperatures. The collections of septic matter were opened where developed, and the cases finally recovered; but the complication entailed upon them a slow recovery and a 84 ABDOMINAL TUMORS. weakened general condition which those escape who pass through their ordeal free from such complication. Both with these serious conditions and other slighter ailments, less severe but absent entirely in perfectly aseptic cases, the fault must be laid upon my own shoulders. At first, lack of experience, then want of attention to detail in appliances or sur- roundings, and finally, perhaps, over self-confidence. It is my belief that he will have the best success who is modest enough to be haunted by some doubts about himself, and so to be ever on the watch to prevent the entrance of harm from without. The internal remedies from which the best results have been obtained for the relief of tympanitis are the spts. terebinthina and tr. nux vomica; the former to allay gaseous fermentation and as an antiseptic; the latter acting probably as a stimulant to intestinal peristalsis. It has never seemed to me that much of any good was accomplished by the rectal tube. It is not my wish to advise against its use, for many operators believe in its efficiency and use it constantl). It is quite possible that I do not use it skillfully. However that may be, I do not remember to have gained much if any good by its use. Cases in which the intro- duction of the rectal tube released any amount of gas could always relieve themselves by exercising a little will power, par- tially that of relaxation of the sphincter, mainly that of contrac- tion of the abdominal walls. It has seemed to me that its presence in the rectum, if left there, as is practiced by some, might be of service as a foreign body in exciting peristalsis. Tympanitis, like so many other complications when they come, is usually the result of septic infection, and is best dealt with by keeping the germs away from the patient before, during, and after the operation. The fluid I am in the habit of using for purposes of washing or irrigation is plain distilled or boiled water, with the addition of a small quantity of carbolic acid, making a solution of a strength of about two per cent. It does not seem certain that the germicidal power of this solution is of much consequence, still it does not seem worth while to dispense with it entirely. In washing out the peritoneal cavity, if occasion requires, a strong solution of boracic acid is used, and has done its work harm- lessly and satisfactorily. Of course, reference is made here entirely to ovarian tumors, pure and simple. Infected cases with pus present and other harmful fluids, require more powerful antiseptics and assiduous care in getting rid of their presence by every known means. ABDOMINAL TUMORS. 85 The fifth and thirty-fifth cases of this series showed papillom- atous degeneration and rupture of the cyst wall, with the pres- ence of extensive accumulation of ascitic fluid, rendering the diagnosis extremely uncertain. I have operated on several cases since, and they have all been difficult to diagnose and to handle. Fortunately, these two presented no secondary infection of the peritoneum, and they recovered. The diagnosis must be made by a process of exclusion. Heart dropsy, by the absence of facial cedema and heart lesions; kidney dropsy, by the absence of leg cedema and the signs of kidney degeneration as shown by the microscope; ascites, from liver or vessel obstruction, by absence of the mani- festations of disease of those organs, as shown by careful physi- cal examination and inquiry as to their usual constitutional manifestations. Digital examination in all the cases seen by me has demon- strated the presence of a somewhat circumscribed mass in the pelvis, from which the uterus could be isolated. The feel of the mass itself gives one the sensation of touching an irregular, doughy, cauliflower-like tumor. The differential diagnosis from tubercular peritonitis with ascites will be, in the absence of the tumor from the pelvis and the presence of a greater or less num- ber of irregular, hard, perhaps movable masses distributed through the cavity, showing involvement of the omentum. Differential diagnosis of cancer will be probably in the fact that the latter shows less ascitic accumulation, a more easily defined mass, much harder to the touch. Examined through the pelvis, every tissue is apt to show infiltration; the uterus is fixed and implicated in the growth; the roof of the pelvis everywhere hard and resisting. There will more likely be evidence of inter- ference with the circulation of one limb, as shown by cedema confined to one side. Enlarged and tortuous external abdomi- nal veins, and more rapid and profound constitutional manifes- tations will be present. Even after rupture of the sac, and moderate infection of the peritoneum, these cases seem to do perfectly well after operation and removal. It seems to be of paramount importance to institute such care of the patient as will most surely prevent, diminish, or overcome the occurrence of shock. After every severe operation, much can be done by the use of external warmth, and also care during the progress, by keeping wet clothes away from the body. I am still convinced of the efficacy of morphia and quinia adminis- 86 ABDOMINAL TUMORS tered half an hour or so previous to the commencement of an operation. It can scarcely be denied that the patients do best if little, or better still, nothing, is put into the stomach for twenty-four hours or more. If introduced, the effect is merely to increase the dis- position to vomit. Judging from the results of considerably over one hundred laparotomies for different diseases, I think it proper to say that, as a rule, an operation for the relief of a simple ovarian tumor is about the simplest proceeding the surgeon is called upon to do in the abdominal cavity, and one from which the patient is most likely to recover. Professor C. T. Parkes in closing the discussion, said: There is very little to say, except, perhaps, in reference to what was said about the simplicity of the operation. I tried to make it plain that in reference to many other operations that are done in the abdominal cavity it is simple, not in reference to all opera- tions. Surgeons in all parts of the country are doing ovari- otomy, and the result is favorable in most of these cases. It must be a simple operation, or the results would not be so favorable. ABDOMINAL TUMORS. i Sept., '71 Hughes '7i May, '75 Sept., '75 Dec, '75 73 73 Peters. O'Mally.... Carney..... McGovern., Hunt...... Edwards. '75 Foster. Martin... McNulty. Jones..... Nov., '79 Henderson Pollock..... Probiski... Healy...... Dayton.... Johnson ... Jones ...... Mason..... Multiloc....... Mul. colloid... Mul. cyst...... Broad lig. cyst. D'ble. papilloma Unilocular___ Multiloc......... Unilocular....... Colloid tumor... 52 Multiloc.......... Broad lig........ Multiloc.......... Multiloc cyst.... Multiloc cyst.... Multiloc cyst.... Multiloc cyst.... Uniloc. cyst..... Multiloc cyst, colloid. Multiloc cyst, Unilocular cyst Parovarian cyst.. Dermoid cyst.... Parovarian cyst.. Multiloc cyst___ Multiloc cyst.... R & L R R & L R L L R No No Yes No No Yes Yes No Yes Yes No No Yes Yes Yes Yes Yes No No Yes No No Yes Yes No Yes No No No No No No No 3 No No No Yes No No No No No No No No No Good M Died Good Died In 1881 good Good Died 1884 Good Died 1878 Good Good Good Heard 3 years after, fair Don't know Good 5 years after, fair Fair Died 1876 Fair 3 years after Poor Good Fair Fair Good Fair Good 5 years ago Good Died 2 years after, Fair to death ABDOMINAL TUMORS. 89 ■a jy ~c K A -9 (fi ~ x, V ~ Pedicle, Kind and How Remarks. 3 ffc "3 JZ bo a •2 Treated. ^j bo ■£ be '5 a '3 u t5 "3 1> 1 « 3 H a < X No Yes No 27 lbs No Yes Transfixed: ligated. R Ligature discharged through abscess in cul-de-sac of Douglas two weeks subsequent. No No 43 " Yes Yes Long pedicle; transfixed and ligated, D Left very large; right small and single. Tap-ped once, previously. No No No 34 " No Yes Moderate pedicle; trans-fixed and ligated; silk. R Right ovary also remov-ed; cystic degenera-tion. Tapped twice. No No No 22 " No Yes (Enucleated), ligated; silk. R Caecum and colon carried upon wall of tumor some distance. Yes No No 42 " Yes Yes Short; transfixed, clamped, cauterized, and ligated. R Cyst small. Free fluid. No No No 26 " No No Fair; transfixed and liga-ted. R Contents milk-white. No No No 21 " No Yes Long; transfixed and liga-ted. R No No No 33 " No No Long and slender; trans-fixed and ligated. R Thick walls; chocolate-colored fluid. No No No 32 " No Yes Broad; short four sections; clamped; cautery; liga-ted. Short and broad; trans- R No No No 24 " No Yes R fitced, ligated, and cau- terized. No No No 28 " No No Transfixed and ligated. R Enucleated. No No No No Yes Ligated in many sections and divided. R Also removed mass of omentum. No No No 22 " No Yes Thick; transfixed and li-gated. R No answer to letter. No No No 25 " No Slight Short and thick; transfixed. ligated and cauterized. R No No No 18 " No No Moderate; transfixed, li-gated and cauterized- R No No No 39 " Yes Yes Broad; short and thick, transfixed, ligated and cauterized. R Semi-solid contents. No No No 18 " No No Moderate; transfixed and ligated. Medium; transfixed, li- R No No No 23 " No Yes R gated and cauterized. No No No 38 " No Yes Fair; long and broad: transfixed, ligated and cauterized. R No No No 23 " No ' No Short and broad; ligated in four sections. R No No No 18 " No Yes Broad; transfixed; ligated in three sections. R Adherent portions of cyst wall to caecum and uterus left. No No No 23 " No No Long and slim; transfixed and ligated. R No No No 19 " No Yes Broad; ligated in three sections and cauterized. R No No No 19 " No Yes Broad; transfixed and li-gated. R 90 ABDOMINAL TUMORS. Aug., June, Feb., June, '83 '83 Sept., Nov., June, April, Sept., Jan., Aug., June, '87 Mastin......... M, Herman.. . Peterson....... Allen, Mary.. Connelly.Bdgt Mackey,Maggy O'Neil.......... Dwyer, Marg.. Haggerty, Nel Riley, Mary.. Emerson...... Murphy........ Rush......... Piper ......... Morrill....... Patterson..... Holland:...... Ripkow....... Lewis........ Meehan....... Bick, Honora. Anderson..... Conroy ....... Mitchell, Mag Muldahl...... Hamilton..... Parovarian cyst. Sarcoma..... Multiloc. cyst. Multiloc. cyst.. Multiloc. cyst.. Simple cyst... Multiloc........ Dermoid cyst. Simple cyst . . Multiloc. cyst. Double papillo- matous cyst Multiloc--- Multiloc. cyst. Double ovarian Dermoid cyst.. Multiloc. cyst.. Multiloc. cyst.. Multiloc. cyst.. Multiloc. cyst___ Uniloc. cyst..... Colloid.......... Uniloc. cyst..... Multiloc. colloid. Multiloc. cyst.... Multiloc.......... Multiloc......... O 2 4> U C in rt 2 V a a U 6 « '-J 2 V a 35 a V 2 2 u "bo a 35 u o ■a November 26.- Changed dressings; dog seems bright. Gave pint of milk; also opium, which he drank readily, but soon vom- ited. Gave more milk about noon, which he retained. In the afternoon he seemed much weaker. Gave deod. tincture of opium gtt. 20 at night. Still lives, but is not strong. Lies in any position in which placed, and seems quite prostrated. Opium as before seems to revive nim; he refuses milk, but drinks freely of water, which the stomach promptly rejects. In the afternoon, being no better, removed dressings, and although wound was quite healed, made an opening for medium-sized drainage tube, and let out about a quart of bloody serum; re-dressed the wound after injecting a weak carbolized solution of warm water into abdomen through tube. Gave a rectal injection of alcohol and water (1-2 1-2) warm and gtt. 20 of opium. Is getting very poor, but respiration is regular; pulse very weak and rapid. November 28.- Gave enema of soapy water very weak. Washed out wound and inserted short drainage tube and fresh bandages. About 11 o'clock had a passage from bowels of a large quantity of black, tarry, and badly smelling faces, result of injection per rectum. At 2 p. m. was very weak. Gave enema of whisky and milk, warm, about two oz., and made a stew of small bits of beef and milk in whisky, which he ate greedily. Gave milk and whisky per rectum every three hours, also Valen- tine's extract of meat. November 29.—-Seems much stronger; had a semi-liquid pas- sage from bowels. Gave enema ever)' four hours of Valentine's extract, milk and whisk)-; and also fed pieces of raw meat in milk. November 30- Stead)- improvement; another passage, which evidently came from above scat of operation. Fed him on raw steak, and gave whisky per rectum every four hours. Sutures through integument have ulcerated their way out; were removed and dog allowed to lick his wound, as he promptly tears off all bandages. December 1.— Feeding as before, with steady improvement. December 2.—Another passage from bowels during night- Gave meat, about one-half pound every three hours, which he eats greedily; marked improvement daily in strength and appear- ance. December 3.- Same improvement. December 4. - Sent dog down stairs in basement. 136 GUN-SHOT WOUNDS OT 'THE INTESTINES. December 10.—Alive and apparently in perfect health. PLxter- nal wound closed completely. December u.—Seems sick; refuses to eat; howls at night. December 12.— Has marked symptoms of tetanus, and is in a state of rigidity with episthotonos. December 13.— Died, and post-mortem showed an obstruction of intestine by a large mass of meat or a collection of various substances of a gritty consistency which completely obstructed and occluded bowels for some distance. The bowel was opened above this, and abdominal cavity filled with intestinal contents, and organs all adhered, as result of peritonitis; resection wound quite strongly united. Dog died from careless feeding and obstruction following adhesion of knuckle of intestine to omental stump. P>XPER1MENT N(). 5. Monday, November 26.—(Ball cal. 32.) Medium-sized, well- conditioned and sturdy dog. Shot passed thiough a six-inch piece of intestine, making several perforations. Much faecal matter free in abdomen, some opposite each opening. Main- tapeworms. November 27.—Made a resection of but one piece six inches in length, including both wounds. In this instance the larger silk sutures were used. After the continuity of the intestine was restored there was a great deal of bleeding from the interior of the abdomen, the origin of which could not find, but allowing the air to reach into all parts of the abdominal cavity, it ceased after considerable loss of blood. A portion of the omentum being filled with blood, it was ligated and removed. In closing abdomi- nal wound was obliged to tear away a certain amount of fat which was closely adherent to interior wall of abdomen, along the line of the wound, in order to introduce sutures so they would not include the fatty mass. Introduced two drainage-tubes, and applied large pad of cotton. Gave some opium, about gtt. 15. p. m. dog seemed considerable shocked, but was quite thirsty. At night gave more opium. November 17. —Cotton was soaked with fluid from drain-tubes. Removed dressings, and, upon getting him upon his feet, a small quantity of fluid escaped. In the evening washed out the abdo- men with a warm solution of carbolic acid, about )A, and applied dressing of gauze. During the da)' he vomited considerable milk and water which he had drank, and was evident!)* very weak. GUN-SHOT WOUNDS OF THE INTESTINES. 137 Gave about gtt. 20 of opium at night. Died at 8 a. m. on Nov- ember 28. Post-mortem showed that sutures had parted at mes- enteric edge, and death was from peritonitis. Mortification of edges of resection. PLxi'EKIMENT NO. 6. December 5.— ( Ball cal. 32.) Died of hemorrhage, after being shot, from wound of renal arteries, the ball perforating one kid- ney. Several perforations of the small intestines, all of them showing extrusion of contents. One large round worm free in cavity. PAperiment No. 7. December 7. Died under ether. PAperiment No. 8. December 7.- (Ball cal. No. ^2.) Ball opened one of the mesenteric arteries, and after resecting three pieces of intestine, and closing wound nicely (every perforation showed faecal matter, worms, etc,); she died in less than nine hours from shock. Great loss of blood; died of loss. PLxperimhxt No. 9. December 10.—(Ball cal. 32.) Gave morphinehypodermically at 9 a. m. Medium-sized female dog. Anaesthetized at 9 a. m., and shot at 9.30, first shot simply going through abdominal walls; second shot higher up and perforating spleen. Operation began at 10.15. P"ound abdomen full of blood, faecal matter, and some worms. Removed spleen and large mass of omentum; ligated and removed one piece; resected about three inches in length; perforated in two places. Much hemorrhage; operation con- cluded at twelve. Gave opium and whisk)'; much shocked. Died. Experiment No. 10. A well-nourished bull-dog (female), about twenty-five pounds in weight. Was anaesthetized about 9.15 a. m., and then shaved over the abdomen. Was shot at 9.45 by a 32-100 calibre revolver just posterior to the umbilicus, the bullet entering on the right side about three inches from the median line, the point of exit being in the corresponding situation on the opposite side. On opening abdomen found animal pregnant. There was one wound through the right cornu of the uterus, rupturing the membranes of one fcetal dog, and allowing the escape of the amniotic fluid into the peritoneal cavity. One of the smaller mesenteric art- erial branches was cut, and the small intestine perforated in one place. The abdomen contained considerable blood on opening 13S GUN-SHOT WOUNDS OF THE INTESTINES. immediately after the shot, and there was slight extravasation of faecal matter from the gut at openings. The vagina and uterine ligaments were ligated by single carbolized silk ligatures, and the large gravid uterus removed. The hemorrhage in the mesentery having been checked, the wound in the intestine was resected, about two inches being removed. The free ends were united with the interrupted silk ligature. The peritoneal cavity was sponged out and washed with slightly carbolized warm water. The exter- nal wound was united with about ten silk ligatures, and dressed with iodoform and gauze, the whole being covered with oakum and bandaged. About half a grain of morphia was administered hypodermically; and at twelve the dog was allowed to come from the influence of ether. She showed marked symptoms of shock, but rallied in the afternoon. She died in the night. Post-mor- tem revealed hemorrhage from the uterine stumps, and some peritonitis commencing. PCxperiment No. II. A full grown, healthy appearing dog. Etherized at 9:30 a. m. Abdomen shaved and cleansed. Was shot at 10 a. m., still under the influence of ether, the bullet from a 32 S. & W. revolver passing transversely through the lower part of the abdomen. Was placed on table and kept partially anesthetized until 10:45. The animal then presented signs of extreme loss of blood, feeble respiration and heart action, cold extremities, pallid gums, etc. Abdomen was opened by large crucial incision and found to be filled with blood. Bleeding was ascertained to come from a divided mesenteric artery, and was readily checked by ligature. Clots were turned out, and two wounds of small intestine found. But slight extravasation of contents of bowel into the cavity, still some matter and worms found at openings. The intestine was resected at the site of each wound, about three inches being removed in each place. The cut ends of each were then united by about twelve interrupted silk sutures, so placed as to bring peritoneal surfaces in apposition. Intestines were then returned to their place, the cavity sponged out, and the external wound closed tightly with silk sutures. This was finished at 12 o'clock, the dog appearing moribund at its close, and remaining in a condition of collapse for about three hours. Reaction then took place, and he was able to stand and walk about. Second day, GUN-SHOT WOUNDS OF THE INTESTINES. 139 took some milk, which was vomited at once. This was repeated at intervals during second and third days. Dressings were changed on third day. No discharge from wound. On fourth day vomiting was increased, and was faecal in character. Dog too weak to stand. Dressings changed again and wound found to be discharging purulent fluid. Died at 4 p. m. on fourth day. Post mortem showed sero-purulent exudation in abdominal cav- ity, intestines glued together by adhesive lymph, wounds uniting well, and occlusion of the bowel in the neighborhood of one of them, from its having been sharply folded upon itself, and bound in the position by the inflammatory exudate. P^xperiment No. 12. December 27, 1883.—The bullet, 32 calibre, entered the abdo- men on a line corresponding to the junction of the anterior and lateral surfaces of the abdomen, just in front of the hind leg, its point of exit on the other side being on the same line a little above the umbilicus. On opening the abdomen it was found that the lower part of the jejunum was cut in two places within two inches of each other, and that there was considerable blood in the peritoneal cavity from these cut surfaces, there being no mesenteric vessels cut; also faeces and worms. Both wounds were included in the parts excised, and the cut ends of the intestines were fastened together by three sutures, and then stitched to the abdominal parieties, thus forming an artificial anus. Considerable shock was experienced, and owing to a desire to hasten the operation, the peritoneal cavity was not as carefully sponged as it should have been. The dressing consisted of iodoform, protective and oakum. Of tinct. opii. deod. gtts. 20 were given by the mouth. The oper- ation lasted two hours. On the following day he took a little nourishment; there was no tenderness, but some pus was squeezed from the point of exit of the bullet, the dog lying on that side. Next day about one-half ounce of pus was forced from the point of exit of the bullet, the dog lying on that side, and by turning him on to the other side, an equal amount was obtained from the point of entrance, but there was no suppuration from the wounds themselves. 140 GUN-SHOT WOUNDS OF THE INTESTINES. He took a little nourishment and seemed to be in good condi- tion, respiration being normal and pulse regular. He had a free urination, and soft stools were passed from the artificial open- ing. He died during the night. Post mortem revealed a large amount of septic material in the peritoneal cavity. Experiment No. 13. Saturday, December 29.—(Ball calibre 32.) Medium-sized, middle-aged female dog. Gave with the anaesthetic about three- eights grain of morphia hypodermically after shot. Abdomen found full of blood; seat of hemorrhage found at one of the points of perforation, of which there were two; from these issued faecal matter, gas and worms, a medium-sized mesenteric artery having been shct off. All the intestines were drawn out of abdomen for examination, and it was found necessary to resect two portions which were a considerable distance apart, both places closing neatly and perfectly. Abdomen washed out and external wound closed by one set of sutures and a large pad of oakum laid over and held in place by roller first, and over all a many-tailed bandage. Gave 25 gtt. laudanum. December 30.—Dog got loose during night and was running around very briskly; room very cold and disagreeable. (On the afternoon of the clay of operation some person had opened the doors and windows and exposed the animal to a strong, cold draft for about two and one-half hours.) In the evening gave hypodermically morphine, when she vomited for first time and seemed very weak. December 31.— Seemed lively and well all day; gave milk, which she would drink but could not retain. About noon gave an enema of Valentine's extract, and in the evening left a pan of milk. January 1, 1884.—She seems as well as ever, but the floor of the room was profusely decorated with vomit. The milk was all gone. Gave an equivalent of an ounce of whisky, of alcohol and water per rectum, and left a supply of water as she seemed very thirst)'. Bandages changed for the first time since the oper- ation. There had been but little discharge and the wound was in good condition. Applied a large pad of oakum and a wide roller as before. January 2.—Seems quite exhausted. Gave alcohol and water GUN-SHOT WOUNDS OF THE INTESTINES. \\\ (1-2 1-2) per rectum about four or five times a day in quantities of about one ounce; has a diarrhoea and vomits. January 3.—Diarrhoea continues, but no vomiting. Has some appetite, and gave raw meat (steak) chopped fine, every two or three hours; also fresh milk, which she drinks readily. January 4.- Seems quite well, and hungry; fed regularly and removed all dressings; wound in good condition. Removed all stitches and did not apply dressing again. Appetite good. January 5.—Dog is seemingly well; has a voracious appetite. Much wasted in flesh, but appears strong. January 6, 7, 8.—Fed her upon milk; also meat chopped fine and raw. January 9.—She seemed well enough to be sent down cellar, where she continues gaining strength and flesh. January 13.—Is perfectly well. Recovery. Experiment No. 14. January 9, 1884.—This dog was allowed some milk a short time previous to the operation, hence his stomach was distended. The first bullet (32 calibre) grazed the abdominal walls, not entering the peritoneal cavity The second entered on a line corresponding to the junction of the anterior and lateral surfaces of the abdomen, a short distance in front of the hind leg, coming out a little nearer the median line, and two inches nearer the front leg. On opening the abdomen it was found there was some hemor- rhage, mucous and particles of food in its cavity and on surface of stomach, and that the lower part of the stomach was wounded, the point of exit being two inches from the point of entrance, passing through the whole thickness of the .stomach. There was no wound of the gut. The peritoneal surfaces were drawn together with catgut, by inverting the edges and using the con- tinued suture. Great care was taken in the toilet de pcrito?de. Immediately after closing the external wound he vomited a half pint of blood, mucous and milk. Time of operation was one hour and a half. Then he was given tincture of opii deod. gtts. xx. The wound was dressed with iodoform, protective and oakum. On the tenth was given nothing except a little water. On the eleventh he was given a little milk, which caused some disturb- ance. On the sixteenth the stitches were removed and no 142 GUN-SHOT WOUNDS OF THE INTESTINES. dressing applied, there being but slight discharge from the wound made by^ the incision and none from the bullet wounds. Recovered. Experiment No. 15. Small dog, female, was anaesthetized and shot at 10:30 a. m. (S. & W. revolver, 32 calibre.) First wound passed through abdominal muscles only. Shot again immediately, bullet this time passing transversely through middle of abdomen. Opening made at once by linear incision. But little blood in cavity. All bleeding stopped upon exposure of intestines to air. Five wounds of small intestine found, all showing extravasation of contents. Two resections of five inches each were made to include all wounds. Cut ends were united by a continued catgut suture in each place. Intestines returned and abdominal incision united by silk sutures, after thoroughly washing out cavity by a 2 per cent, solution of carbolic acid. The operation was finished at 10:30 a. m. Dog was laid in a warm place, apparently suffering but little from shock. External wound dressed with iodoform, covered by protective carbolized gauze, tow and a bandage. Animal died in about twenty hours. Was not given any food or medicine in that time. Post-mortem showed some small blood- clots about the wounds in the intestine. No serum or other fluids in cavity, and no signs of peritonitis. Death from shock. Experiment No. 16. A dog of uncertain breed, about twenty pounds in weight, was shaved over the abdomen and anaesthetized at 10 a. m. Was shot in the abdomen in front of umbilicus, the bullet entering on the right side and coming out on the same side about two inches nearer the median line, not entering the abdominal cavity or wounding the peritoneum. Was shot again, the bullet entering on the right side, external and posterior to the first, and coming out on the opposite side, about two inches from median line. The calibre of the revolver was 32-100. Upon opening the abdominal cavity the peritoneum was found to be plowed across between the wounds of entrance and exit, and the spleen to be slightly nicked, the bullet having skirted the abdominal walls, The only hemorrhage was from the external wounds and the GUN-SHOT WOUNDS OF THE INTESTINES. 143 spleen and track of bullet. The spleen was removed, its peritoneal toneal connections being ligated by five silk ligatures. The small intestine was resected, about four inches being removed. The abdominal cavity was washed with warm carbolized water. The external wound was sewed up by about ten sutures. The dog came from under the influence of ether at 11:30 a. m. The wound was dressed externally with iodoform and oakum, and fifteen drops of deodorized tr. of opium administered by the mouth. A curious phenomenon was observed upon cutting out the spleen. The stomach and intestine became distended enormously with gas, extruding from the abdominal cavity and covering a large area of the operating-table. They were with difficulty returned with steady pressure. The dog died in the night from shock and hemorrhages from splenic stumps. P'xperiment No. 17. January 2^,.—(Ball cal. 32.) Good-sized coach dog. Bullet passed through abdominal walls without wounding intestines and just entering the peritoneal cavity, as was found after opening abdomen, the point of entrance and exit being on either side of the middle line and five inches apart. Removed the major por- tion of the greater omentum and also resected about six inches of the ileum and closed the wound by five sutures, the external wound being but two inches long. January 24.—Seems inclined to be quiet all day; had defecated during the night and urinated very little; drinks but little water, and does not vomit it. Is by nature a very frisky dog, and do not think his extreme quiet very favorable. January 25.—Seems quiet; no bloating of abdomen; removed bandages; re-applied dressings. Refused milk all day; also water. January 26.—Gave small quantity of milk in the afternoon; re- applied the dressings which had been removed the day before; found the bullet wounds much puffed up, and that the stitehes had slipped in two places, leaving a hole opening into abdomen large enough to admit little finger. The portion of intestine viewed through opening in external wound looked red and inflamed, but not badly so; little running from the wound. Filled it with iodoform and applied pad of oakum. 144 GUN SHOT WOUNDS OF THE INTESTINES. January 27.—Gave about one-half pound of meat and a quart of milk; seemed to be ready to get well. January 28.—P^ed meat and milk during day, and he seems to be rapidly getting well. January 29.—Wound gaping, but discharged him to the cel- lar. Recovered. P2xperiment No. 18. January 25, 1884.—-This dog, a black and tan bitch, having been shaved the day before, was anaesthetized and shot. The bullet, 32 caliber, passed directly through the abdomen about its middle, piercing the gravid uterus in two places, and cutting the gut longitudinally. No large vessels were cut. The uterine attachments were ligated en masse and the uterus removed. Contents of bowel found at site of wound in intestines. During the time that an excision of the gut was being made, a profuse hemorrhage occurred from the uterine stumps, before they could again be ligated by passing a suture through and liga- ting one-half at a time, the animal was almost exhausted from hemorrhage. The excision of the gut was then completed, and the cut ends stitched together with silk. The peritoneal cavity was then thoroughly washed out with slightly carbolized warm water, and the external wound closed. The dressing consisted of iodoform, gauze and oakum. Of tinct. opii. deod., gtts. xx were given. Death occurred within ten hours after the operation, from effects of the hem- orrhage. Experiment No. 19. Dog was full-grown and apparently healthy. When the abdo- men was exposed by shaving, two small abscesses, each the size of a filbert, superficially seated and non-inflammatory, were dis- covered. They were not disturbed. The animal was anaesthet- ized at 8.30 a. m., and at once shot through the middle of abdo- men with a 44 caliber revolver. The dog was placed upon the table, and a linear incision of about three inches made in the median line. It was there found that the ball had glanced upon the abdominal muscles, and instead of going through the mass of small intestines, had been deflected so that it just entered the GUN-SHOT WOUNDS OF THE INTESTINES. 145 peritoneal cavity beneath the linea alba, traversed the cavity for about an inch, producing a contused wound of afold of intestines, and then entered the abdominal parietes to make its exit opposite the wound of entrance, about two inches from the linea alba. Only a small amount of blood was found in cavity. Although none of the intestines were wounded, a resection of about two inches from the middle of the ileum was made. The divided ends were united by about a dozen interrupted silk sutures. The cav- ity was washed thoroughly with a I per cent. sol. of carbolic acid, the intestines returned, and stitches were being placed in external wound, when the abdominal cavity was found to be filling with blood. Source of the hemorrhage was found to be a branch of mesenteric artery at the site of the resection, which had com- menced to bleed as soon as circulation was restored by warmth of abdomen. A ligature was applied, the intestine returned and the cavity again thoroughly washed out. The external wound was now closed by silk sutures, the wound dusted with iodoform, and dressed by applying a few thicknesses of carb. gauze, covering this with a mass of tow and a bandage over all. Animal appeared to suffer but little from shock. On morning of second day was given ~%. grain morphia with i-iooth grain atropia by the mouth. On the third day appeared greatly prostrated, vomited at inter vals, and a muco-purulent discharge was noticed coming from nostrils and eyes, Vomiting ceased on fourth day. Prostration and evidence of fever kept up to the morning of fifth day, when improvement began. Discharge from nostrils continued about ten days. On the fourth day a small quantity of milk was taken and retained. Loose discharge from bowels on fifth day slightly colored with blood. A rectal injection of alcohol and water was given on the sixth day. Dressings changed for the first time on sixth day. Wound appeared healthy and united in its deeper portions. Some pus from superficial part of wound from this time on, the dog ate milk regularly, and had regular normal pass- ages from bowels. On ninth day sutures were removed from external wound, which had entirely closed. On the thirteenth day, February io, 1884, dog is apparently perfectly well; has been eating regularly of raw beef, and has begun to gain in flesh. On the evening of thirteenth day dog was well. Recovery. Experiment No. 20. February 2.— (Ball cal. 32.) Died from ether before any incis- ion was made. 146 GUN-SHOT WOUNDS OF THE INTESTINES. Experiment No 21. A strong black dog, about 20 pounds, was shaved over the abdomen and then etherized at 9:15 a. m. Was shot with a 38-100 calibre revolver through the abdomen about opposite the umbilicus, and five inches to the right of the median line, the point of exit being in a corresponding situation on the opposite side. Upon opening the abdominal cavity such a large amount of blood was found that it was necessary to enlarge the incision by a cross cut. A large mesenteric artery was found to be cut and was ligated. Another smaller one was treated in the same way. There were two wounds in the small intestine close together, about six inches intervening between them. Extrava- sation of contents of both. One was perforating and the other nicking the gut on the mesenteric side. Eight inches were removed, and the free extremities of the intestine united by interrupted silk sutures. There were three other wounds nicking the intestine which were sewed in the same manner without resection. The end of the caecum, which is peculiarly shaped in dogs, was shot off. Stained mucous and some shreds at the opening, This was sewed, turning the cut end in. The spleen was cut in one place, which was left with one deeply-planted suture. A large fold of omentum was ligatured and removed. The abdomen was thoroughly washed with carbolized water, and the external wound united with about fifteen sutures. It was then dressed with iodoform and oakum, one-half ounce of alcohol and 15 gtts. of deodorized tincture of opium were administered per rectum, and at 12:15 the dog was allowed to come from the influ- ence of ether. The same amount of alcohol and opium were administered as before at 6 p. m. The dog died during the night. Post mortem revealed no evidence of inflammation, and some slight bleeding from the spleen. The sutures in the intes- tine were in good condition. The piece of gut, about eight inches long, supplied by the mesenteric artery, which was cut by the bullet, was found to be completely mortified. PAperiment No. 22. February 12, 1884.—(Ball cal. 32.) Brindle bull dog. No attempt to sew up the holes in the intestines, of which there were about twenty. Died the day following. "Tilley's anaesthe- tizer." Every opening showed evidence of extrusion of contents. GUN-SHOT WOUNDS OF THE INTESTINES. 147 Experiment No. 23. February 28, 1884.—Tilley's anaesthetizer. Died before opera- tion from effects of ether. Experiment No. 24. February 28, 1884.—(Ball cal. 44.) A short, strong Spitz dog. Bullet wounds of entrance and exit four inches apart. Intes- tine perforated in four places and abraded in one spot. Intes- tinal worms free in abdomen. Tape worms protruding from perforations. Extravasation of contents of the bowel. No arteries divided by bullet. Resected one piece (including three perforations) 12 in. length. Removed a V-shaped piece including the fourth perforation, and inverted the serous surfaces by interrupted sutures, the same as in complete section. The apex of the V (pointed to the attached border of the bowel) controlled the ooz- ing from the abraded spot by small suture passed across mesen- teric side of abrasion, the abrasion being the size of a copper cent, and on the side of intestine. Washed the intestines and abdomen cavity as clean as possible by stream of weak carbol- ized and pretty warm water from the irrigator; closed abdomen wound by five deeply-placed sutures about one-third inch apart; gave hypodermic of one-fourth grain of morphia. Shock and little loss of blood. Omentum also removed. February 29.—In morning seemed very lively and bright; gave some water, which was immediately rejected by stomach. Dur- ing morning vomited foul-smelling fluid and two large chunks of meat. About 10 a. m. gave hypodermic of one-half grain mor- phia; in very few minutes he laid down and began to whine as though in pain, and threw up large quantity of offensively- smelling fluid. Died about 3 p. m. Post mortem.—Abdomen showed evidence of intestinal extrav- asation, all organs being bound together by peritoneal inflam- mation; extravasation of blood beneath peritoneal covering of intestines, and small clots adherent all along the length of ileum. The stumps of ligated mesentery and omentum were black. The seat of the operation showed adhesion of the serous surfaces, and water could be forced through the excised piece which was taken out by a cut six in. to each side of the stitches, with- out any leaking at seat of operation. The spot of abrasion was 148 GUN-SHOT WOUNDS OF THE INTESTINES. swollen and blue, and there had been a little hemorrhage from it, The intestines generally were contracted, glued together and pressed into prismoidal and other shapes. Stomach empty. Experiment No. 25. February 28, 1884.—(Ball cal. 44.) "Tasso." Bullet under skin opposite to point of entrance. Intestine riddled in about four places, for which a complete section 20 in. in length was removed and was nicely adjusted; another hole in the ascending colon was closed on each side by the continuous suture; the tip of spleen being shot off, to arrest hemorrhage a ligature was passed around proximal side of wound tight enough for that purpose, but yet not enough to cause death of the spleen tissue beyond ligature. The stumps of ligated mesentery being gathered upon a suture, were united to intestine near or about at the seat of the approximation of the divided ends; omentum removed; gave rectal injection of alcohol and water y2 y, about. Each opening in bowel had more or less of the contents around it. February 29.—Seemed very quiet all the morning, and was quite indisposed to move. Towards noon, gave him, about 11 o'clock, about 1 oz. of alcohol and water y2 ^ per rectum and some water to drink, which was at once vomited. Seemed very tired all day and disposed to lie stretched out before the heat of the register, and his breathing was entirely thoracic and by means of the cervical muscles. At 6 p. m. gave hypod. of morph. gr. y% and left water where he could drink. March 1.—Seemed very weak all day; gave hypod. of morph. y2 gr. twice, the last at night. About noon gave rectal injection of alcohol and water. March 2.—Still alive, but very cold; listless and indifferent; gave morph.,in a. m. and tied him up in blanket. Returned at nine p. m. and poor "Tasso" was in rigor mortis. I think the ex- posure to cold during the day (Sunday) which was a very wintry day, was in a great measure the cause of his death. He refused to drink any milk during the day, and also seemed to have lost his thirst for water. Post-mortem March 4.—Extensive peritonitis present; no sep- aration of the united intestine to be found at the seat of operation. GUN-SHOT WOUNDS OF THE INTESTINES. 149 Experiment No. 26. March 3.—(44 cal. cartridge.) Large, fat and old bitch. Used Frank Gould's revolver, 44, and upon opening the abdomen, found four large rents in the intestines (every one of which showed extrusion of contents and some worms) at a considerable distance apart, and a very profuse hemorrhage from the wound of exit, which was not discovered until the resections were made, of which two included the wounds in the gut, which was about shot off, and much bleeding took place before they were found and ligated. The animal was so fat and boggy that it was with the greatest difficulty that hemorrhage could be controlled. The beast was old and presented signs of cataract in both eyes. The bladder was greatly distended, and the structure of the intes- tines themselves seemed "sleazy" and the sutures tore out with readiness upon slight traction. Cleansed out abdomen as best we could by thorough washing, but a little bleeding was going on when the wound was closed in the abdomen, and the operation given up as a bad job of one-half hour's duration. March 4.—Found dead. Experiment No, 27. March 4.—(44 cartridge.) Medium-sized dog; died from shock on night of 4th. Experiment No- 28. March 6.—(Ball cal. 22, revolver.) Very small, black and tan dog. Shot him with a 22 cartridge, and had to use three shots before could get a good perforation and but little bleeding. Resected a piece around the bullet-hole of %. inches long, cleaned abdomen and closed tightly; gave morph. gr. y. March 7.—Seemed very bright. March 8.—Gave little milk and morphia in evening. March 10.—Milk. March 11.—Sent down cellar to be fed on milk. March 12, 13.—Very hearty, and eats ravenously of milk and very little meat. March 14, 15;—Doing nicely, Recovery. 150 GUN-SHOT WOUNDS OF THE INTESTINES. Experiment No. 29. March 6.—(Ball cal. 44.) Large, strong dog. Used 44 cart- ridge. Found the abdomen full of blood, spleen perforated, and intestines wounded in three or four places. From these issued faeces, gas, etc. Removed spleen, omentum, and resected about 12 inches gut, including all the holes but one, which was sewed up by continuous stitch. The animal having lost nearly all his blood by this time, and as death was sure to ensue, one of the mesenteric arteries was ligated to ascertain results. March 7.—Found dead in morning. Post mortem.—Intestine black, but the animal had evidently not lived long enough to get any positive mortification of liga- tured part, or any interesting appearance at all. Experiment No. 30. March 10.—Tilley's Inhaler. Large chandler bitch. Killed bX ether. Experiment No. 31. March 10.—Tilley's Inhaler. Large Hastman dog. Killed by ether. Experiment No. 32. March 10.—(Ball cal. 22, rifle.) Medium-sized bitch. Found three mesenteric arteries severed, and intestines riddled in many places and far apart. Perforations showed faecal matter and tapeworms. Stopped bleeding and returned intestines without closing the perforations, and closed abdomen. No dressing but iodoform (C. T. P). Spleen also removed, being perforated. March 11.—Still alive, and sent down cellar. March 13, a. m.—No better. March 14, 15, a. m.—Vomiting, and refused food. March 18.—Dead. Peritonitis septic. Pockets of faeces. Experiment No. 33. March 10.—Small dog (yellow). Shot with 22 calibre rifle. Three perforations of small intestine, showing faecal matter. GUN-SHOT WOUNDS OF THE INTESTINES. 151 Removed a four-inch piece in two places, and brought ends together very closely; stitched mesenteric stumps to attached border of intestine. Removed omentum, tying tightly, and also putting in three side stitches, connecting sides of stumps on each side of ligation with one another. March n.—Alive, but feverish and vomiting. March 12.—Died. Separation at seat of operation, and stumps mortified. See specimen. Faecal extravasation. Experiment No. 34. March 12.—(Ball cal. 22 rifle.) Old, mangy bitch. Died under ether. Tilley's Inhaler. Perforation showed extravasa- tion of contents, faecal matter and worms. Experiment No. 35. March 12. — Medium-sized, short-haired, yellow cur (white nose). Shot with 22-ball rifle. Upon opening the abdomen, found blood flowing from a rent in the side of spleen. This organ was three times the normal size, but no holes in the intes- tines anywhere, and no hole could be found in the abdominal wall on either side. The bullet lay next the abdominal muscles, and was cut out from the wound of entrance. Free bleeding from the laceration in the spleen, which was controlled by a continued suture. Resected six inches of intestine and closed abdomen. Also omentum removed. Iodoform and oakum dressing; gave morphia. March 13.—y gr. morph. a. m.; very weak p. m. March 14.—Morph. a. m.; very weak p. m. Temperature 102. March 15.—Re-opened, but found intestine in solid mass and filled with badly-smelling fluid. Washed out as best I could and reclosed. Seat of operation showed mortification on one side, and stumps mesentery also were black and soft. March 16.—Still alive. Morph. gr. y. March 19.—Dead. Found intestinal worms in abdominal cavity. Experiment No. 36. March 12.—Short, black, stumpy and very fat dog. Fired four 22-balls at the animal before was sure that any had entered. 152 GUN-SHOT WOUNDS OF THE INTESTINES. Found abdomen full of blood; two perforations five inches apart, and two mesenteric arteries shot off near the gut. Each perfora- tion showed extravasation, faeces and worms. Ligated the arter- ies; resected one piece, including both holes; sponged out abdominal cavity; removed omentum, also a large quantity of fat which hung to the inner wall of the belly, and closed wound. Iodoform and oakum dressing; gave morphia. March. 13— Quite bright. Morph. a. m. and p. m. March 14.—Dead. Post-mortem. Found considerable perito- nitis and mortification of the ends of the intestines where they were stitched together. The stumps of mesentery and omentum also showed signs of mortification. Experiment No. 37. March 13.—Medium-sized brindle bitch. No. 22-ball rifle Resected one piece six inches having two holes; removed omen- tum very little; hemorrhage; gas and faeces from wounds; tem- perature 98 2-5 at close of operation. March. 14.—y gr. morph. a. m. Temperature 102 2-5. Morph. p. m. March 15.—y gr. morph. p. m.; temperature 102 2-5. March 16.—Morph. p. m.; temperature 102. March 17.—Gave milk and morph. p. m. March 19, 20.—Gave milk and morph. p. m.; seems well. April 22.—Perfectly well; recovery. Experiment No. 38. March 13.—Medium-sized yellow dog (with bare spot on tail). No. 22-ball rifle; found one lateral hole which closed by continu- ous suture, and three holes which were included in one piece which was cut in half by mistake; two arteries gave some bleed- ing, but were ultimately controlled. Contents of bowel found at each wound. Abdomen closed while yet there was some oozing from the wound, which ceased when bandages were applied; omentum removed. March 14.—Very weak and much prostrated. Refused to lie down, and can stand with difficulty on his feet. Gave morphia 3/z hypodermically, morning and evening. GUN-SHOT WOUNDS OF THE INTESTINES. 153 March 15.—Found dead. Post-mortem. Mortification at seat of operation, and escape of intestinal contents. Experiment No. 39. March 14.—(Ball 22-cal. rifle.) Medium-sized brindledog (wolf face); found three ragged holes. Resected one piece which included all openings, the piece being seven inches long; closed neatly, the omentum being removed also (many tapeworms and considerable faecal matter from openings), then washed clean by irrigator. The entire ileum was inspected and sponged off, and returned to abdomen. Spleen also pulled out and inspected; gave morphia and dressings of iodoform and oakum. March 15.—Some shock; morphia. March 16.—Morphia p. m. only. March 17.—Morphia p. m. only. March 19.—a. m. morphia, stercoraceous vomiting, and seems very sick; p. m. is evidently dying. March 20.—Vomiting has stopped, and seems much better Died in the evening, p. m. Septic peritonitis. Post-paritoneal abscesses. Experiment No. 40. March 14. 4.45 p. m.—A young black, bitch pup; anaesthetized and abdomen opened without shooting; ligated a mesenteric artery and closed wound to be re-opened to-morrow p. m. and resect the part supplied by ligated vessel; gave morph. ^. March 15.—Opened her at 3 p. m. in presence of Prof. Parkes. Intestine supplied by the ligated artery seemed softer than nor- mal and its mesentery showed inflammatory exudate considerable effusion; closed wound, gave morphia at night. March 16.—Gave morphia, gr. y. March 17.—Sent down stairs. March 19.—Seems quite well. April 22.—Perfectly well. Recovery. Experiment No. 41. March 19.—(Ball 22-cal. rifle.) Medium-sized young bitch (black). Found one abrasion which closed up by continued suture and the intestine in another place was about shot off; faecal 154 GUN-SHOT WOUNDS OF THE INTESTINES. matter scattered all about, worms divided; resected the piece about one inch long; irrigated the abdominal cavity; removed omentum and then found a hole or rather the tip of the spleen shot off which bled some and was controlled by two interrupted sutures; gave morphia, gr. y, and applied dressings. March 18, 19.—Morphia, gr. y. March 20.—Seems bright, but very quiet. April 22.—Quite well. Recovery. Experiment No. 42. March 19.—Twenty-two ball rifle (brindle, white bitch,) Found one abraded edge and one hole through free edge of ileum, from which contents issued. Closed one by continued suture and re- sected across the hole by cutting out a % inch piece. Did not remove omentum. Gave morphia y% and applied dressing. March 18 and 19.—Morphia. Seems to have a paralysis of left fore-leg since operation and for two days past seems to be sali- vated. March 20.—Better. April 22.—Well. Recovery. Experiment No. 43. March20. (Stub tail.) A small half-breed terrier dog. Twenty- tow ball rifle. Found two perforations and one abrasion, extra- vasion of gas and stained mucus and shreds of matter from openings going through mucous coat. Made a resection including all three wounds, the excised piece being six inches long, closed very snugly and connected the ligated mesenteric stumps with the attached border of intestine by a single ligature passing through both stumps (but two sets of vessels having been ligated) and both sides of the mesenteric borders of the united ends of the gut; removed omentum and irrigated abdominal cavity freely with a 1 per cent, of carbolic acid solution. Dressings, oakum and iodo- form; gave morphia, y. Recovery. Experiment No. 44. March 20.—A young, shaggy, cur dog opened without shoot- ing, and ligated three sets of branches from the superficial mes- enteric artery, close to the main artery, and also a good-sized anastomatic connection with an adjoining vasa intestine tenuis, GUN-SHOT WOUNDS OF THE INTESTINES. 155 which ran parallel with and along the attached border of the bowel. The intestines supplied by the vessels blanched immed- iately. Closed abdomen; gave morphia, gr. y; applied dressings. Recovery. Died subsequently from ether during examination as to result of above operation six days after it. Found intestine perforated by stick of wood four inches long, rolled in twine. Had removed it. and was about to sew up wound when ether killed him. Experiment No. 45. March 20.—A good-sized spaniel dog (old). Stopped breath- ing once from ether before shooting. Shot with a rifle twenty- two ball. Found the abdomen full of blood, two arteries having been shot off and the ileum perforated in four places; from each contents extruded, two being so near together and the wound so great as to almost carry away an entire segment of the bowel, necessitating a removal of about twenty inches. Much bleeding, which took about half an hour to control, being from the ligated stumps and bullet wounds; the tissues were very brittle, and so loaded with fat as to make the operation difficult. Died in one half-hour after closing abdomen wound. Pathological Specimens Shown. First. Section of ileum made 24 hours after operation, show- ing the sutures all covered with exudate. Union sufficiently firm to allow distention with water without leaking. Second. Sections of intestines made four, six and eight weeks after operation—the animal having fully recovered. The union is firm and solid throughout entire circumference of the bowel. No narrowing of tube, or disposition to formation of a stricture. Two of the specimens show several of the sutures ulcerating into the lumen of the bowel. Third. Several specimens showing mortification of distal ends of stumps, and also mortification of applied edges of the bowel from tight sutures and ligatures. Fourth. Several specimens showing giving way of sutured bowel ends at the mesenteric junction, allowing extravasation causing fatal inflammation—sutures failed to include the muscu- lar coat. Fifth. Specimens showing many varieties of wounds pro- duced by the bullet. 156 GUN-SHOT WOUNDS OF THE ABDOMEN. A Review of Some Facts Connected with Gun-shot Wounds of the Abdomen, amd Practical Deductions Therefrom.* The object of this contribution to the subject of gun-shot wounds of the abdomen is to pass in review such facts as are at our disposal in its consideration, to make such deductions from these as their limited number will afford, and to offer some sug- gestions based on personal experience. Probably no question submitted to the consideration of sur- geons has ever arrested the attention of the profession more promptly than the general question of surgical interference in penetrating gun-shot wounds of the abdominal cavity, and it is at once remarkable, and to the honor of the profession, that the obvious deductions have been as promptly applied. Up to 1885 the whole number of recorded operations for gun- shot wounds of the abdomen that I have been able to find is six; by this is meant cases in which the surgeon has deliberately sought out the wounded intestines, and repaired the damage inflicted, in accordance with surgical principles. Surely a small number in view of the wars which have gone by, contributing and bringing under the surgeon's care, great num- bers of these injuries under consideration, and the many individ- uals shot through the abdomen in brawls of civil life, also placed under medical supervision. Up to 1885 the profession had not looked the real question square in the face; surgeons held uncertain opinions, with the large majority opposed to any interference whatever, and, as might be expected under such complicating conditions, the results were not brilliant. Operations previous to three years ago were the exception. The magnitude and importance of the subject seemed not to be realized. Now, I would venture the assertion that there are few modern surgeons who, confronted with a bullet wound of the abdominal walls and not able to convince themselves that the ball had not effected a penetration, but would explore the cavity. * Read before the Surgical Section of the Ninth International Congress, September 5. 1887. GUN-SHOT WOUNDS OF THE ABDOMEN. 157 When in the winter of 1884 I reflected on the necessity of sys- tematically and experimentally studying this subject, I did not anticipate that in so short a time such radical change would take place in the method of treating such cases, which previously had been relegated to cure by opium, rest and hopes in Providence. The results of my observations were published in the Journal of the American Medical Association, 1885; they were the observa- tions and outgrowing deductions from a series of experiments systematically carried out during the previous winter for the pur- pose of throwing light upon the pathology and treatment of these iujuries, and of recording the clinical facts attending shot wounds of these organs. Since the publication of my address to the American Medical Association in 1885, thirty-six cases of operative interference in gun-shot wounds of the abdomen have been recorded, with nine recoveries following opening of the abdomen, suturing the wounded intestines and treating other complicating injuries. Sir William MacCormac in the Annual Oration delivered by him May 2, 1887, before the Medical Society of London, has col- lected from all sources thirty cases. To these must be added one case reported by Prof. McGraw, of Detroit, of double perforation of the ascending colon, exposed by enlarging the surface wound, and suturing the intestinal perforations; recovery following. Another, by Dr. J. B. Murphy, of Chicago, of shot wound of the liver, in which the abdomen was opened, blood clots removed, and the wounds sutured; recovery following. Also a death, reported by Dr. J. B. Murphy, from post-peritoneal hemorrhage; post-mortem showing the intestinal wounds to have been safely sutured. One other case of recovery is reported by Dr. J. J. Skelly, of Potomac, 111., and two fatal cases coming under my own care, to which further reference will be made in this paper; in all thirty-six cases, with nine recoveries. A reference to the extended reports of these cases, or to the tables of Sir William McCormac, shows plainly that there has been no selection of favorable conditions; that the operations have been done under a great diversity of surroundings, without special assistants, and in many cases with injuries the fatality of which it seemed impossible to overcome. These results furnish the greatest encouragement for further trials in saving the lives of persons so certainly condemned to death, unless relieved by operation, when suffering from the wounds under consideration. 158 GUN-SHOT WOUNDS OF THE ABDOMEN. Every case, whether of recovery or death, following operation should be published in full, so that our experience may be increased, the nature and character of these wounds better under- stood, and definite rules of procedure elucidated. We might in this way be able to set aside those cases, which from the special character of the wounds will necessarily prove fatal. With our present limited knowledge of reliable symptoms, all is uncertain with an unopened abdomen. Gradually we may be able to posi- tively recognize these cases which possess "a faint hope of relief" to be followed by a good percentage of recoveries after operation. Where to draw the line, and what to do, when oper- ation is decided upon, and how best to carry out the necessary manipulations, are the questions which the future must settle. Judging from the valuable papers of Drs. Bull, Dennis and Bryant, of New York City, Dr. Tremaine, of Buffalo, Dr. Nan- crede, of Philadelphia, Dr. Senn, of Milwaukee, Dr. Marcy, of Boston, Genl. Hamilton, of Washington, Sir William MacCor- mac and others, and from the expression of opinion, published as coming from the surgeons present at the last meeting of the American Surgical Association, it is certainly just to claim, that the belief that surgical interference in proper cases is the accepted course to pursue is rapidly being adopted by the pro- fession at large. To me this is a great victory gained. The method of procedure has been tried; and notwithstanding the crudest of data to build upon—the deficiencies in practical experience in man; with prop- ositions already made not thoroughly tested, or perhaps only superficially studied, with the dimest of light for a guide, the results have been remarkably good. What interferences are justifiable from an external gun-shot wound of the abdominal walls? A single wound of the abdominal walls, in so far as it affords any inference at all, from its being single, furnishes a hope that no penetration of the peritoneal cavity has taken place, but it is merely a hope. The resistance of the walls and viscera, though considerable in every case, varies greatly. Consequently, a bullet, although not having momentum enough to make an exit, may have force enough to do much damage among the viscera. Or its momen- tum may be so slight, and its direction so oblique, as to cause it to remain between the planes of the abdominal walls. Even the existence of an entrance and exitwound widely separated is not GUN-SHOT WOUNDS OF THE ABDOMEN. 159 always a proof of injury to the viscera. Observations have shown, both on man and the lower animals, that a bullet may enter the abdominal walls at one point and reappear at another, at a con- siderable distance from the first, and yet not enter the abdominal cavity. If penetration be present with only a wound of entrance, it suggests that the firearm used might have possessed moderate penetrating force, that the velocity of the bullet may not have been extreme, and that the damage done by it is very likely amenable to treatment, with fair prospects of relief. If there exists a continuous track of tenderness, especially if accompanied with slight redness, from the wound of entrance for some distance over the abdominal surface, it is fair to infer that the missile has wormed itself between the layers of the abdominal walls, and that penetration does not exist. This was plainly' shown in a case seen in 1886, and reported by myself in a paper read in New York that year. The peculiar appearance presented by the edges of the wound, and its size, when carefully studied, will furnish pretty reliable information of the size of the bullet, and its direction of impact, both items of considerable importance in estimating the possible damage. Bullets from firearms of large calibre are the most destructive to the opposing tissues, and have the maximum penetrating force. A large bullet hole argues a large bullet, certainty of penetration, and large destruction of tissues and organs. Powder marks on the clothing or body prove a close body shot, and hence greater probability of complete penetration of the abdominal cavity, with wounds to the viscera; and this is true, no matter what may be the calibre of the firearm used. If the edges of the skin perforation are equally stained through- out and clean cut, the fact suggests that the bullet struck perpen- dicularly to the surface upon which the wound is found. Again, if these edges are unequally stained, if unequally ragged, or if the surrounding surface shows a stain, or abrasion, or discoloration leading to some portion of the edge of the perforation, all these facts suggest valuable information as to the probable course of the missile in its transit through the abdomen, and the conclusion is justifiable that the impact was not perpendicular to the surface, and, of course, in proportion as the course of imact departs from the perpendicular, the greater is the probability that penetration of the cavity has not occurred. 160 GUN-SHOT WOUNDS OF THE ABDOMEN. Naturally, one of the most important items of estimation is to determine the probable course of the bullet in the injuring body. To this end information as definite as possible must be obtained as to the direction from which the shot came, and the distance from which it was fired; both faces having great bearing on the organs wounded, and the damage done them. It is no easy matter even with very complete data to guide one, to feel certain as to the direction of the missile inside the cavity, when there is only one wound. A great many cases will furnish no corroborative information; the surgeon will be compelled to depend upon the signs belonging to the wound itself. If in doubt as to penetration, the wound should be enlarged by an incision directly through the skin perforation in some chosen direction. By carefully following the track of discoloration left in the tissues by the bullet, not only the fact of penetration or non-penetration will be positively determined, but its directness or obliquity through the abdominal walls, will furnish positive information as to the course of transit of the entering body. With the usual precautions this incision will not increase the patient's danger, even if central section becomes necessary; it throws valuable light upon subsequent requirements, makes clear the fact of penetration, or non-penetration, and. in some situations. may enable the operator to repair all the damage done. The presence of a wound of entrance and exit, produced by the firearms and missiles of the present day, especially if the shot is delivered in close proximity to the body, with scarcely an excep- tion possible, indicates injury to all the fixed organs lying in the estimated line drawn between the two external wounds made by the missle. Moreover, it is highly probable that the small intes- tines are also damaged, although these latter wounds may be found some distance away from the line of the ball, their changed position being dependent upon the extreme mobility of the vis- cera at the time of the receipt of the wound, and from the move- ments of the body subsequent to the passage of the bullet or other causes. The great majority of double wounds tell positively of com- plete and direct perforation and damage, more or less severe, to every organ in their path, there seems scarcely any probability of deviation from their course, caused by the resistance of the soft tissues of the body. Whether wounds in organs (as contended by Prof. McGraw), found some distance away from the line of transit of a bullet, are GUN-SHOT WOUNDS OF THE ABDOMEN. 161 to be explained by the elasticity and mobility of the tissues, their constant change of form by inherent contraction, enabling them to get in or out of the way, or by subsequent change induced by weight of the bullet or movements of the body; or, as contended by myself, are sometimes dependent upon an erratic course of the latter, from deviations in its line of flight, caused by deflections therefrom, through impingment on tissues of different powers of resistance or elasticity, is a matter that must be settled by an appeal to physical laws through experimentation; it will never be settled by assertions or assumptions. I am fully convinced that the time does come in the "life" of a flying bullet when its vel- ocity and power of penetration bear such a relation to the power of resistance of the different tissues in the abdominal walls and contents, that the softest of these, touched in a certain way, will deflect its course. In no other way than through this supposition have I been able to explain the character and kind of damage I have seen done by a bullet in its transit through the body. My conclusions and deductions, on the course of a bullet, are based mainly upon the results of experimentation, during which the animal was profoundly anesthetized, and consequently muscu- lar contraction and activity abolished. If the ball deviated at all from a straight line, there was nothing else to cause the deviations but the soft tissues in its track. The situation of the wounds will, of course, call attention to the likelihood of damage inflicted upon the organs, in the prob- able course of the bullet. The severity of the injury and gravity of prognosis is surely greatly enhanced if the movable viscera are wounded. It is much less if only fixed organs are hit. In both the absolutely necessary manipulations by the surgeon, re- quired for the repair thereof, will be suggested, and due prepara- tion to meet all indications can be provided for. There is no opportunity to hunt up necessary appliances after the operation is begun. An antero-posterior shot below the level of the umbilicus and well toward the lateral surface; of the body, will be very likely to miss the small intestines entirely and expend its damage on the large bowel, as in Prof. McGraw's case. The same kind of wound high on the lateral surfaces may pass into or through the liver, without injuring the intestines, or the spleen alone if the entrance is on the left side. If the wound is so situated that the bullet enters the abdomen through the diaphragm, adding injury of abdominal viscera to 162 GUN-SHOT WOUNDS OF THE ABDOMEN. that of the contents of the chest, the surgeon's help will prob- ably be of little use. A wound of entrance and exit, or an entrance wound alone showing perforation of the ball from side to side through the cavity, means the worst of injuries, and suggests the need of the greatest care in staying of hemorrhage, repair of intestines and toilet of the contents. Antero-posterior perforation, if complete, can only fail to wound the small intestines when situated well on the outskirts of the surface of the abdomen; seemingly, there can be no excep- tion to this proposition, save in those extremely rare instances, in which the perforating body traverses the cavity without injur- ing the contents. Penetration through the posterior walls of the cavity, if com- plete, with likelihood of laceration of important fixed organs, argues an injury of the most severe character, one in which the surgeon's art will be of no avail in the majority of instances. The exceptions, in which the severity will not prove unsurmount- able, will be transit through the space between the lower end of the kidney and the crest of the ilium, and in wounds occupying the outskirts of the entire posterior surface. If the penetration be incomplete, as can, in the majority of instances, be determined by enlarging the bullet wound, the injuries are by no means nec- essarily fatal, and do not require any other surgical interference than the enlargement of the wound and proper dressing. Many instances are recorded of recovery from posterior penetration of the large and fixed viscera of the abdomen, without any surgical operation whatever. What collateral evidence influences the formation of a diagnosis? The peculiarities of the individual injured constitute so import- ant an element in the development of collateral manifestations, that all such testimony should be subjected to the most rigorous search; in fact, much value cannot be attached to subjective manifestations. It is not necessary to state to you that one per- son may be prostrated and literally frightened to death by the sound of a firearm, or the "swish" of a bullet, while another will continue his course or perform his usual duties after he has been injured, and can only with difficulty be persuaded that he has been shot. Between these two extremes all gradations present themselves. There are other phenomena, independent of personal peculiar- GUN-SHOT WOUNDS OF THE ABDOMEN. 163 ities, which contribute to the formation of the surgeon's opinion. Among these may be mentioned: tympanitic resonance, unusual dullness on percussion, the presence of faecal matter, or any of the normal secretions or contents of the different viscera in any of the external wounds, blood in the stools or urine, or egesta from the stomach, paralysis of any kind', persistent nausea and vomiting, and the general condition designated shock. Allow me to briefly refer to the probable significance of these symptoms when present. Unusual and rapidly forming tympanites would suggest the escape of the intestinal gases into the peritoneal cavity through a perforation, and, if found in a region of normal dulness, as in the liver region, it is considered good corroborative testimony in favor of intestinal rupture, by some authorities. Circumscribed dullness on percussion, with localized bulging in the abdomen in the neighborhood of the wounds, or in the most dependent region of the cavity, argues the possible presence of blood accumulation from wound of a large vessel, and conse- quent penetration of the abdomen. The rare but possible phenomenon of faecal matter appearing in the external wounds renders the demonstration of perforation of the alimentary canal absolute. That such extrusion does occur as an early symptom after wounds made by large bullets finds illustration in the case to be reported by myself in this paper. The presence of blood in the urine, in connection with the situation of the external opening, demonstrates a wound of the kid- ney, ureter or bladder; the two former adding greatly to the gravity of the prognosis, and certainly in so far as its presence influences opinion at all, such condition would favor the necessity for operative procedure. Paralysis of any part of the body, below the level of wounds in the abdomen, necessarily complicates matters very much, render- ing it very probable that the ball has not only injured the viscera in its course, but has also done irreparable damage to the spinal cord or important nerves. "Shock" cannot be relied on as a positive indication of the presence or absence of perforation of the viscera. Cases with many perforations have presented no evidence of shock whatever. Its presence is rather an indication of some special nervous con- dition of the patient, of some injury to nervous structure, or, per- haps, more often than any other condition, it indicates the lacera- 164 GUN-SHOT WOUNDS OF THE ABDOMEN. tion of some large blood vessel with free bleeding, the last a con- dition of itself requiring abdominal section for its relief quite as surely as the rupture of the sac of tubal pregnancy, and proving quite as fatal if the operation is not done. It is to me a source of disappointment to be compelled to put the presence of " shock " among the doubtful signs of perfora- tion, for I was at one time fully convinced that its presence surely meant bowel wound, and I am still of the belief that when pres- ent, the probability of such injury is very great. Absence of pulsation in either of the femoral arteries will call attention to injury of the iliac vessels, and as well, when present, gives a second point with which to estimate the course of the bullet. In three cases of penetrating wounds seen by me, all had per- sistent nausea and vomiting present. Other reported cases have shown similar symptoms. It is also a common symptom with ruptured intestine from other causes: hence I deem it proper to claim that its import as a symptom be borne in mind. What symptoms make it probable that the issue in Any case will be fatal, whether operated upon or not? It seems quite proper to say that the majority of cases of through and through perforations of the abdominal cavity, with injury to both fixed and movable viscera and blood vessels, will prove fatal in spite of the best efforts to save them. Still, it would not take much time or thought to bring to mind instances of individual experience, or cases of record, in which the injuries done to obdominal viscera, and the shock incidental to a pro- longed operation performed in recognized procedures for the relief of abdominal tumor, has been quite as severe as could be produced by a bullet in transit through the cavity, and yet the patient has survived. So it becomes a difficult matter to decide when to decline operative interference. Cases of recovery have followed surgical care of the wounds when many perforations of the intestines* were found, and in which solid viscera f have been traversed by the bullet; many cases have perished in which, after death, examination showed the simplest injury to repair, and indicated the probability of speedy recovery had the abdomen been opened at once and the wounds treated. One is almost ♦Hamilton, Bull. t Murphy. GUN-SHOT WOUNDS OF THE ABDOMEN. 165 tempted to say that all cases are entitled to the chance of life offered through operative procedure. It is hazardous to predict a fatal issue. However, if the abdominal wound is complicated with a severe injury of the spinal cord, or bad wound of the solid viscera, or so great a time has elapsed as to allow of extensive extravasation and infiltration, with consequent virulent inflamma- tion, the probability is that the issue will be fatal. In application I will present the following cases: Mr. J. F., shot himself in two places in rapid succession with a 32-calibre revolver. I saw him four hours after the injury was produced, and found two bullet wounds, four inches to the left of the median line on the same line with each other and one and one-half inches apart; the lower wound was even with the umbilicus. One bullet had gone through the body; its exit pos- teriorly was just below the last rib and close to the outer edge of the rectus muscle. There had been and still was considerable hemorrhage going on from the posterior wound. He had eaten a hearty dinner just previous to the shooting. The patient was moderately collapsed, pulse very fast and countenance pale. By the time he was anaesthetized and necessary preparations were made, darkness had come on, and the operation was done with the light from a single gas jet. The two bullet wounds were joined by an incision and the fact of penetration demonstrated. An opening was then made in the median line four inches long through the abdominal walls. Con- siderable blood was found in the peritoneal cavity. This was removed and the wounded intestines sought for. These were easily found and the perforations quickly closed with a straight needle, carrying No. 1 silk thread. Five perforations were found and secured. On examining the posterior peritoneal surface a bullet perforation was found in it directly over the body of the left kidney. On passing the finger through it the kidney was found to be perforated by the bullet. The hemorrhage from the wound was at this time very slight. During this period operative procedures had to be discontinued several times to prevent the patient from choking during his attempts to evacuate the stom- ach, as he was vomiting large masses of meat and other food. The kidney was not removed. The wounds were closed, dressed antiseptically and the patient put to bed. He rallied fairly well in a few hours and seemed to progress nicely for twenty- four hours, when he began rather suddenly to fail rapidly and died in collapse. There had been considerable bleeding from the pos- 166 GUN-SHOT WOUNDS OF THE ABDOMEN. terior wound, and the patient died from hemorrhage from the wound in the kidney. It is to be regretted that the organ was not removed. The other wounds were comparatively simple in character and easily secured. There was but slight extravasation and the cavity was left quite clean. P. J., aged 45 years; was shot while walking in the street on the night of July 4th. He was seen by me at the Presbyterian Hospital sixteen hours after the injury was inflected. I found a large-sized bullet wound in the right iliac region, slightly below and two inches inside of the right anterior superior spine. The surface had been rendered aseptic and the patient anesthetized before I examined him. The edges of the wound were more ragged and more deeply discolored on the outer and upper por- tion, showing that the missle struck obliquely to the surface of the abdomen and that its direction was from the right and above. Considerable faecal matter was found in the wound. The man held his right thigh semi-flexed even when fairly anaesthetized. The right half of the abdomen, the upper portion of the thigh and buttock was fiery red in color, the margin of the erythema- tous blush being well marked. The respiration was entirely thora- cic, the abdominal walls hard and motionless. An incision was at once made in the mid-line after emptying the bladder of a pint of urine. As soon as the peritoneum was opened large quantites of a stinking ichorous serum poured out, bringing with it faecal matter and small pieces of potato undigested. This material was washed away by a free flow of mild boric acid solution. The wounded intestine was then sought, and after drawing out about six inches of badly inflamed tube, it was reached. It was a large perforation of the small intestine, but was secured by the contin- uous suture, without difficulty. All the folds of the bowel in the iliac fossa and pelvis were examined, but no other openings were found. A question of perforation of the bladder was raised, but a thorough examination with finger failed to find any. To further prove the uninjured condition of the bladder, it was distended with warm milk, but no leakage was noticed and the milk was allowed to flow away through the catheter. The external bullet wound was enlarged and its track followed by the finger. The missle barely entered the abdominal cavity at the fold between the abdominal walls and iliac fossa, and just outside of the fem- oral vessels, and was then lostinsoftpartsofthethigh on posterior surfaces. It evidently gouged out the convexity of the knuckle of intestine lying in its course. GUN-SHOT WOUNDS OF THE ABDOMEN. 167 After thorough cleansing, the wounds were all closed and drain- age left in the abdominal cavity. It was now noticed that the patient had abdominal respiration and straightened his right leg. The operation was done in the presence of Profs. Gunn, Ether- idge and Merriman, and Drs. Talbott, Mellish, Ward and others All expressed their belief that no other incision than that through the mid line would have enabled the surgeon to as easily and positively repair the injury and clease the cavity. The man died sixteen hours after the operation. With such extensive extrav- asation and virulent peritonitis as was found, no other result could be anticipated. With an early operation I believe the recovery would have been prompt in a case with so simple a wound and the absence of any complication. The case certainly points to the necessity of prompt relief in these injuries. The post mortem confirmed all the facts ascertained during the oper- ation, and I have present a section of the bowel showing the wound and the condition of the suture used to close it. One can fairly believe that the abdominal incision adds but little to the patient's danger, and if there be any, it is quite off- set by the benefits accruing from a perfect knowledge of the wounded person's true condition, as is exemplified in the follow- ing case: Dr. John I. Skelly, of Potomac, 111., reports, in the July number of the Annuals of Surgery, a case of penetrating shot wound of the abdomen. The cavity was opened by median section; no injury to the intestines was found, the bleeding was controlled, the peritoneal wounds sutured, and the patient recovered. The injury was done by a bullet from a 32-calibre revolver. Great shock was present in this case although no important viscera were wounded. Dr. Skelly refers especially to the great confi- dence in recovery, expressed by the patient, when assured that the intestines were not injured. What technical measures are best in the treatment of 'bullet wounds of the intestines, mesentery, stomach, kidney, spleen, liver and bladder? It is yet my firm conviction that in the great majority of cases the incision in the mid line will allow the most room for all the manipulations absolutely necessary on the surgeon's part, and yet be conducive of rapidity of action. It will furnish the surest way of following the course of the bullet, and thereby enhance the certainty of securing all injured viscera in all cases of through and through perforation, especially if the course of the ball is transverse, oblique or median. It will furnish the best way ot 168 GUN-SHOT WOUNDS OF THE ABDOMEN. reaching all parts of the cavity through which to insure perfect toilet of the peritoneum. Prof. McGraw's case shows there may be exceptions to what it seems should be the general rule. Here, as elsewhere, each case has its own indications and must be man- aged according to them. It seems proper for me to refer to a few conditions found in the wound of the intestine itself dependent upon the character of the ball producing it, previous to passing in review the means to be adopted for its closure. The character of the wound in the bowel depends greatly upon the size and shape of the bullet producing it, and much also upon the velocity of the missile. Round bullets moving rapidly make a clean cut, rather small wound with the minimum amount of bruising, so that they are comparatively easy to close. Rapidly moving conical bullets do much more damage than the round; still, even with these the great velocity makes the injury less severe than might be expected from such terribly destructive agents. The extent of bruising is greater, the edges of the per- foration are more ragged, still, if they strike the tube fairly in the lateral surface many such wounds can be safely managed without resection. The greatest amount of damage, in my expe- rience, is done by the rather slowly moving missile, be it either round or conical; these tear, mash and lacerate the tissues instead of making a clean punch, like the swift ones. However made, the large proportion of perforations in the bowel will be well secured, and quite rapidly, by means of the continuous stitch, applied so as to invert the edges of the wound towards the lumen of the tube, by entering the needle a safe dis- tance away from the margin of the wound and sewing over and over until all of it is covered with the opposite surfaces of the peritoneum held together by the stitches. As the result of experimental research, the following state- ment was made by myself in 1885 in an address before the Amer- ican Medical Association, written on this subject. "This way (that is the use of the continuous suture) of treating the bullet openings in the bowel is susceptible of much wider application than would appear possible at first glance. I am quite well sat- isfied that it will take the place of excision in not a few cases of quite severe injury. The torn edges of the wound can be turned in, and peritoneal surfaces fastened together, even in large wounds, with perfect confidence in the result of safe and secure adhesion following." GUN-SHOT WOUNDS OF THE ABDOMEN. 169 This statement has been borne out absolutely in my own expe- rience since then in the human being, and I believe it is the experience of all other operators. In no instance in any of the reported cases submitted to surgical treatment, since then, do I remember that the operator has been called upon to make a sec- tion of the bowel. All seem to have trusted to the continuous suture over the inverted wound, The recoveries are a positive evidence of its success and none of the fatal cases show a failure to secure the bowel wound by its use. It apparently makes no difference whether the wound in the bowel is closed parallel to to the course of the tube, or transversely or obliquely. The result is the same, provided the stitches are securely taken. Of course, the most easy and most rapid method of procedure is the best to be adopted, and of this the operator must be the judge. With a through and through penetration of the cavity,, we may expect to find clean perforations and the openings of mini- mum size in the intestine; with a single entrance wound, arguing diminished velocity of the bullet, the tube openings will be very likely ragged, bruised and difficult to repair without sacrifice of intestine. If the perforations found in the bowel are situated fairly away from the mesenteric surface, little difficulty will be found in car- rying out the manipulations necessary for their closure. Still, in cases in which many perforations of the tube are close together the intervening portions between the wounds have their vitality so greatly impaired by contusion, that complete resection of the implicated portion of intestine will be required. When the ball opening is directly at the mesenteric junction repeated instances of imperfect union followed by extravasation have occurred to me in experimentation. This kind of injury requires exceptional care in the application of the sutures, so that they include something more than the pertioneal covering, and do not include the larger blood vessels entering the coats in this position. When the injury is so extensive as to positively require resec- tion of the wounded portion, my experience from experimental injury, was positively in favor of two methods of procedure. 1st, cases in which the mesenteric border could not be saved, were most successfully treated, by making the section in healthy bowel tissue, and removing the injured portion with a triangular piece of the mesentery, the base of the triangle representing the 170 GUN-SHOT WOUNDS OF THE INTESTINES. length of intestines, removed. The first sutures are best intro- duced at the mesenteric border of the divided ends of the intes- tines, because this plan furnishes more room, in which to make sure of the engagement of sufficient tissue in the loop of the sut- ure, to make a fast and secure hold, than there would be if the other portions of the circumference were united before reaching this border. F"ailure to get good union, and to avoid extravasa- tion, followed in every case in which this plan was not adopted. Neither in man nor animal, have I found it necessary to intro- duce more than one row of sutures, either in the repair of single perforations, or in complete resections, provided the hold of the suture included about one-third of an inch of peritoneum with underlying muscular coat, and the sutures were placed about one- eighth of an inch apart. In no instance, in my experience, except when drawn too tightly, have the sutures failed to perfectly close the opening so that at the end of twelve hours sufficient plastic adhesion had taken place to resist powerful hydrostatic pressure, and, that too, in cases in which there were thirteen perforations in eighteen inches of intestine. That method which safely accomplishes the object of surgical interference, in the quickest possible time, and with the least possible disturbance of the viscera locally, or in general, is the best to adopt; saving of time alone is of vital importance to the patient. The edges of the divided mesentery should be sutured and all raw surfaces covered with peritoneum by means of stitches, with very fine catgut or silk, in order to avoid leaving any secreting surfaces free in the peritoneal cavity. Second. Cases in which the mesenteric or nutritive border can be saved. A plan which I have successfully adopted experiment- ally is as follows: The wounded part is cleanly cut out leaving the uninjured mesenteric portion. From this the mucous mem- brane is stripped, and the muscular coat with its peritoneal cov- ering, drawn downwards in a loop. This loop is closed with stitches and the bowel circumference remaining, fastened as in complete resection. This method produces no flexure of the bowel and does not interfere with the free flow of blood in the vessels coming from the mesentery. The most reliable and safest clamps, for use in holding the bowel during the manipulations of making a resection, were found in experimentation to be the fingers of an assistant, and GUN-SHOT WOUNDS OF THE INTESTINES. 171 further experience has not changed the result of that observation; they can do the least damage, and produce the least amount of shock, and will prove an intelligent aid to the operator. The wounds of the large intestine can be rapidly, and usually easily repaired by means of the continuous stitch on account of their large calibre and comparatively thick walls. Here, if any- where, the wounded bowel can be reached through an enlarge ment of the external bullet opening, as has been successfully done in one case by Professor McGraw, of Detroit, but this is only possible, in my opinion, in cases in which the shot is a direct antero-posterior one, over the course of the large intestines, and does not touch any small intestine. It seems impossible to me so easily to find the injured parts, or so rapidly repair them; or to carry out so successfully proper cleansing of the cavity, through any other incision than the median section, in oblique or through and through penetration in any transverse plane of the abdominal cavity. My belief is based upon trials on the cadaver, and living animals, and wounded men. No other incision, to my mind, gives such perfect command of the entire cavity. In one instance an incision extending over the entire length of the lateral surface of the abdomen and fully to the midline of Poupart's ligament, failed to enable the operator to find the ves- sel from which the fatal hemorrhage came. The track of the bullet could be traced to the opposite side of the cavity, but the intestine could not be drawn through this lateral incision so as to properly explore the course of the ball, There was no wound of exit. It seems very probable that the median section, by bisect- ing the bullet's course, and allowing easier access to the cavity would have made this case, as it will others, simpler to manage, at least. It is a matter of record in surgical experience that the wounds confined to the large intestines have often been recovered from without surgical interference, still, it is certainly probable that the number of recoveries will be increased, and rapidity of res- toration to health more surely provided for, by closing the wound in the intestine and cleansing the cavity at once, and without adding materially to the patient's danger. In animals, and probably likewise in man, a perforation of the great omentum is followed, sometimes, by a universal extravasa- tion of blood throughout the meshes of the mass, producing a condition that requires ablation of the greater portion, after proper ligation. The end of the stump left after separation can 172 GUN-SHOT WOUNDS OF THE INTESTINES. be covered by sewing adjoining surfaces of peritoneum over it. All slits or openings in the mesentery should be carefully closed with the continuous suture so as to avoid contaminating secretion into the peritoneal cavity. The wound in perforations of the stomach is occasionally diffi- cult to find, but when found, no difficulty is met with in applying the means of closure. The continuous suture has not failed to securely fasten them, and in every instance they have been fol- lowed by speedy recovery unless they were complicated by severe injuries to other viscera. There are on record quite a number of cases of penetration or perforation of the liver alone followed by recovery. If in doubt, with a posterior wound of entrance, enlargement thereof, with an- tiseptic care and dressing, would be justifiable. With an anterior wound, the course pursued by Dr. Murphy, of Chicago, in a case reported by him, was followed by recovery. Median section was made, the cavity cleaned of blood, and the wounds on the surface of the liver drawn together with catgut sutures. In my experience, wounds of the liver were managed in the same way and did well if the sutures were deeply placed. Wounds of the spleen bleed freely and are difficult to manage with sutures on account of the brittle nature of the spleen tissue, still sutures rather deeply placed will hold the edges of the per- foration in apposition. If badly lacrated, the many reported cases of recovery, after complete removal of the spleen for injury, rather indicate that extirpation is the best means of treatment in such injuries. Perforation and wounds of the kidney, from the character of the organ and the profuse hemorrhage from its torn surface, from the danger of urinary infiltration and decomposition, seem impos- sible to manage without extirpation, especially ifinjured by an an- terior wound of entrance. In one case of my own a complete per- foration of the kidney was found. It was decided to leave the kidney. The patient did well for about twenty-four hours and then succumbed to a profuse hemorrhage from the wounded or- gan. It seems the chances would have been better with it out. If the kidney is wounded, with posterior opening only, and enlargement thereof shows the injury to be confined to this organ alone, the cavity of the abdomen is not perforated, and recovery is possible either with or without removal of the organ. Perfora- tion or damage done to either the liver, spleen or kidneys, accom- panying similar injuries to the small intestines, greatly increases GUN-SHOT WOUNDS OF THE INTESTINES. 173 the gravity of the case, and probably very few cases will recover, whatever is done for their relief. Sir William MacCormac has positively demonstrated the suc- cess, following abdominal section in ruptures of the bladder, in order to securely suture the wound. It is proper to infer that bullet perforation of the viscus can be quite as easily secured in the same way. The results of the experience of Varick, of New Jersey, and Wylie, of New York, should always be borne in mind. They have demonstrated that hot water introduced into the peritoneal cavity accomplishes three purposes of great moment: relief of shock,. arrest or abatement of hemorrhage, and cleansing of the cavity. I think carbolized silk of fine size is the best material to use for the bowel suture, simply because perfectly reliable catgut cannot always be obtained, and the risk is too great, if there be the least likelihood of any strand giving way. No doubt, well prepared catgut may answer every purpose, but the silk never fails to do the work required of it satisfactorily. If asked what are the points most likely to be neglected or slighted in such an undertaking as giving surgical relief to a case of perforating gunshot wound of the abdominal viscera, my attention would be drawn to the items leading to failure in experimentation, and the conditions mentioned as found in the repeated unsuccessful cases in man. Among these would come first the paramount necessity of searching out and securing all bleeding vessels, dependent upon the danger of immediate or secondary hemorrhage. Hamilton, of Washington, tells us that his successful case passed through a period of extreme danger, in the last days of his illness, from the formation of a blood tumor. Murphy, of Chicago, reports a case lost from post-peritoneal bleeding. And in this case post mortem showed all the intes- tinal wounds thoroughly closed and water-tight. I have reported a case in which the immediate cause of death was kidney hemor- rhage. It is, no doubt, a hazardous ordeal to put a patient through, to examine the intestines from one end to the other in order to be well satisfied that no perforation has been overlooked, yet it is far more hazardous (in fact the result will be surely fatal) to leave an opening in the small intestines untreated. In some of the reported cases wide open bullet wounds have been found with their surrounding faecal extravasations and contaminated blood. 174 GUN-SHOT WOUNDS OF THE INTESTINES. It is to me extremely doubtful if all the wounded parts will be found, in an estimated transverse plane drawn through the demonstrated track of the bullet, especially if the missile impli- cates the ever gliding and moving small intestines. I am not prepared to believe that a supposed probability as to the seat of injured parts, should take the place of a regular, carefully made and satisfactory search for the wounds, and yet I would very carefully avoid practicing, or advising any procedure that might unnecessarily add to the shock already present. We do not know all that it is best to do yet, and still we do know that failure to close all the wounds means death to the patient, and some risk must be taken to avoid so great a hazard. It needs no argument or demonstration to prove the harm resulting from tight suturing. It has been my experience to see in animals the edges of several wounds slough away to the extent of the bowel tissue included in the sutures, followed by extrava- sation, making a failure out of a case that otherwise gave good promise of being a success. The temptation is great to be over- sure of good union. In my experience peritoneal surfaces need only be laid in contact with each other and kept quiet for a few hours in order that adhesion may occur. The paralyzed condi- tion of the bowel at the seat of wound from the injury, in itself favors this desirable quiet. CHAPTER HI. RENAL CALCULUS AND SURGICAL OPERATIONS UPON THE KIDNEY. The next patient, a working woman, twenty six years of age, has this history: Three years ago she was taken with severe pain, suddenly coming on, referred to the left side of the abdomen in the neighborhood of the left kidney. The pain extended over the front of the abdomen, after a time, and spasms of it, described as shooting, ran down towards the left side of the pubis. After lasting for a few hours it ceased quite as suddenly as it began. During the presence of the pain the patient felt a frequent de- sire to pass urine, but discharged only a tablespoonful or so at every attempt to evacuate the bladder, and its passage was accom- panied with considerable tenesmus and a severe burning pain. When the attack ended the urination was accomplished easily and attended with a large flow of urine. In addition to the agonizing pain which marked the onset of this attack, and which persisted during its continuance, the patient suffered from nausea and vomiting. There was also great pallor of countenance; the features were pinched; the skin was bathed in clammy perspiration; and all these were associated with symp- toms of profound constitutional disturbance of the circulation and nervous system. This aggregation of symptoms accompanies the passage of a renal calculus, or kidney stone, from the pelvis of the kidney into the ureter or through it into the bladder. The pain commences as soon as the stone enters the ureter, and does not cease until it either falls back into the pelvis of the kidney or is forced by the accumulation of urine behind, aided by the contractions of the muscular fibers of the ureter, through the length of this tube into the bladder. Knowing this you can readily understand the special character of the accompanying pain in that it commences suddenly and ends as quickly. This cycle of events is termed technically an attack of renal colic. 176 RENAL CALCULUS. Remembering that there is a fair sized cavity at the renal end of the ureter, consisting of the pelvis of the kidney, and a very large cav- ity at the opposite end, in the shape of the bladder, you are pre- pared to understand how a stone or a shred of tubercular tissue, or a dense clot of blood, may, on the other hand, just enter the ureter and be displaced therefrom by some sudden movement of the patient. The renal colic caused by its impingment in the ureter suddenly ceases when it falls back into the pelvis. As well can you understand how the attack of colic is far more severe and more prolonged if either of the foreign bodies ment- ioned is compelled to make the long transit through the entire ureter into the bladder, when the pain will also cease suddenly. Such attacks of colic will occur at intervals so long as calculi form in the calices of the kidney and are displaced therefrom, and take up their journey to the bladder, as is the condition in quite a number of individuals. Similar attacks may occur if there are present in any patient certain other pathological conditions of the kidney, such as tub- erculosis, or cancer, or papilloma, etc. It is true also that cal- culus formations are very apt to be associated with these pathol- ogical conditions. We find in this patient, that she was free from any return of the attack until eighteen months after the first manifestation descri- bed, since then she has suffered from them as often as once in every two or three months. Since the second attack, the urine has contained concretions of urinary salts, some of them of con- siderable size, as large as a kernel of wheat, or larger. The urine has shown the presence of pus and blood in some quantity; of late the pus has been present in large quantities. The patient's general health has suffered very much, until now she is emaciated, weak and broken down in spirits and physical strength, and is practically a confirmed invalid. Some time ago her attending physician, while making an ex- amination of the painful region during an attack of colic, discov- ered a tumor occupying the situation of the left kidney, and now you can see this tumor, showing as a slight projection of the ab- dominal walls on the left side over the neighborhood of the kid- ney. It is quite easy to feel it with the fingers of one hand press- ed against the tissues between the last rib and the crest of the ilium, while the other hand is pressed against the front of the abdominal walls. RENAL CALCULUS. 177 It is slightly movable, semi-elastic, smooth and even of surface, and is the left kidney distended with fluid of some kind. Prob- ably the fluid is pus, as such a large quantity of this material is found in the urine, and its presence is due to infection with the pus microbe through the genito-urinary tract. It is my belief also, that there is present one or more calculi, and this is based upon the fact that so many calculous concretions have been passed in the urine, as well as upon the fact that renal calculi are very sure, sooner or later, to be accompanied by an accumulation of pus through infection. It is scarcely possible that this will prove to be a kidney affect- ed with tuberculosis either with or without a stone, because it is unusual to have no other manifestations of the tubercular infec- tion than is present in this one kidney,besides the bacillus of tub- erculosis has not been found in the urine. The diagnosis in this case is renal calculus with suppurating kidney. It is, as well, certain to me that the substance and capsule ot the kidney is intact, because had destruction of these taken place by ulceration or tissue necrosis, a peri-nephritic abscess would have formed, with the usual signs of accumulation in and bulg- ing of this space between the rib and ilium. A few days ago, we had occasion to direct you that whenever a patient came under yourcharge suffering from indications of blad- der disease, never to think your examination is complete until a sound has carefully searched every portion of the bladder cavity. In this case we have an additional caution to give; never to be sat- isfied with an examination of a case of disease of the genito-urinary apparatus, without a rigorous inquiry into the condition of the kidneys by resorting to inspection and palpation of the organs themselves, as well as their entire neighborhood, just as carefully as you would examine their secretions microscopically, and by all known tests, for evidence of change from normal condition. In all these operations the primary incision to expose the kid- ney is made in exactly the same way, and all the steps will be illustrated to you upon this patient; and as we will no doubt find a calculus and remove it—this will be a nephrolithotomy. The direction is given, in order to make the diagnosis in such cases absolute, to sound the kidney by means of an exploring needle carried into the substance of the kidney, with the hope of having it come in contact with the stone—to strike the stone as it is termed—a very positive confirmation, if it can be elicited. 178 RENAL CALCULUS. It is even advised to go so far as to introduce the needle into the organ in several different directions for this purpose; and the trial has often been made before the primary incision uncovers the kidney, but of course oftener with failure than with success attending its practice. Even after the kidney is to be seen at the bottom of the exter- nal wound, the exploring needle, or the probe, or even the finger introduced into the pelvis of the kidney or through its substance, sometimes fails to find the calculus; especially when it is small and hidden in an expanded calyx. Consequently you are not to conclude hastily that there is no stone present if this test fails even when the kidney itself is under inspection; certainly not, if the trial does not determine its presence when the instrument is introduced without an incision. Given pointed and unmistakable evidence of the foreign body, as indicated by the occurrence of repeated attacks of renal colic —with deep-seated and continuous pain referred to one kid- ney—with pus or blood or both, in the urine, even in compara- tively small quantities, yet constantly discoverable; with the his- tory of the passage of concretions of urinary salts; certainly if several, or all, of these signs are present in a marked degree, the surgeon is justified in exposing the kidney and incising its walls freely, in order that the pelvis can be explored in all directions and portions, by the finger—truly the only reliable probe. It is true that even this crucial procedure sometimes fails to bring forth the calculus or to discover its presence. The kidney has been exposed a number of times and the pelvis explored without finding a stone. • The renowned Mr. Henry Morris, of England, relates a case in which failure followed his search, but so well convinced was he of the presence of the foreign body, on account of the marked symptoms of his patient, that he pro- ceeded to do a nephrectomy and found the stone in one of the calices of the kidney after the organ had been removed from the body. Mr. Morris was among the first, to diagnose the presence of a stone in the human kidney and to deliberately plan, and successfully execute, an operation for its removal. It has happened to me to fail to find a calculus on two occa- sions. In one a large calculus had been removed from the other kidney a year previously; in the other it seemed certain that the stone was lodged low down in the ureter. We may be able to get at it yet. RENAL CALCULUS. 179 If an operation is done merely to expose the kidney and incise it, the operation is termed a nephrotomy. If, in addition, the operation is done to remove a calculus from the kidney, it is termed nephro-lithotomy. If the operation is to relieve the dis- tressing symptoms due to the extreme mobility of the organ, called a movable kidney, in which the organ is first exposed and then fastened in some way to the edges of the wound, it is termed a nephrorrhaphy. If the operation is done to remove the entire kidney through the tissues of the back, it is termed lumbar nephrectomy. Prognosis.— The successful ending of the many operations already done and being done upon the kidney for a variety of diseases, is leading surgeons to the conclusion that the operations are not especially hazardous. My own experience, embracing all the operations performed upon this organ, and including several repetitions of some of them, points in the same direction. There has been but one death, and that followed the most formidable of them—a nephrectomy for a greatly enlarged suppurating kid- ney. All of the operations short of nephrectomy have ended favorably and with rapid recovery. The simpler procedures of exposing and exploring the organ are not attended with much danger, if such rigorous aseptic precautions are taken as are secognized by every surgeon as necessary in all operations. You understand that the incisions which we will make in this case, are exactly the same in every respect as those which are necessary for the execution of a nephrotomy, a nephrorrhaphy or a nephrectomy. The external incision should be about four in- ches in length, and made parallel with the last rib and fully half an inch below its lower border; commencing posteriorly, a little behind the prominent ridge marking the external border of the erector-spinas muscle. The course of the incision should always be made as directed, at the distance mentioned below the border of the last rib, on account of the dangers of opening the pleural cavity in any case in which the pleura descends below that rib or in cases in which there is present a supernumerary rib, or in which one rib is absent, and the normal relations of thepleuratherebyaltered. The patient should be placed in the position here illustrated, on the sound side, with a tightly rolled pillow, covered with an oil-cloth having an aseptic towel over it, placed under the oppo- site loin; thus the side to be operated upon will be made very prominent, and the interval between the rib and the crest of the ilium increased to its fullest extent. 180 RENAL CALCULUS. The first incision should be carried with a free hand through all the tissues and fasciaed own to the anterior layer of the lumbar facia. The length of the incision through the deep tissues being the same as that through the skin. The operator should avoid opening the sheath of the erector-spinae muscle. All bleeding vessels are secured. The anterior layer of the lumbar facia is then opened and divi- ded to the extent of the wound. As soon as this is done, there wlil bulge into this opening, the peri-nephritic tissue in which the kidney rests. Its investing connective tissue should be opened and the operator will then readily recognize the peculiar white fat surrounding this organ. A portion of this fat may be pulled out and snipped away, or its spaces opened and torn by the fingers, as you now see me do, after which the kidney can be readily felt by the finger or seen with the eye, as a darkish red body, moving slowly up and down with each respiratory act. If the kidney is not now easily found, as is frequently the case if it is not enlarged to any extent, it can be brought into view sometimes by a simple procedure. An assistant introduces two fingers into the wound and pulls strongly upward against the last rib. This widens the wound and at the same time stretches the peri-nephritic tissues towards the wound. The assistant with his disengaged hand should also press strongly backwards through the anterior abdominal walls over the region of the kidney, thus pushing it into the wound. The space for operative manipulations, in cases of enlarged kid- ney, can be greatly increased, and with safety, by a vertical inci- sion commencing in the one already made, and carried downwards towards, and forward parallel with, and close to the crest of the ilium. With the finger deep in the wound as a guide, this latter incision can be rapidly made without danger of opening the per- itoneum. It was used upon one occasion successfully by myself in the removal of a kidney enlarged to the size of a cocoanut; and made a space large enough for all the necessary manipulat- ions without difficulty. After the kidney is exposed in the manner described and brought fairly under the touch of the finger and the sight of the eye, by the removal of its investing fat, the next step will depend upon the operation which is being performed. In this case the object is to remove a stone from the kidney and evacuate what other accumulations may be present. So we will now first introduce the finger into the wound and palpate the RENAL CALCULUS. 181 kidney over its anterior and posterior surfaces, reaching as far beyond the pelvis as possible in both directions. The best command of the kidney can be obtained in these cases. by the finger passed over its posterior surface. The finger used in this way will sometimes detect the stone in the kidney, or de- termine a noticable bulging and hardness is some portion of its surface which may indicate its presence. If no information is gained by this examination, the kidney is fixed as mnch as possible in the wound by pressure through the anterior walls of the abdomen, and by forceps grasping the peri- nephritic tissue; then a grooved director is thrust through its substance towards and into the pelvis, which is examined thor- oughly in all directions by changing the direction of the probe, until the stone is struck, or none is found. Of course, if, as in this patient, the tissue of the kidney and its pelvis is distended with pus, as soon as the director enters the cavity the pus. will flow through its groove, as you see it does in this instance. The blunt-pointed director is the best instrumeut to use in this trial; it or any other cutting instrument, should always be intro- duced into the kidney some little distance above the lower end of the organ, on account of the frequency of the presence of the artery aberrans entering the organ at this point, and the free hem- orrhage attending the wounding of it. It is also said that fatal hemorrhage has followed the use of the pointed aspirator used for this purpose, the needle being thrust so far forward as to punc- ture the main renal artery or vein. No attempt should be made to fix the kidney by means of for- ceps attached to its substance, or by threads passed through it, because, owing to the structure of the kidney tissue—its softness and brittleness—they will surely tear out: no fixation will be ob- tained, merely unnecessary damage done the organ. It can some- times be fixed very well by passing the finger behind it in the wound. In case no pus escapes along the groove of the director, as not infrequently happens when the kidney is not much increased in size, and it is thought necessary to make further exploration, a scalpel is carried along the groove of the director through the substance of the kidney, making an incision large enough to ad- mit the finger easily; the finger is passed through it into the pel- vis of the kidney and a careful search made in all directions for the foreign body. 182 RENAL CALCULUS. If the stone is of large size, filling and distending the cavity of the pelvis, the examination by palpation of its entire surface, as already described, will have probably discovered its presence; in which event the knife is carried directly through the substance of the kidney to the stone, and the proper incision made. If the stone is discovered by the use of the director, without any flow of pus, an opening is made by the knife sufficiently large to admit the finger. In this patient, in which pus is found to be present, after the introduction of the director, the incision should be made as free as possible, not only for the removal of the stone, but especially to lay open freely the pouches which are so apt to be present in these cases. This will provide for free drainage and prevent the retention of pus in these pockets, as the kidney contracts after operation, leading to the occurrence of secondary abscesses so common in the history of suppurating kidneys. How will you proceed after the finger has touched the stone,. no matter by what method it has reached it? The calculus is carefully and slowly loosened from its bed, by keeping the pulp of the finger in contact with it, and pushing the investing tissue away from it by the finger nail carried in all directions, until the stone lies perfectly loose in the cavity. Then a pair of dressing forceps introduced along the finger, is made to seize the stone firmly, and it is drawn quietly and slowly through the wound until its removal is accomplished. The directions about removing the stone are thus minutely given, because it is especially desirable to remove it entire, and thus avoid leaving any small pieces, which, owing to its brittle- ness, can be easily broken off. They often avoid the most rigor- ous search and become the nucleus, around which may form other stones in the future. Besides, the calculi are frequently very irregular in shape, hav- ing off-shoots developing from the main stem, in different direc- tions, like pieces of coral. These off-shoots are firmly embedded in the calices of the organ or accidental pouches, so that they are easily broken off, and may remain embedded in these pockets if any forcible attempts are made to withdraw the stone before it is entirely loosened by means of the finger. Of course many times the stone or stones, are found loose in the pelvis of the kidney, or in the cavity of the abscess, or they are smooth of surface and even and regular in their development, in which case there is no difficulty attending their removal. REN A L CALC UL US. 183 In this patient, you notice that I have considerable difficulty in loosening the stone which we have found, and I am compelled to enlarge the opening in the kidney very much, because the stone is of large size and very rough and irregular in its shape. Now I think I have it loosened and the incision made long enough to allow of its easy exit. Introducing this pair of forceps, the stone is seized, and while extracting it slowly and carefully, with my finger I push the kidney substance away from its irregular sur- faces. Unfortunately I have broken this piece in the grasp of the forceps, away from the main portion of the stone, which accident, not only spoils the beauty of the specimen, but shows you how brittle the concretion may be and how carefully it must be handled. There is no fear of this fragment causing any sub- sequent trouble because I have it on the outside. The stone is seized again with the forceps, at a larger, denser portion of its surface, and with the same careful method of extraction, it is finally removed entire. The specimen is fully three inches long and over an inch in width at its widest portion. It is very irregular in formation and shows the presence of the offshoots, to which your attention has already been directed. The hemorrhage is very free following the first incision made into the kidney substance, but in my experience, it has never been hazardous or sufficient to cause any anxiety, for the pressure of the finger, introduced through the wound, soon causes it to cease. The manner of treating the wound is different according to whether pus be present or not. If there be no pus and the kidney not much enlarged, very little special treatment is required. A large size drainage tube, long enough to reach into the pelvis of the kidney, should be introduced and left for a few days to pro- vide for the easy exit of bloody serum and urine, which will flow immediately after the operation and as a consequence of it. The external wound is closed up to the drainage tube, by means of interrupted silk sutures passed through all the tissues of the edges of the wound in the same manner as in the abdominal opera- tion, although in this operation, there is no peritoneum to be includ- ed in them. The drainage tube prevents the probability of the occurence of urinary infiltration. After a few days clear urine will flow through the tube, when it can be removed and the resulting sinus will rapidly close and 184 RENAL CALCULUS. securely heal by cicatrization, leaving nothing to mark the occur- rence of such a severe operation, but the external scar. The urine passed from the bladder, will show the presence of blood in a greater or less quantity for a few days, gradually resuming its normal condition. This symptom has its advantage, because it proves that the ureter is patulous. If pus is present, the several pockets in which it is apt to be contained are usually found to be separated from each other by incomplete trabeculae of connective tissue or kidney substance. These are broken down with the finger, thus converting the many into one cavity; this cavity is then thoroughly irrigated and washed with some mild antiseptic solution, such as boric acid or with sterilized water. It is to be remembered, that solutions of powerful antiseptics, especially mercuric bichloride, contain in themselves the elements of extreme danger, in that they may poison the general system or seriously impair any normal tissue which may remain in the organ itself. Hence, if used at all, great care should be practiced and the cavity thoroughly washed out with sterilized water after their use. The use of bichloride of mercury sometimes leads to acute granular degeneration of the kidney. The ragged portions of debris are then removed, and when thoroughly and satisfactorily cleaned, the cavity is packed to the bottom with iodoform gauze. No attempt being made to close the wound by suture. This treatment is advised, because it is my belief that it is least likely to be followed by secondary abscesses. In all conditions, the external dressing consists of the application of masses of loose iodoform gauze and borated cotton, held in place by a body bandage. The operation, as you see, is prolonged, and hence likely to be attended with evidences of shock, therefore every provision should be adopted to counteract the dangers which accompany such conditions by the administration of quinine or whiskey before the operation; by keeping the patient's body covered with blankets during the operation and by providing artificial heat through radiation after the patient is put to bed. The profession has come to the conclusion that chloroform is the best anaesthetic to use during all operations upon the kidney, but no matter what anaesthetic is used, the anaesthetizer should be careful to give as little of it as possible; often allowing the patient to breathe freely of fresh air, by the removal of the cone, RENAL CALCULUS. Iy5 in this as well as in all operations which are prolonged and exhaustive in character. Kidney stones are developed from the salts of urine, which are normally held in perfect solution and are oftenest found to con- sist of the crystals of uric acid. Many are made up of oxalate of lime, while some are composed of phosphatic salts. They are found in both sexes and at all ages of life; they vary immensely in number and size, thus they may be so small as to pass easily through the ureters when loosened, and escape from the bladder; or so large as to change very greatly the shape of the kidney which is expanded about them. In form they may be smooth and even, or rough; or possess the greatest diversity in shape and irregularity of surface. The symptoms indicating their presence have already been described to you as forming the history of an agonizing attack of renal colic. Still there may be no signs present indicating their existence, other than a steady, persistent, deep-seated pain, sometimes burning in character, referred to the region of the kidney, accompanied by the persistent presence of blood or pus in the urine. The suffering in these cases bears no relation to the size of the calculus—one patient from whose kidney I removed a concretion not larger than the end of the little finger, suffered repeatedly with excruciatingly severe attacks of renal colic, while in another with a larger calculus than the one removed to-day, the pain during such attacks was not severe. These formations may take place in both kidneys at the same time, and when this occurs there is great difficulty in forming a conclusion on which kidney to operate, or whether to resort to surgical interference or not. In all these cases, the microscopical examination of the urine is very apt to show the salts of which the stone is composed, present in the urine in large quantities. If there is present a tumor in the region of the kidney, with the history of previous attacks of renal colic, there can be no doubt as to the diagnosis, and surgical interference should be practiced. Treatmeid.—The treatment of these cases must be be considered under three heads: prophylactic, palliative, and surgical. The latter has been illustrated to you in the operation performed upon the patient before you. Prophylactic treatment consists in directing your patient's diet —avoiding the use of meats; and advising the free use of water, 186 RENAL CALCULUS. especially such mineral waters as are known to have a beneficial effect upon the condition of the system termed lithiasis. The mineral water possessing the best effect is probably the one con- taining a large per cent, of the salts of lithia. It is my belief that large quantities of distilled water are beneficial. It is gen- erally supposed that people living in countries in which the water used for all purposes contains a large portion of lime, are most likely to suffer from these troubles. It is also supposed that in children poor and improper food accompanied with faulty assimilative powers, have much to do with the production of the disease. The palliative treatment has reference particularly to the man- agement of the attacks of renal colic, the pain of which is con- trolled by the use of the preparations of opium, particularly the hypodermic injection of morphia, in doses of such size and suf- ficiently often repeated as is required to control the pain. Frequently in severe attacks the careful administration of chloroform or ether to partial or complete anaesthesia is neces- sary to at least temporarily assuage the patient's agony until the foreign body has passed the ureter. Hot fomentations freely applied over the painful area and the use of hot baths are beneficial. We know of no remedy, the administration of which through the mouth, will dissolve or in any way diminish the size of these renal concretions. No perma- nent relief can be given in any other way than by the removal of the offending body by surgical interference. Renal calculi occasionally become lodged in some portion of the ureter; the most common place of stoppage seems to be near the point of termination of the tube in the bladder: at least quite a number of instances are on record in which the calculus form- ing in women, has been located in this position by vaginal exam- ination, and their removal attained by operation. If the stone becomes arrested at other points and cannot be located as in women, catheterization of the ureters can locate it; or if the kidney has become exposed in search of it, the passage of a sound from above will fix its position. When found it must be, and can usually be safely removed by any operation which will expose its position. Of course any operation for this con- dition should be post-peritoneal. The urinary fistula following such procedure is not usually permanent, but heals kindly and rapidl) ; every precaution for RENAL CALCULUS. 187 free drainage should be used to prevent urinary infiltration into the loose tissues in which the necessary incision is made. Suppuration in the kidney and accumulation of pus dependent upon any other causes, such as tuberculosis or other degenerative changes, sometimes lead to the formation of various enlarge- ments or tumors of the kidney which fluctuate freely. The condition of distention of the kidney substance and its pelvis with pus, is technically called " pyo-nephrosis," and for its relief requires exposure of the kidney in the manner just illus- trated. The abcess is then opened by free incision through the kidney. This operation is called nephrotomy. The treatment after the incision is the same as for cases of stone with pus accu- mulation. A similar distention, frequently reaching great size, follows injuries or diseases which occlude the ureter and there occurs the formation of a fluctuating tumor, the contents of which are clear, pale in color, and contain a slight evidence of the presence of urinary salts. This condition is called " hydro- nephrosis." While the pus cases always show severe constitutional disturb- ance, with sweatings, chills, high fever, and other evidences of septic infection, hydro-nephrosis causes very little or no trouble until the increase in size calls attention to the tumor, and pro- duces a varying amount of discomfort. Aspiration, with a complete emptying of the cyst (for the kid- ney substance is so attenuated and thinned out it forms nothing but a cyst wall) will sometimes cure a hydro-nephrosis, at other times a cure will only follow free incision and drainage of the tumor by means of a nephrotomy. In cases of pyo-nephrosis, as the result of pressure necrosis or ulceration from accumulation, the capsule of the kidney is destroyed and the pus leaks out into the surrounding cellular tissue, forming a peri-nephritic abcess, with the local signs of bulging of the space between the rib and crest of the ilium; with hardening and infiltration of all the tissues of the back in this space; with redness of the surface and cedema and finally circum- scribed fluctuation. The abcess points and breaks of its own accord or the surgeon incises it. Sometimes the opening in the kidney can be found, at other times not. If a fistula persists after the opening of the abcess, always suspect the presence of a calculus in the kidney. Expose and remove it by the proper surgical operation. 188 RENAL CALCULUS. Hydro-nephrosis is classified under the head of cystic tumors There occasionally form in connection with the kidney, sim- ple serous cysts, and also those dependent upon the presence of the echinococcus or hydatid. Both of these conditions are suc- cessfully treated by exposing the tumor, incision and drainage, or sometimes by simple aspiration. It is quite surprising how seldom urinary fistulae persist even after very extensive incisions and bruising of the kidney. The urine may flow through the wound in the back for a few days or weeks, but if the ureter is patulous, they are quite certain to close. Wounds of this organ heal quite as rapidly and as per- manently as those of any other tissue of the body. The operation of nephrectomy, or complete removal of the organ, is a very serious one primarily, and has dangerous sequelae attending it, even if the patient recovers from the operation, for the remaining kidney, called upon to do double duty, is particu- larly liable to the occurrence of diseases apt to be fatal. It should always be remembered that the abnormality of one kidney is not very infrequent, or that the two may be joined together in the peculiar formation of a horse-shoe kidney, some- times found present. A nephrectomy under these conditions would necessarily prove fatal. The operation should not be advised or undertaken except under the most pressing need, that is, in cases in which the disease or injury is of more menace to the life of the patient, than this hazardous operation. It should also be remembered that even in advanced disease of the organ, in many cases, there still remains a considerable por- tion of the kidney substance, able to perform a portion of the normal function of the organ; a patient with a badly damaged kidney, is in less danger, if some portion remains to do duty, than after the entire removal of the organ. Every means'possi- ble should be resorted to, to determine the existence of the abnormality of one kidney before the operation is done. Some surgeons recommend the catheterization of the ureters, in order to establish this fact; others favor what is termed abdominal incision—anterior operation—so that after opening the abdomen both kidneys can be found, before either is removed. The first successful nephrectomy was done by Simon, of Ger- many, for an incurable fistula following a difficult parturition. The disease for which the operation is recommended, are destruction of the kidney from suppuration resulting from any RENAL CALCULUS. 189 cause; or tuberculosis, if confined to one kidney; or cysts other- wise incurable; for the removal of solid tumors developing in this organ, and for such injuries as are followed by a persistent and incurable fistula; or which absolutely destroy the organ itself, such as gun-shot wounds. The solid growths which we find developing in the kidney are,. rhabdo-myoma, adenoma, papilloma, carcinomata and sarcoma; the sarcomata and rhabdo-myomas occur oftenest in infancy or childhood. Adenomata and carcinomata are growths oftenest found in adult life. Sarcomata develop very rapidly and grow to a large size. Their removal is attended with many difficulties, and even if not primarily fatal, does not add materially to the patient's tenure of life. The same is true with the carcinomata with the exception that they never attain a great size, because their malignancy leads rather early to a fatal issue. Adenomata are simple tumors; can be removed safely, and the patient's life may be prolonged in comfort for years. There are two methods of performing a nephrectomy: first, the lumbar; second, the abdominal. The lumbar is the one most com- monly chosen; the operative manipulations are executed outside the peritoneum; free and perfect drainage is easily carried out; and for these reasons it is best adapted for cases of suppuration in the kidney, and all tumors of moderate size. The abdominal method is of diagnostic value in enabling the operator to at once decide positively that both kidneys are present; it necessitates an abdominal section, hence opens the peritoneal cavity—and no drainage can be practiced unless a counter open- ing is made through the loin. It is best adapted to the removal of tumors of large size, as it allows perfect control of the growth. The dangers attending both operations are first, hemorrhage; second, infection; third, uremia from insufficient elimination of urine; fourth, shock. Hemorrhage can be avoided by special care in the management of blood-vessels; sepsis prevented by the usual aseptic or antisep- tic precautions rigorously carried out; uremia counteracted by elimination and derivation through other emunctories; and shock diminished to a great extent by free stimulation and protection of the patient from loss of body heat. The lumbar incision for nephrectomy calls for exactly the same incision in all its details, as the one just practiced before you to- day, carried so far as to expose the tumor. After the organ is exposed it is loosened with the finger from its bed of perine- 190 RENAL CALCULUS. phritic fat. As soon as this is accomplished, the blood vessels entering the hilus are carefully isolated and a needle armed with a double ligature of sterilized silk is carried between the vein and artery, through the pedicle made by these vessels, dividing it into halves, and it is securely tied. The ureter is then sought after, temporarily secured with forceps and divided between them. The pedicle is then cut through, sufficiently far away from the ligatures not to endanger their security, and the kidney is removed. In cases of suppurating kidney, the organ is often so firmly imbedded in vascular adhesions that bleeding is dangerously free during its separation. If this be the case it is best to ligate the main vessels first. After the removal of the organ, the ureter may be managed in either of two ways. Its free end is made thoroughly aseptic by the application of the actual cautery or pure carbolic acid, and it is drawn out aud fastened to the most dependent part of the external wound; or its extremity may be inverted into its lumen, like the finger of a glove, and the perintoneal edges fastened by sutures. Quite large and vascular growths of this organ can be safely removed through the lumbar incision, by first securing the base of the mass with a temporary rubber ligature, drawn tight enough to close the blood vessels. The tumor is then cut away piece- meal without bleeding until it is so far reduced in size that the permanent ligature may be easily applied inside the rubber tube, in the usual manner. The elastic tube is then removed. Some operators include the ureter and the blood vessels in the same ligature, but the better plan seems to be to tie them separately. If no pus is present, the wound is perfectly closed after pro- viding for drainage by means of a large size drainage tube. If pus is present, the wound is best treated by the iodoform tam- pons as already described and illustrated to you to-day. The dangers of this operation are increased by opening the peritoneum, and this accident should be carefully avoided. When the abdominal method is practiced, an incision is made through the linea semi-lunaris in the usual manner common to all operations which open the peritoneal cavity. The intestines are pushed out of the way by means of a large flat sponge. As the tumor is behind the posterior layer of the peritoneum, this layer, too, must be incised before the tumor is exposed. The RENAL CALCULUS. 191 colon, in these cases, usually lies on top of the tumor, and the incision which opens the posterior layer of the peritoneum should be made some distance away from the outer edge of the colon and parallel to it. It must be of sufficient length to allow the operator to have complete control of the tumor, and to pro- vide for its easy removal. The sponge is then withdrawn; and the inner edge of the incision of the posterior layer of the peri- toneum is sewed securely to the inner edge of the incision through the abdominal walls; in this way shutting off completely the peritoneal cavity from the field of operation. The blood vessels entering the tumor are now sought after and ligated. The ureter is found and secured temporarily by forceps, the tumor separated from its attachments and removed. It is just as well if the tumor is rather large and the space lim- ited, to secure the blood vessels temporarily by long-jawed for- ceps, as they can be ligated inside of these after the removal of the tumor. It seems best to always provide for drainage through the pos- terior lumbar region; this can be easily done and without fear of hemorrhage by thrusting a pair of scissors directly backwards to the interval between the last rib and the crest of the ilium and expanding their blades to make an opening through which a large drainage tube can be easily drawn. The ureter is managed in either of the ways that have already been described in the directions for lumbar nephrectomy. After the tumor it removed and the manipulations mentioned are satisfactorily carried out, the edge of the posterior layer of the peritoneum which was sewed to the abdominal wound is unfastened by snipping the sutures. The sponge is again used to keep the intestines out of the way while the incision in the posterior layer of the peritoneum is secured closely by means of the continuous catgut suture, thus perfectly isolating the peri- toneal cavity from the large space recently occupied by the tumor. The abdominal wound is sutured in the usual manner, the sponge removed, and the external wound closed. Nephrorrhaphy is the name given to the operation practiced for the relief of the symptoms accompanying a freely movable kidney. It has only been during a few years past that the profession has adopted the belief that any operation is required for the cure or attempted cure of such cases. It is possible that it can be justly said that it is only within a few years that the condition of 192 RENAL CALCULUS. a movable kidney has been recognized as the cause of a certain array of symptoms which interfere materially with the health and comfort of a patient suffering with this affliction. Such patients as have come under my care have complained of quite serious trouble and have shown well marked evidences of failing health. All of them have become aware of the presence of the movable body and have insisted that the movements of the organ were the cause of much pain, at times even severe, and that the stomach was disarranged in its function—that the appe- tite was either lost or very much impaired—and that they had lost flesh noticeably and rapidly. All of these cases had borne children—no doubt the condition occurs oftenest in women who have borne children, still the con- dition is met with in men. We know that normally, the kidney is not absolutely fixed in its position—that it is movable to a slight extent in its surround- ing loose cellular tissue. For some reason or other after extreme distension of the abdomen its mobility becomes increased in these cases, occasionally to a considerable degree; a true meso- nephron is developed, at the end of which the organ has a range of motion in proportion to the length of the peritoneal fold. Probably such cases as possess a complete meso-nephron are the ones in which the severest pain is felt; which may be due to a twisting of the vessels and the ureter. In some cases the kidney can be displaced downwards as far as the ilium, or inwards as far as the median line. It moves upon the slightest touch, and can always be replaced into the position in the back which it properly occupies. The well known shape and contour of the movable kidney can usually be readily palpated with the fingers through the loose and flabby abdominal walls, and hence as a rule can be positively differentiated from any other growth. If the kidney is only movable in the loose post-peritoneal fat, even if the area of motion is considerable, the operation for its relief is much more simple than in the cases in which the kidney is invested on all sides by the peritoneum, and has a long meso- nephron developed from this tissue. In the first condition, probably a nephrorrhaphy will bring about a cure; in the latter, probably a nephrectomy will be required if any operation is demanded. RENAL CALCULUS. 193 Most often the kidney is normal in every way except its free- dom of displacement. At times it is diseased and enlarged, and this may necessitate the more radical operation. The long meso- nephron makes it very difficult or quite impossible to uncover the posterior surface of the kidney for the application of sutures without opening the peritoneum, an accident to be avoided. This condition greatly increases the difficulty of finding or fixing the organ at the bottom of the wound made to expose it. The prognosis as to the operation is favorable—in the matter of permanent cure it should be guarded. The operation has not been done often enough, the cases subjected to operation have not been sufficiently long under observation in all instances, to enable us to speak very positively about them. In my experi- ence, they have all been noticeably improved at first, the appe- tite has been better, the food better assimilated and the pain relieved. But this favorable result followed during the confine- ment of the patient in the recumbent position, with little or no disposition to displacement or interference with the organ. It remains yet to be seen whether the adhesions formed as the result of the operation, are sufficiently firm to withstand the weight of the organ and the influence of the movements of the body, when the patient assumes the erect position and performs ordinary duties. It is quite fair to mention the fact that quite a num- ber of cases have been reported by surgeons, in which, even after a lapse of two years, there has been no return of the displacement, and the general health of the patient has been permanently benefited. The primary incision for nephrorrhaphy is exactly similar, in all details, to that already illustrated, to you to-day for exposing the kidney in the nephro- lithotomy just finished. As soon as the peri-nephritic fat is uncovered, the kidney is found. Usually the assistant is able to fix the kidney in its normal position, by pressure against the organ through the anterior abdominal walls, so that it can be easily exposed to view by separating and displacing the sur- rounding fat. The posterior surface should be widely uncovered. Its capsule should then be incised for a length of two inches, and the edges of the divided capsule stripped off the surface for a short distance in opposite directions so as to uncover the small portion of corticle substance. Then the edges of the elevated capsule should be sutured with silk to the edges of the deep por- tion of the external wound. The needle should be full curved 194 RENAL CALCULUS. with a blunt edge, and it should be introduced so as to take up a fair amount of the kidney substance. It should be introduced very carefully, as the kidney substance is very soft and brittle, and easily torn; the silk suture should be drawn carefully after the needle, and without any tension on the kidney, for it is easily torn through the included portion of the organ. Sutures should be placed, at least, at the upper and lower ends of the opening in the capsule, and a third or fourth one may be applied near its center. When these sutures are satisfactorily in place, the external wound should be closed, as has already been explained and illustrated, except that a narrow strip of iodoform gauze is to be placed in the center of the wound, reaching from the exposed surface of the kidney to the outer surface of the body. This strip of gauze is left in position for some time, and is said to answer the excellent purpose of establishing a band of cicatricial tissue from the surface of the kidney to the outer sur- face of the wound, permanent in character, which acts powerfully in fixing the organ in position. In one case in which I adopted this plan, there remains in the.center of the scar a deep depres- sion, which draws the skin inwards, and is no doubt produced by the cicatricial track left by the gauze used in this way. The external dressings, the same as those applied in the case before you to-day, are designed to keep the wound perfectly aseptic until the healing process is complete. The wound stitches can be removed at the end of the week, when, if the case has followed a course free from infection, the wound will be found united. The deep stitches have given rise to no trouble in the cases operated upon by myself, and are left to take care of themselves. The patient should be confined to the recumbent position for several weeks, so as not to interfere by dragging upon the newly formed and easily torn adhesions. Some surgeons claim that they are able to control all the symptoms incidental to the presence of a movable kidney, with- out operation, by a properly fitting pad applied to the abdomi- inal wall against the organ, after returning it to its normal situation, and holding the pad in position by a body bandage. The operation of nephrorrhaphy is not a dangerous one, and further experience with it may give to it a definite and positive position among the surgical operations upon the kidney. NEPHRECTOMY. 195 NEPHRECTOMY* Last July I received a communication from a friend out of the city, stating that a patient had come under his charge who had been suffering for two years with cystitis, the diagnosis being based upon pus in the urine. When I returned from my vacation in September, I found the patient awaiting me at one of the hospitals in the city. Upon examination it was found that a tumor could be easily palpated in the right side of the body beneath the ribs, large enough to extend down to the superior spinous process of the ileum, and reaching up to the hypogastric region below the liver. Upon the usual attempts at palpation and percussion, the dullness over the tumor was found to be continuous with the dullness of the liver. But the tumor appeared to me to be so elastic as to present some of the characteristics of a sac containing fluid. So I intro- duced an aspirator needle into it, and as was expected, found pus. As it presented none of the usual symptoms of a perinephritic abscess, it was diagnosticated to be a case of suppurative disease of the kidney communicating with the bladder through the ure- ter, the bladder being the outlet of the pus. There was no appar- ent disease of the bladder itself, other than that which would be present as a consequence of the foreign substance in the bladder. Obtaining the patient's consent to an operation, an incision was made over the tumor to the outside of the erector spinae muscle, and the tumor was exposed; then the pockets of pus in the organ were located by the hypodermic syringe. On this occasion, three pockets of considerable size were opened, and drainage tubes introduced. About a pint of matter was let out. It was decided that these three pockets, that were found by introducing the syringe in different places, did not communicate with each other; they were separate cavities, and I think that is the usual condition found in this sort of disease of the kidneys. * Read before the Chicago Medical Society. Nov. 7, 1SS7. 196 NEPHRECTOMY. One of them opened freely into the pelvis of the kidney, so that through the incision that was made the finger passed into the pelvis, and water injected into this went into the bladder, showing that there was a direct communication from this cavity of pus to the bladder and urethra. The drainage tubes were left in and the patient improved promptly, losing the fever and symp- toms of pus accumulation and retention. For two weeks the improvement continued, then it was noticed that she began to fail rather rapidly and to show signs of fever again; there were signs of septic accumulation, and the tumor began to increase in size, so that from diminishing, perhaps half the size when first examined, it increased one-third. As she was failing and the diagnosis was as complete as it was possible to make it, it was decided to perform nephrectomy. There are some points of importance in the case: The drain- age tube that went into the pelvis of the kidney gave free exit to quite a quantity of urine. I think that most of the secretion from that kidney came through the drainage tube; it was sufficient to wet thoroughly in two or three hours a large dressing; this dress- ing was sufficient to keep the discharge from the wound pure so that there was nowhere decomposition of pus so far as the out- ward manifestations were concerned. It struck me that if this drainage tube from the diseased kidney gave exit to such an amount of urine, and at the same time there was a good flow of urine from the bladder, it was a fair indication that the other kidney was not diseased, and that success would attend the removal of the diseased kidney, and it was decided to do the operation. Sixteen days ago the operation was done. The patient was prepared in a certain way that I have followed in reference to all patients upon whom I do what is considered a serious operation, and I think it has a certain influence in preventing shock. Two or three hours before the operation is performed the patient is given gr. v. to x. of quinine, and gr. y of morphine. This medi- cine was administered to the patient of whom I am speaking, and the operation for the removal of the kidney was performed. The whole proceeding from beginning to end occupied an hour, and she went to bed without any manifestation of shock, and with a pulse of 112. She had no rise of temperature until the second day, and then it rose to 100 degrees, subsequent to that it fell to normal and did not rise above normal until the twelfth day, when other symptoms appeared. During all this time the NEPHRECTOMY. 197 wound was absolutely aseptic. It healed promptly by first inten- tion, so that on the seventh day all stitches were removed; the wound was solid from one end to the other. There are some points about this operation to which I desire to call your attention, and I will pass the specimen around to show the nature of the trouble. You will see at the lower end a cavity, which was found to contain six or eight ounces of pus; there is another cavity in the interior of the kidney, the pelvis is entirely destroyed and filled up with adventitious material. Here was an operation to be done upon a moderately sized woman for the removal of a tumor containing pus, a tumor which reached up under the ribs, down to the crest of the ilium, and forward to the anterior spinous process. There was a tumor con- taining pus in which large pockets had formed—what was the best way to remove it? There is no question in my mind that the best operation, in general, for the removal of the kidneys is the posterior operation. However, there are many diseases for which this operation is done where it is impossible to do it in another way than by the anterior operation, such as cases of cystic degeneration where the tumor is so large that it cannot be extruded posteriorly, but here was a tumor of moderate size, con- taining pus, in which it was desired above all things to avoid getting into the peritoneal cavity, a tumor which had sacs, the walls of which were in moderate degrees of thickness and strength, but could easily be broken open on pressure. Therefore, the day before the operation I took a cadaver and experimented upon the lines of incision which would best expose this tumor and give exit to it. I finally decided upon the incis- ions represented in Figure I. This represents the patient lying upon the opposite side from the diseased kidney. In these experiments I found that by a certain incision I could get the amplest room without doing injury to the colon or peritoneum; certainly no more likely to injure the colon, the peritoneum or other contents of the abdominal cavity than in an operation for the exposure of any of the large blood vessels of the abdomen. It is hardly necessary for me to state that there is some little difference between subserous tissue in the lower portion of the abdomen and that of the upper. In the lower portion it is very loose and easily separated, whereas at the upper portion it is quite thin and the peritoneum is more apt to be torn, hence more care should be used in an operation in this position. The com- mencement of the incision is supposed to be two inches above 198 NEPHRECTOMY. the anterior superior spine of the ilium. It is carried in a curved direction downwards and backwards to the tip of the last rib. The incision is carried through all the tissues, down to the fascia transversalis, everything is carried forward out of the way, and with the finger the dissection can be made, well behind the tumor; all the parts are separated, then a straight incision is made through all of them, straight back from the first incision and half way between the crest of the ilium and the last rib. The introduction of a ligature at the point of the posterior flaps, and pulling aside, gives a wound one can get both hands into, and by exposing the kidney in all its parts, reach the tissues which one wishes to have under control, without difficulty. (Figure 2.) Figure i. Figure 2. In this case as soon as the incision was made the tumor pre- sented itself, the finger could be carried around it in all direc- tions so that the kidney with its blood vessels, ureter, and all were well exposed to view. I desired to adopt the plan, which is a good one to adopt in all tumors that are difficult to reach, of dimininishing the size of the tumor, and attempted to divide it in halves by the cautery, but after a few strokes of the knife I approached a pocket of pus, and gave that up for fear of infecting the wound. I had very little difficulty by taking an eyed probe, threaded with a stout double ligature, in passing the probe through the center of the pedicle, NEPHRECTOMY. 199 and then with the double ligature ligating it in halves. The liga- tures controlled the circulation perfectly. The vessels in the exposed stump were picked up and ligated one by one as a spec- ial security. Drainage was perfect, and the anterior wall of the peritoneum fell easily into place and united by primary inten- tion. At the end of a week there was nothing left of this large cavity but the track of the drainage tube. This case is an important illustration, it seems to me, of the safety of the posterior incision for tumors of considerable size, where the line of incision is carried out, somewhat in the way here indicated. The saddest part of my report is to come: Four days ago this patient was taken with symptoms of cerebral trouble and suppression of urine, and she died with all the symp- toms of uraemia this afternoon at I o'clock, sixteen days after the operation. As yet a satisfactory examination has not been made to determine the condition of the opposite kidney, neither has there been a satisfactory microscopic examination of the tumor. Several sections have been submitted to examination, but none have shown the bacillus of tuberculosis. The post mortem examination showed a highly congested and swollen organ in the remaining kidney; the capillary vessels were ruptured in many places. Hydronepurosis. Harry B., 3341 Wood St., age 8, American. Ten weeks ago this boy was run over by a wagon, and now he has a large tumor in the abdomen. It was first discovered two weeks after the injury as a swelling as large as two fists in the right hypochondriac region. It has increased rapidly of late and causes much discomfort to the little patient by pressing upon the surrounding organs and by displacing them. It is confined to the right side of the abdomen, is even and smooth, and is a typical tumor in which to feel an impulse known as fluctuation. It concerns the kidney or the liver. If this were a cyst of the liver, there would be other symptoms in connection with it before this time. Cysts of the kidney often follow accidents. In these cases there is a closure of the ureter and a dilatation of the pel- vis of the kidney. We have here a case of hydronephrosis, from injury to the right kidney or to the ureter. 200 NEPHRECTOMY. We have frequently discussed this subject so thoroughly that it is not necessary to say anything further about it now. We will introduce a trochar into this cyst from the lumbar side, remove the fluid completely and apply a pad anteriorly to take the place of the swelling which has been removed by the tapping. In case the cyst should refill, this treatment may be repeated, and if found inefficient after several trials, the cyst may be per- manently drained by enlarging the opening and inserting a drain- age tube. If the ureter is permanently occluded a permanent urinary fistula may remain in the course of the drainage tube, which will heal only after the removal of the kidney, or the re-establishing of a patulous ureter. Nephritic Abscess. A little more than two years ago this patient began complain- ing of pain in the left lumbar region, and had trouble in urinating. About that time a physician examined the lumbar region, and believing that it contained matter, made a small opening which has remained a suppurating sinus ever since. At the time of the operation a considerable amount of pus was evacuated through the bladder. The patient was undoubtedly suffering from a nephritic abscess, and the matter passed down the ureter into the bladder, and thence out through the urethra. In the region of the left kidney I can feel a distinct mass which seems to fluctu- ate a little on deep palpation. So I think it is reasonable to sup- pose that we have some trouble with the kidney, the exact nature of which, of course, we do not know. The patient excretes a fair amount of urine in twenty-four hours, which now contains a quantity of pus. Not only has the patient discharged pus, but she has passed three calculi of brown color, one-fourth to three- fourths of an inch in length. What we propose to do is to open to the seat of the disease and ascertain the exact nature of the trouble. I see now oozing from the sinus a slow discharge of pus. I shall follow along the course of the director in opening this abscess. If I were going to open directly down to the kid- ney without regard to the sinus, I should, perhaps, make a dif- ferent opening from the one I am making now. I have now gotten NEPHRECTOMY. 201 into the cavity of the abscess, and find that it extends up as far as the twelfth rib; I have as yet found no connection existing between it and the kidney. Introducing the hypodermic needle in the direction of the director, I find that it enters another pus cavity in the substance of the kidney, so the abscess is in the kidney itself. Now, I shall follow along the director with these forceps, in the-same manner that I did with the aspirator, and when they have entered the cavity I shall open them, enlarging the opening into the cavity so that I can introduce my finger. I now have my finger in the cavity of the abscess of the kidney, and I am unable to find any foreign body. This outer abscess is a secondary trouble arising from this abscess in the kidney. I find that the substance of the kidney is very much broken down. I feel trabeculae running across the surface, and the separation of the parts is not so perfect as it should be. I can feel all parts of the cavity with my finger and I am satisfied that it does not con- tain a calculus, but I will scrape out the granulations which it contains. You see that they are very dark and unhealthy look- ing, as you would expect to find them after being present so long. I should have felt better if I had found a calculus in the kidney; but it is impossible to find what does not exist. I find that this is a condition which is very common; it is a multiple abscess cavity. I have broken it down as nearly as I could into one cavity, and we will pack it with iodoform gauze. This will not prevent hemorrhage, but will cause a healthy surface. It should be left in about seventy-two hours, then a drainage tube is in- serted, and thorough irrigation every day will lead to^a rapid cure. You see from the amount of gauze that goes into this cavity that it is as large as a hen's egg. I will pack the abscess cav- ity above the kidney separately. CHAPTER IV. TUBERCULOSIS. The Pathology, Etiology and Treatment of Hip-Joint Disease.* Pathology. Following the publication, a few years since, of the experimental researches and the deductions therefrom, made by Professor Koch, of Berlin, with reference to the introduction and develpment of the bacillus of tuberculosis within the human body, has come the belief that hip-joint disease is directly and absolutely the result of the changes produced in the joint tissues by the irritation and growths caused by the presence of this bacillus; therefore the name of tubercular degeneration is now used to express the manifestations incidental to the presence and progress of this affection of the hip joint. It is a disease of com- mon occurrence, and frequently leads to very great destruction of the joint elements, often having a fatal issue. The great variety of the manifestations of the presence of the disease in the joint is dependent upon the variety of the com- ponent elements thereof, any one of which may furnish the pri- mary focus of its onset. Hence there has been a corresponding diversity of opinion as to the tissue in which the disease exists primarily, some surgeons asserting that its frequency of com- mencement is first in the synovial membrane; others in the cap- sule; others in the ligamentum teres; and still others, constitut- ing the largest majority, contend that its primary manifestation is in the development of a tubercular ostitis in the head of the femur or the cancellated bone tissue at the bottom of the acetab- ular cavity; the same principle holding true here as elsewhere in * This lecture was delivered by the late Professor Parkes before his class at Rush Medical College in October, 1890, six months before his death. TUBERCULOSIS. 203 the predominance of epiphysial affection. The examination of a large number of specimens after resection of the hip joint favors the supposition that an ostitis, resulting from the implan- tation and development of the bacillus tuberculosis in the can- cellous tissues of the bony elements of the joint, is the starting point of this disease most frequently by far, in children at least. In adults the synovial membrane of the joint is often the first tis- sue to be affected, leading to distinct and regular changes, such as thickening, loss of function and tissue degeneration. Thicken- ing, from infiltration, cell proliferation and tubercular growths; loss of function, in painful and limited motion and hyper-secre- tion with over distention of the joint and consequent loss of its normal landmarks; tissue degeneration, showing formation of granulations and fungus outgrowths on the internal surface of the synovial membrane and interference with local circulation, marked by whiteness of the skin covering the joint and the arbo- rescent ramification of dilated superficial veins. The changes in the tissues, when ostitis marks the onset of the disease, are exactly similar to those occurring in inflammation of bone from any source. These will be hyperemia, rarefication of bone spaces, absorption of calcareous matter, softening, liquefac- tion; and added to these there will be the formation of a cheesy deposit, tubercles and granulation tissue. Such changes cannot occur without absolute interruption of circulation in the blood vessels of the bone itself over greater or less areas, leading to destruction of bone in small particles, termed caries, or in larger masses, termed necrosis. If necrosis results in consequence of this cutting off of the arterial supply the peculiar distribution of the arteries of the bone near their extremities quite fre- quently leads to the production of a triangular or cone-shaped fragment of dead bone, the base of which is directed towards the joint surface. The extent of the caries or necrosis will depend upon the degree of development of the bacilli and the changes they produce after infection, and the consequent amount of interference with the vascular supply of the bone concerned in the disease. Such changes as we have indicated cannot occur without lead- ing to well-marked evidences of interference with the nutrition of many tissues in the immediate neighborhood of the disease process. The cartilages of joints are dependent entirely for their nourishment upon the looped arrangement of blood vessels in the bone tissue immediately beneath them and to which they 204 TUBERCULOSIS. are attached; hence very soon, accompanying the bone changes, the cartilage covering the head of the femur or lining the bottom of the acetabular cavity is deprived of its nutrition, is separated from its bony attachments by the growth of granulations beneath it, and becomes necrotic; its surface, perforated here and there by the pressure of subjacent granulations, finally is loosened entirely or broken into many fragments, and its debris will be found floating in the fluid discovered in the joint when it is opened. Its condition of partial or complete destruction depends entirely upon the degree and severity of the disease or the length of time this disease has been in progress. If the -infection includes or progresses so as to attack the synovial membrane, this membrane is doubled and more in thick- ness; its polished surface is destroyed, and in lieu thereof is found a covering of soft, velvety granulations, sometimes present in such abundance as to constitute real fungosities. Their integ- rity is easily destroyed and the destruction is accompanied with profuse bleeding, a condition called by older writers fungous degeneration of joints. Again, this synovial tissue may be necrotic in many places, rough, irregular upon the surface and dirty in appearance, accord- ing as the progression of the disease has led to greater or less disturbance of its vascular supply, and hence of its nutrition. This amount of disturbance varies from a condition which leads only to a constant over-distention of the joint with serum, either natural in color or slightly bloody, with or without flakes of lymph floating in the fluid, or to one which causes an accumula- tion of turbid fluid filled with the products of destructive action upon the granulations or the joint tissues. If pus infection is added to the disease already present the capsule may be filled with pus as well. The distension of the joint with fluids quite frequently leads to rupture of the capsule at its weakest points and dissemination of its contents into surrounding parts; hence the tubercular abscesses which approach the surface gradually, showing fluctuation and pressure changes of the skin covering them, and indicating the necessity for incision. The head of the femur presents much diversity of form as the result of the changes produced in it by the ravages of the dis- ease; it is apt to be much softened and its substance more or less destroyed by liquefaction and absorption of its tissue, so that many times nothing but a short portion of the neck remains TUBERCULOSIS. 205 continuous with the shaft. If the onset of the disease be close to the epiphysial junction of the shaft, the epiphysis is not infre- quently destroyed at once, is separated from all its attachments and is discharged or removed entire as a necrosed fragment. Pathological changes similar to those already mentioned occur in the joint as the result of the commencement of the disease anywhere in the bony walls of the acetabulum; when commenc- ing there the disease is not infrequently accompanied with a per- foration of the acetabular cavity towards the pelvis, with the formation of abscesses bulging into the pelvic cavity. The direction which the contents of the distended capsule take after its rupture is entirely accidental, and depends upon the site of the rupture in the capsule and the arrangement of the layers of fascia covering the joint and investing the soft parts into which it ruptures. Sometimes it projects upwards and forwards towards Poupart's ligament, and the fluctuating swelling there formed opens spontaneously or by incision above or below that ligament. In the latter case, usually indicating acetabular dis- ease. Again, the pointing may be downwards and inwards at the apex of Scarpa's triangle, or outwards at the edge of the tensor vagina femoris muscle, or backwards upon the posterior surface of the thigh. I have on two occasions opened abscesses originating from hip-joint disease which showed the indications of pointing only when they reached the external condyle of the femur. When the operation for excision of the joint is done early in the progress of the disease the pathological changes in the joint surfaces themselves may be so slight as to be scarcely recogniz- able, yet a longitudinal section of the fragment removed often shows the foci of tubercular degeneration in spots of cheesy mat- ter, also the formation of tubercles and granulation tissue with . corresponding bone destruction. A large accumulation of fluid filled with the detritus resulting from this disease may approach the surface in its progress, may be incised and its evacuated contents have much the appearance of the pus accumulation in ordinary abscesses, although notice- ably white in color and cheese-like in character; yet cultures made from this fluid will fail to produce any of the different pus microbes. Still, you must remember that in the progress of this disease pus infection is particularly apt to occur with well- marked increase in the inflammatory symptoms attending the disease. 206 TUBERCULOSIS. Etiology. The causes of the disease are, first, predisposing; second, exciting, a: Predisposing—hereditary: A very large number of these cases furnish a history of tubercular disease in several members of the patient's immediate or remote family, so that there can be scarcely any doubt but what the special vital power which the patient receives from his progenitors has a cer- tain influence on its occurrence. Yet it must be remembered that he who is compelled to associate with individuals already suffer- ing from some manifestation of tubercular disease is in great danger of infection. This peculiar disposition to the occurrence of manifestations of this special disease in members of the same family is said to depend on the "tubercular diathesis." This, to me, means only that it occurs most frequently in the weakest and most debilitated individuals, hence in those least likely to resist any hurtful influence with which they may be surrounded, and who, above all, are unable to prevent the development of and the ravages incident to the presence of the bacillus of tuber- culosis when once it gains entrance into the circulation and secures lodgment in the tissues of the body. It has been proven that almost without exception the tissues found in chronic arthritis in any of the joints of the body, when subjected to microscopical research reveal the presence of this bacillus, and that these tissues upon being introduced into the body of a healthy animal lead to manifestations of tuberculosis. The bacillus taken from the tissues of such a joint, can be grown into colonies if furnished with the proper culture medium, and when injected into the tissues of a healthy animal they will pro- duce a like disease, so that we are bound to believe that there is a direct relation between the cause and effect—the cause being the presence of this bacillus, the effect being the manifestations of changes in the structure of the joint tissues. Exciting cause. Trauma: Many facts seem to support the assertion that the bacilli, always found present when the disease is in a state of activity, remain latent in the system until their development is induced by the occurrence of any trauma suffi- cient to disturb the nutrition of the part in which the disease is to be developed, this disturbance of nutrition seemingly estab- lishing all the conditions necessary to rapid growth of the bacilli and the development of the many changes in tissues incidental to their presence. The hip joint and the spinal column constitute parts of the body very likely to be the seat of trauma resulting from the incessant TUBERCULOSIS. 207 activity and slight local injuries so often occurring in children hence the great frequency with which the disease is found located in these portions of the body and in early life. The diagnosis of the affection is based upon the well-marked symptoms which outline its course. The consideration of these symptoms should always be preceded by careful and minute inquiry into the patient's family history. This inquiry not only furnishes the attendant with a fair estimate of the patient's vitality, but also the probable source of the infection. Familiarity with and an acute perception of the earliest symp- toms indicating the disease places the patient under the charge of the surgeon at a time when the adoption of remedial agents will often enable him to stay entirely the progress of the disease, or to control its ravages, to the extent of securing for the patient relief with only limited disarrangement of function of the joint; whereas, if left to progress to its later stages of advancement, relief, whatever the treatment adopted, must be somewhat problematic. Symptoms.—Lameness: Among the first symptoms to appear is lameness, beginning with a scarcely perceptible limp, perhaps not even noticeable while the child is at play, progressing insid- iously as the disease advances, to become a constant and uncon- trollable condition. Early in the disease the lameness is most noticeable when the limb is first used after a night's rest, or when it has become slightly stiffened after rest, following constant use during the day. The cause of this lameness is in part the inhe- rent tenderness of the inflamed tissue; but it is oftenest caused by the weight of the body bringing the surfaces of the joint in contact or by making pressure upon the inflamed areas of bone beneath the joint surfaces. Pain: During the later stages of the disease the exquisitely sensitive joint surfaces cause the slightest movements in the joint or the support of any weight to be extremely painful. The patient involuntarily, from the very commencement of the dis- ease, puts all of the joints of the affected extremity in a state of slight flexion in order to lessen shock of any kind transmitted through the extremity to the joint; hence he flexes the ankle, the knee and the hip; and however slight this flexion may be, if it is maintained, a limp will be the result in any attempts at walk- ing. The greater degree of flexion the more marked the lame- ness, and hence this symptom becomes a valuable index to the extent of the disease. 208 TUBERCULOSIS. The amount of pain complained of varies greatly in different cases. Where present from the first it is an indication that the nature of the trouble in the joint should be carefully inquired into. Yet there are many cases remarkably free from this symp- tom; absence of pain does not, therefore, by any means always indicate the absence of the disease. A large majority of cases at first, and sometimes throughout the entire course of the disease, refer the pain to some portion of the knee joint, especially the inner side. When a patient suffering from the lameness already described complains of pain persistent or interrupted, referred to the inner side of the knee, suspicion is always awakened as to the likeli- hood of this pain in the knee being dependent upon disease in the hip joint, and induces an especially careful examination of the case. This pain is supposed to be reflex in nature and dependent upon the fact that the hip and knee joints receive their articular branches from the same nerve trunk, and the irri- tation of the nerve ends distributed to the hip joint is reflected to those of the knee. A very noticeable attendant of hip disease is the special pain termed "startling pains" or "night pains," so called by being accompanied with the sudden contractions of the muscles of the limb and the body in general, startling in the suddenness, and from the fact that they are especially apt to occur at night after the child has fallen asleep. The startling pain indicates that the disease in the joint has reached an advanced stage; has pro- gressed at least to the point of the formation of granulations, which are exceedingly tender and sensitive. During waking hours the fixation of muscular contraction prevents movement of the joint, avoiding pressure upon these granulations, but as soon as sleep relaxes these contracted muscles the joint surfaces fall together, awakening the patient by the excruciating pain pro- duced; the patient moans and cries out with a sudden starting of the entire body; the muscles are forced into sudden contraction, and the patient again falls asleep. These symptoms recur from time to time until the disease has progressed so far that the destructive changes themselves prevent the pressure which pro- duces the pain. Fixation: Another symptom marking the presence of the dis- ease is fixation of the joint in some abnormal position by the contraction of the muscles of the joint. This contraction of mus- cles in confirmed cases not unfrequently becomes contracture, TUBERCULOSIS. 209 with actual shortening of the muscles, and hence permanent fixa- tion of the limb in positions of deformity. The fixation is sup- posed to be dependent upon reflex stimulation of the groups of muscles concerned in its production. Many cases are accompanied with severe pain upon the slight- est movement of or jar to the affected limb. The patient's atten- tion is constantly directed to the protection of the joint from disturbance of any kind on account of the suffering caused thereby. The position of the limb is never changed without the foot of the diseased extremity being supported by the foot of the sound limb. Again, some of these patients seem to have learned that slight extension of the diseased extremity is of service in relieving the pain, and, of their own accord, they attempt to accomplish this result by pressure in the direction of extension made by the sound foot against that of the diseased limb. Deformity: The deformity first present is that of flexion, abduction and external rotation. The depression of the pelvis which accompanies this change in position of the thigh is necessary in order to bring the limbs parallel with each other during walking; it produces also an apparent lengthening of the limb. Later in the disease the deformity present is that of flexion, abduction and internal rotation. In order to make the limbs parallel after the occurrence of this deformity the pelvis is ele- vated, and as a consequence there is an apparent shortening of the injured limb. This apparent lengthening and shortening of the extremity is accompanied with a corresponding depression or elevation of the anterior superior spinous process of the ilium on the diseased side, caused by means of a tilting of the pelvis to one side or the other. The lengthening is always apparent, the shortening may be either apparent or real. It is always real, although at times mod- erate in amount, after the destructive processes of the disease have led to a rupture of the ligamentum teres and partial displace- ment of the head of the femur from the acetabular cavity. When this ligament is destroyed the powerfully contracting muscles force the head of the bone against the upper and outer portion of the brim of the acetabulum and against the corresponding part of the capsular ligament, leading to pressure changes and necro- sis at these points. The shortening is real and extreme in cases in which the pres- sure against the capsular ligament destroys it and allows the 210 TUBERCULOSIS. head of the bone to be entirely dislocated from the acetabulum. Such extreme cases are not of frequent occurrence, but they do happen. In the case of a little boy operated upon by me not long ago, the disease had been exceptionally rapid in its progress and the deformity was extreme. Incision in that case showed that there was not only absolute dislocation of the joint, but also that the formation of a new acetabular cavity had commenced about the head in its abnormal position. The shortening is real also in all cases in which there has been absolute destruction, softening and absorption of any considerable portion of the head of the bone. As the limb is fixed in a position of flexion of a greater or less degree, when the knees are equally extended the thigh of the di eased side carries the pelvis forward, producing a noticeable flexion forward of the lumbar vertebrae, termed lordosis. This condition is found as a symptom of other diseases, such as Pott's disease, infantile paralysis or congenital dislocation of the hip joint, and hence needs careful inquiry to establish the real cause of its presence. Muscular Wasting: Cases of hip-joint disease seldom fail to present, in some period of their progress, the symptom of muscu- lar atrophy, or wasting. This is, of course, partly dependent upon their want of use, yet is so extreme in degree or marked in its results that it must have other causes for its occurrence; among these is the existence of absolute atrophic changes in the muscular fibres, probably incidental to trophic disturbances resulting from nerve irritation; it leads to loss of contour in the joint and obliteration of landmarks; the gluteal muscles become flattened, the inter-gluteal fold changed in direction, and the muscles themselves become flabby. The shortened and contracted muscles about the joint resist any motion therein, and stand out under the skin as rigid cords upon any attempt being made to change the position of the limb, any such attempt being acompanied with extreme suffering on the part of the patient. Swelling: In the later stages of the disease swelling occasion- ally becomes a symptom for consideration; the deformity thereby induced being dependent on the accumulation of fluids upon one or another aspect of the joint, following the progress of destruc- tive changes in the joint itself, and marking the site of the accumulation with resulting abscesses. Not infrequently these TUBERCULOSIS. 211 cases are accompanied with enlargement of the lymphatic glands on the anterior aspect of the joint. General Debility: Cases of hip-joint disease seldom progress far without displaying well marked manifestations of debility and loss of general health; the countenance carries ineffaceable evi- dence of suffering, and soon shows, by its pallor and by wasting of the general body, unmistakable symptoms of faulty or insuffi- cient assimilative powers. The appetite becomes capricious, may fail entirely, and in extreme cases is followed by great emaciation throughout the body. The entire extremity of the side diseased is much smaller than the healthy one, and the con- trast is very evident upon comparison. Complications—Abscesses: Formation of abscesses is of fre- quent occurrence, as a complication of hip-joint disease, and when the attack is sudden, always indicates infection with pus microbes as an addition to the disease already present. Their onset is accompanied with great increase of the signs of inflam- matory action, as shown by high temperature, increased pain and tenderness, chills and sweats. Reference is not here made to accumulation of purely tuber- cular matter and debris which may exist in considerable quantity without any of these symptoms, as is shown in similar accumu- lations occurring in different parts of the body, termed "cold abscesses." The occurrence of the symptoms mentioned as indicating the development of acute abscesses is soon followed by fluctuation in the swelling produced, necessitating incision for the purpose of giving exit to the pus, or if left to itself it will open spon- taneously and the pus be discharged. In either case after the contents are emptied, the opening remains patulous and shows little disposition to heal, although the walls of the abscess may fall together, and its cavity so far diminish in size as to leave only a long tortuous tract, termed a "sinus." The sinus will be kept open and give exit to a persistent discharge of matter in greater or less amount, because of the presence of the dead bone or other necrotic tissue in the diseased joint. In old cases of hip-joint disease it is not unusual to find a number of minute openings discharging pus on different aspects of the limb and widely removed from the joint, General Tuberculosis: A very serious and fatal complication of hip-joint disease is the occurrence of meningitis, or general tuberculosis. These complications not unfrequently are devel- 212 TUBERCULOSIS. oped immediately after an operation, such as excision for the relief of the disease; the operation seemingly introducing the bacilli into the general circulation, thus acting as a direct cause for the metastasis in the meninges or other internal organs of the body. Amyloid Dege?ieratio?i: Cases in which the suppurative process has been extreme or prolonged over many months, or even years, are sometimes accompanied with an amyloid degeneration of the liver and kidneys. The following case of a little girl ten years old, admirably illustrates this condition. She had suffered for several years from prolonged suppuration following tuber- cular degeneration of the lumbar vertebrae and right hip-joint. with almost numberless sinuses traversing both sides of the body. The enlargement of the liver was so great in this case as to fill nearly the upper half of the abdominal cavity, its lower edge reaching quite to the umbilicus; the deformity produce was very remarkable and extensive. The liver in these cases usually returns to its normal condition, if by any course of treatment the suppuration can be caused to cease entirely. It is not a condi- tion which militates against operative interference. Ankylosis: Usually the fixation in disease of the hip depends only upon muscular contraction and contracture, and hence con- stitutes a false ankylosis, which disappears partially or completely during anaesthesia. In many cases of prolonged existence of the disease, the head of the femur and acetabular cavity are immovably joined together by the development of bone, forming a true ankylosis. In such cases the femur and the os innominatum move as one piece of the skeleton, and the deformity present cannot be changed in the slightest degree, even under anaesthesia without the applica- tion of force sufficient to break the bone or the performance of an osteotomy. Both hip joints are occasionally the seat of tubercular disease at the same time or within short periods. The condition of the patient under such circumstances is truly lamentable ; to walk is quite impossible even early in the manifestations of the dis- ease, and even though treatment has stayed its progress, or qui- eted entirely these manifestations, the resulting deformity very often makes the act of walking a great labor. A case in point is that of a young man twenty years of age, who, when eleven years of age became afflicted with double hip-joint disease. Both hips became ankylosed in a position slightly beyond a TUBERCULOSIS. 213 right-angle, and the legs crossed so that one knee was in front of the other. Locomotion was possible by throwing first one hip forward, which act carried the corresponding leg to the front; as soon as the weight of the body was on this foot the other hip was swung forward, and by this alternating, half-rotary, motion he succeeded in walking short distances. In this case an osteo- tomy was made on both extremities at the same time, cutting through the bone with a chisel just below the trochanter major. As soon as the bone was severed the limbs were easily extended and placed in a position of abduction and external rotation; they were kept in this position by the use of Buck's extension, and at the end of eight weeks the fractures were firmly united and his previous deformity was overcome. This case was one of old hip- joint disease, hence the deformity was flexion, adduction and in- ternal rotation. To overcome the malposition it was required to make extreme extension, abduction and external rotation. Notwithstanding the fact that the disease had existed so long, muscular contraction offered no resistance to complete exten- sion, not a single tendon required division, but the skin immedi- ately over the anterior surface of the joint cracked in several places under the tension to which it was subjected. Examination of the Patient: In order that a satisfactory examination shall be made, it is absolutely necessary in all cases to remove all of the patient's clothing; especially is this desirable to enable the surgeon to detect the earliest manifestations of the disease. It is scarcely necessary to claim that the earlier the disease is detected and the more promptly remedial agencies are adopted the sooner and the more certainly will relief be given to any case coming under inspection. The minutest alteration of the joint or limb in position or con- tour, or in its movements, should attract attention and be made the subject of careful and exhaustive inquiry as to their cause and meaning. The absolute confidence of the patient should be secured by every means possible before and during the progress of the examination. Above all things, gentleness in examining is especially desirable. If possible avoid all movements which are likely to give rise to pain. If movements must be made likely to induce pain the patient should be notified of that fact, so that the patient's fortitude may be aroused to bear it. By care in these matters even the youngest of patients can be subjected to a thorough examination at least sufficiently satisfactory to elicit 214 TUBERCULOSIS. the presence or absence of the well-known symptoms which ac- company the disease. It is necessary that the limb, in doubtful cases, should be car- ried through all the motions possible in the joint and to their extreme limits, and also that each motion should be compared with the corresponding one of the sound limb. In the early manifestations of the disease it is only when approaching the extreme limit of any motion under trial that the halt or evidence of partial fixation or pain will be elicited. In cases in which the disease is more advanced the changes in contour, in loss of free- dom of motion and pain will be easily determined, and do not require any roughness of handling to demonstrate their exist- ence. The patient should always be placed on the back on a perfectly even and smooth table, with the spine held close in contact with the table. First, try whether or not the popliteal space of each limb can be brought in contact with the table without producing any curvature or lordosis of the lumbar region of the spine; if this can be done no deformity of flexion has taken place. If the deformity of flexion has commenced as soon as the popliteal space of the injured limb is brought in contact with the table there will be produced a curvature forwards of the lumbar region of the spine, because the fixation of the femur in the position of flexion compels the os innominatum to tilt forward. By reliev- ing the pressure from the knee and allowing the back to again touch the table, the thigh will again be flexed and give the exact angle of fixation. In the trial of all these motions the anterior-superior spinous process of the ilium should be observed to ascertain whether it re- mains motionless during any of the movements to which the joint is subjected; it should not be influenced in the least. If motion is communicated to it during any of the trials it indicates that there is limitation from some cause or other to the special movement under inquiry. In this careful way compare adduction, abduc- tion and rotation in the sound and diseased extremities. In all cases in which this disease has made considerable ad- vance the amount, extent and kind of deformity should be care- fully estimated, for it is only by an accurate knowledge of each of these conditions and of the causes which produce them that one can hope to put into practice the proper remedial procedures necessary for their relief. TUBERCULOSIS. 215 Prognosis. The length of time the disease has been in exist- ence, the amount of deformity already present, the general con- dition of the patient, the occurrence of suppuration are all items to carefully consider before prognosis is given; the degree of severity manifested in either or all of these conditions adds greatly to its gravity. To promise a complete cure is ever un- wise, no matter how early the disease is recognized or subjected to treatment; every case is followed by some degree of deformity or debility in the joint. It should always be remembered that in cases in which treatment has been followed by seemingly per- fect results, foci of tuberculosis may still remain latent in or about the joint tissues, likely to be stimulated to fresh activity by any trauma sufficient to disturb the circulation in their neigh- borhood; indeed this relighting of the disease not infrequently happens after cases in which complete excision has apparently relieved all sources of trouble. Differential Diagnosis. Affections stimulating hip-joint disease are not of infrequent occurrence. Among them may be mentioned superficial abscesses in any of the tissues surrounding the hip-joint. The acuteness of their onset and rapidity of pro- gress will usually furnish valuable items leading to their recogni- tion. Like all tubercular affections, hip-joint disease is compar- atively slow in its manifestations. Abscess under the iliac muscle gives rise to flexion and partial fixation of the joint. Psoas abscess has its previous history of spinal fixation and deformity. Pure synovitis from traumatism has a much shorter history for its development as a distinguish- ing peculiarity. An almost insurmountable difficulty is offered in cases of osteomyelitis affecting the epiphysis of the upper end of the femur, and the only special symptom belonging to this affection that is at all distinguishing is the remarkable sudden- ness of the onset of an attack of osteomyelitis with its accom- panying rapid inflammatory changes. Treatment—Natural Cure. Like most other diseases in the hu- man body, hip-joint disease shows a tendency to limitation in its progress by the natural powers of the system. When this occurs it follows usually as the result of the suppurative process with the formation of abscesses, ulceration of their coverings, elimination of their contents and the discharge of the necrotic bone. If the destructive action of the disease is not extensive this result is accomplished by the natural powers alone, all the sinuses heal completely, the process of cicatrization destroys or 216 TUBERCULOSIS. isolates the cause of the disease, and the case is cured ; usually with some permanent deformity resulting. The special treatment to be adopted for the relief of any case of hip-joint disease depends upon and is regulated by the condi- tion ascertained to be present after a careful examination of the case. In all cases absolute rest to the joint must be secured. All special appliances used have the accomplishment of this ob- ject in view. Recognizing the fact that there is an ever-present tendency to deformity, its prevention by every means at one's command constitutes also another item of consideration in any plan of treatment adopted. If relief comes as a result of treatment it will not occur even in mild cases without many months, and perhaps years, of care- ful attention. General and Medicinal Treatment. The general hygienic sur- roundings of the patient should be the best possible to obtain ; abundance of fresh air and sunlight can certainly be secured, and personal cleanliness should be insisted upon. Food must be regulated according to the patient's power of assimilation—easy of digestion and rich in fats. It is the testimony of experience that all tubercular patients avoid the hydro-carbonaceous foods if allowed to have their own choice. Cod liver oil or butter ad- ministered with ale or malt are always supportive to the patient's vital powers. The dose of cod liver oil should never exceed one teaspoonful three times a day ; given in larger quantities it is not absorbed and does harm. Some of the preparations of iron and the bitter tonics are found useful in many conditions of the general system accompanying the progress of the disease. The special condition of the patient will furnish the indication for their administration. The presence of pain from any source frequently necessitates the use of some preparation of opium to subdue it ; but this pain being oftenest dependent upon the pressure of the joint surfaces against each other, it will be most certainly relieved by the use of some appliance which will obviate such pressure. During the earlier manifestations of the disease, counter-irri- tation over the surface of the joint by means of the application of cantharides, or heat, or cold, gives temporary relief to many of the painful symptoms accompanying its onset. Treatment is of two kinds—conservative and operative. The conservative treatment has for its object the application of such dressings as will provide rest to the joint and at the same time TUCERCULOSIS. 217 overcome the already exisiting or prevent entirely the occurrence of the deformities which attend the disease. All of the various plans secure extension in order to keep the joint surfaces as widely separate from each other as possible, and they may be divided into portable splints and fixed apparatus. The first allows of some motion in the joint and general movement of the body, and the second secures either absolute fixation of the joint or positive confinement in the recumbent position. The plan suggested by Hutchinson is considered by many as very efficient and particularly applicable to the treatment of the disease in its earlier stages. In it the shoe of the sound limb is raised by a sole two inches in thickness, and the patient required to use crutches ; the diseased limb is thus allowed to swing free, and is prevented from coming in contact with the ground, the weight of the extremity thus acting as the extending force. Fixation of the joint is better accomplished by the use of Thomas' splint. This consists of a band of steel a quarter of an inch thick and one inch wide and long enough to extend from the inferior angle of the scapula to a point just above the heel of the diseased limb ; it is bent so as to fit accurately into all the natural curves of the body on the diseased side while the body is in the erect position. It is padded throughout its entire length and secured in position by a broad band surrounding the body, a second band surrounding the thigh, and a third one surround- ing the leg towards its lower end. If now the patient is elevated by means of a thick sole on the shoe of the sound limb, and ad- vised to use crutches, this splint constitutes a very efficient means of fixation of the joint, the patient at the same time securing the full benefit of moderate exercise in the open air. A third plan, adopted by many, consists in the use of some modification or other of Taylor's splint, which consists of a bar of steel made in two pieces with a ratchet attachment between them near the knee, to allow of extension. It is secured firmly at its lower end by a steel plate fastened to the sole of the shoe at its upper end, which reaches to the crest of the ilium ; it is fitted to the middle of a welhpadded cross bar of steel curved to correspond with the shape of the crest of the ilium. The attach- ment of the upper end of the splint to the cross bar is in the shape of a ball and socket joint. The extremities of the cross bar are perforated for the purpose of attachment of the perineal band, which is fitted in the crease of the perineum on the side of the diseased.hip. The splint is secured to the limb by means of 218 TUBERCULOSIS. a well-padded band surrounding the upper part of the thigh, a second surrounding the upper part of the leg and a third fastened about the leg just above the ankle. When fastened in position along the outer side of the diseased extremity, and the perineal band in proper place, the ratchet attachment permits a consider- able force of extension to be produced and at the same time al- lows of motion in the joint and general exercise of the body. Thomas' splint is certainly a very satisfactory appliance to make use of for protection against injury in cases in which other treatment, which will be suggested, has led to a cessation of the manifestations of the disease, especially as a means of prevention of shock to or strain of the joint when the patient first com- mences to take exercise. Personally, I have had no satisfactory results follow the use of either of these appliances in anyway equal to those obtained either by the application of Buck's ex- tension and confinement to bed, or the plaster cast and the use of crutches. Absolute fixation of the joint can be obtained by making use of the plaster cast ; when used it should be so ap- plied as to cover the entire extremity as well as the hips and body for some distance above the diseased joint. The ordinary plaster bandage, made of crinoline into the meshes of which plaster of Paris has been spread, is the best material to use. All portions of the body covered by the plaster bandage should be thoroughly padded with cotton batting before its application, as well should the diseased limb be held in forced extension, ab- duction and external rotation and securely maintained in this position until the plaster has hardened. Many cases under my care have been treated satisfactorily with this, appliance; deform- ity prevented, pain abolished and health restored. No more efficient or satisfactory means of treatment in the ma- jority of these cases can be instituted than that of Buck's exten- sion. This is very simple and easily applied. It requires con- finement to the bed on the back, yet I have never seen any ill effects attend its use. The most excruciating pain and the agony of night startings is almost immediately relieved after its proper application with sufficient weight. The occurrence of deformity is prevented and that already present is surely overcome. These results far outweigh the ill effects supposed to be caused by the confinement. It has been my experience, as well as that of many other surgeons, to constantly witness improvements in every way secured by the adoption of this plan of treatment. Its success is in main obtained by always making the extension in thedirection TUBERCULOSIS. 219 of the deformity which is present. At all times during its use care should be had that the spinal column is in close contact with the bed on which the patient lies—that no lordosis is present. The shoulders also should be in contact with the bed, and the patient secured in this position by a broad bandage extending over the chest and under the arms and fastened to the bed; the head can be slightly elevated by the use of a small pillow. The bottom of the bed should be so far raised as to certainly secure the weight of the trunk as a counter extending force. Broad strips of adhesive plaster are fastened, to the inner and outer sides of the diseased limb, reaching as high as the middle of the thigh and some distance below the foot; they are secured in position by the ordinary roller bandage. The lower ends of the plaster are fast- ened to the ends of the usual spreader to prevent pressure on the malleoli. The rope used to carry a proper amount of weight is attached to the middle of the spreader and carried over a pulley which is already fixed in a movable upright attached to the lower end of the bed, in a direct line with the diseased extremity. The pulley should be placed at such height as to allow of the exten- sion being made in the direction of the existing deformity of flexion. The amount of weight used should be about one-twelfth of the entire weight of the body, and never sufficient to cause dragging pains in the groin. As the constant traction of the weight overcomes, as it surely will, muscular contraction about the hip, the pulley is lowered from time to time in accordance with the degree of improvement in the deformity of flexion until complete extension is permissible in the diseased limb without the occurrence of any lordosis. If severe deformity of adduction be present it can be overcome by the use of the weight and pulley adjusted so as to act at a right angle with the thigh by means of a plaster band fastened around the lower end of femur. The dressing should be kept on) or re- applied if not acting efficiently, until all pain is relieved and free motion is permissible in all directions. If the disease has pro- gressed to any noticeable extent this result will not be secured short of one year's time. Operative Procedures. First under the head of operative pro- cedures are to be considered injections into the joint of a 10 per cent, emulsion of iodoform in glycerine. The iodoform treatment certainly possesses a remarkable curative effect upon tubercular degeneration in any of the joints in the body. In my hands it has proven more satisfactory in staying the 220 TUBERCULOSIS. progress of the disease and leading to a disappearance of the results and repair of its ravages than any other remedy or treat- ment that has been suggested. If the capsule is distended with fluid this should be emptied by the introduction into the joint of a good sized trocar, it being understood that the puncture is pre- ceded by all the usual aseptic and antiseptic precautions with which you are familiar. After the fluid is emptied out through the canula, or its introduction has not been followed by the dis- charge af any fluid contents, from two to four drachms of the emulsion is thrown into the joint by means of a syringe and caused to be disseminated all over the joint surface by manipula- tion and free passive motion of the joint after the canula is with- drawn and the puncture opening protected by a pad of iodoform gauze- Some care must be used in the amount of force to which the weakened capsular ligament is subjected by the pressure of the distending emulsion for fear of rupturing this membrane followed by the exit of the fluid into the surrounding cellular tissue. This can always be easily regulated by fastening a piece of soft rubber drainage tubing about four inches in length to the canula and fitting the syringe into the free end of it. As long as there is not much pressure upoh the fluid it passes through the rubber tube without difficulty. As soon as the joint becomes over distended a well-marked bulb is formed in some portion of the length of the tube, the character of which is a sure indication as to the amount of pressure which is being made upon the capsule by the emulsion. My experience has not shown any constitutional effects from this use of iodoform, except in one case, and that was a little boy afflicted with tubercular degeneration of both knee joints and one ankle joint. I injected all three joints at the same time, and this was followed by quite well marked evidences of iodo- form poisoning, lasting over two days. After two injections all evidences of the disease have disappeared with the exception of deformity in the position from muscular contraction. It has been asserted, upon good authority, that this injection is very satisfactory as well in cases in which the degeneration has gone so far as to lead to the formation of sinuses—a cure follow- ing its use without any other operative procedure. Even in cases so badly diseased as to be relegated to amputaiion, its use has been so satisfactory to me that I am ready to assert that no tubercular joint should be subjected to any open operation until a fair and exhaustive trial has been made of this emulsion of TUBERCUL OSIS. -221 iodoform. It has not been found necessary to make the injection oftener than once in two weeks. Operations: Cases are often met with presenting considerable deformity in which the surgeon is at once compelled to decide as to the advisability of forcible replacement of the limb in its nor- mal position, especially cases in which the active processes of the disease have ceased, leaving such deformity. Focible replacement js not to be undertaken hastily, for the traumatism accompanying such procedure often starts the disease again with apparently increased fierceness of action. When anaesthesia proves that the fixation is neither from bony ankylosis nor severe muscular contraction, by steady and yet quiet force the limb may be restored to its normal position. If contracture is extreme it may be necessary to practice subcutaneous division of the tendinous portion of the muscles offering greatest resistance. As soon as the limb is restored to its normal position it must be retained in that position by the application of a plaster of Paris cast already described or by the use of Buck's extension. These appliances should be kept in position until all tenderness or other evidence of inflammatory action has disappeared from the joint. In performing tenotomy about the hip-joint aseptic and anti- septic precautions should be observed, and the division of the muscles should be made through the tendinous portions, care- fully avoiding all important blood vessels and nerves. Occa- sionally the principal obstacle to extension is produced by con- tracture of the fascia lata of the thigh. This fascia constitutes the main element of resistance ; it should be divided by an open incision of triangular shape, the base towards Poupart's ligament and the apex towards the middle and some distance down the thigh. As the limb is extended the edges of the incision are widely separated, and this extensive wound can subsequently be closed by suturing together its lateral edges. The formation of abscesses frequently require surgical inter- ference, and they may either be treated by aspiration with sub- sequent over-distension with the iodoform emulsion already men- tioned or by free open incision. If by open incision the contents are thoroughly evacuated by means of the scoop, and the cavity irrigated with a 1-3000 solution of bichloride of mercury or a solution of tincture of iodine in water strong enough to have the color of sherry and either packed with iodoform gauze to the bottom or drained with a drainage tube. 222 TUBERCULOSIS. Old sinuses resulting from previous abscesses can sometimes be made to close by repeated injections of the iodoform emulsion or the injection of a 10 per cent, solution of chloride of zinc. This result is not likely to be obtained when their existence is dependent upon the presence of necrotic tissue in the diseased joint. Under such circumstances, and perhaps in the majority of cases, cure will oftenest follow the plan of laying them open freely throughout their entire length, curetting their walls, and then thoroughly scrubbing the resulting cavity with a i-iooo solution of bichloride of mercury, after which they may either be closed by proper sutures introduced throughout the principal portion of their length to a point in close proximity to the joint, or the entire cavity packed with iodoform gauze and allowed to granulate, or closed by secondary sutures four or five days after the first operation. Any necrotic tissue found in the joint must be removed, even to the extent of excising the remnant of the head of the bone if this is found to be totally destroyed. In many cases the excision of the head of the bone will con- stitute the starting point of the operation, the full opening of the sinuses and their treatment as directed accompanying that pro- cedure. Frequently the sinuses follow such a course in their tortuosity or depth as to endanger the large blood vessels of the thigh, thus preventing the surgeon from laying them wide open. Under such circumstances these important structures must not be injured, but the sinuses should be thoroughly curetted and rendered aseptic by the use of the antiseptic fluids recommended. Osteotomy: Bony ankylosis following old hip-joint disease is not infrequently met with, either with the presence of sinuses or without any external openings leading to the joint, and requires for its relief a division of the bone, together with a tenotomy of the contracted muscles if these offer any resistance to the re- placement of the limb in its normal position after the bone is divided. The instruments necessary to perform an osteomony are a scalpel and a key-hole saw or a mallet and chisel. The point of division of the bone may be either through the neck of the bone or through the shaft just below the great trochanter. If the key- hole saw is the instrument used for dividing the bone the exter- nal incision is short, only sufficiently long to admit of the easy entrance of this very narrow bladed saw. In this operation for the purpose of dividing the neck of the bone the scalpel is thrust TUBERCULOSIS. 223 through the soft parts just above and in front of the tip of the anterior border of the great trochanter and carried firmly to the neck of the bone, all the tissues being freely divided in its course; after its withdrawal the saw is carried along the track thus made in front of the neck of the bone, which is sawed through from be- fore backwards and the limb placed in a normal position. When the saw is used to divide the trochanter major the scalpel is thrust through the soft parts directly down to the femur just in front of the edge of the tensor vaginae femoris muscle, and at a height corresponding with the contemplated line of section. After the bone is exposed by the incision with the knife the saw is intro- duced into the opening and carried in front and over the inner surface of the femur, and that bone is sawed through in a direct- ion from within backwards and outwards. After the division of the bone the limb is placed in the position desired. An ordi- nary carpenter's chisel suffices for the purpose of dividing the bone in these cases. When the chisel is used to accomplish this result the point chosen for the severance of the bone is feeely exposed by an incision with the scalpel through all the soft parts covering it. This incision should be long enough to allow of the introduction of the chisel through it to the bone surface, and then to permit the cutting edge of the chisel to be tured in a di- rection transverse to the long axis of the bone. The chisel is then driven through the bone in different directions by blows of the mallet until entirely severed or sufficiently weakened to be easily fractured by the application of slight extending force, after which the limb is carried into the position necessary to overcome the deformity and the wound closed by sutures. If contracted mus- cles resist replacement of the limb to its normal position after any of these operations they must be subjected to subcutaneous division. All these operative procedures must be proceded, ac- companied and followed by the most perfect attention to every detail of aseptic and antiseptic preparation, care and treatment of the parts operated on, of the wound and of the subsequent dressings. Excision of the hip joint for tubercular disease thereof is an operation frequently performed and sometimes followed by last- ing relief to the patient with a very useful limb. When performed very early in the manifestations of the disease before much de- struction has resulted from its action, the operation is promptly recovered from and the limb possesses correspondingly greater usefulness; but even when done thus early the operation does not 224 TUBERCULOSIS. always secure permanent relief from the disease, for many such cases have subsequently come under my care for the treatment of tubercular abscesses, persistent sinuses re-forming in the course of the scar, or developing in some previously unaffected portion of the joint tissues. If excision is to be followed by the longest periods of relief from disease and to secure the most useful limb, it must be done before the ravages of the disease have led to any extensive destruction of the joint elements; when done thus early the operation can be made an absolutely aseptic one, and be followed by rapid primary union of ad the tissues incised with scarcely any constitutional reaction. Although many times re- markably rapid recoveries follow excision of the head of the bone, accompanied with the removal of the diseased acetabular cavity and other tubercular tissues, even after suppuration has occurred with resulting sinuses, still the probabilities of a successful and satisfactory result are greatly diminished by the presence of any such complications; the operation is far less likely to be aseptic on account of the almost insurmountable difficulties attending the purification of the sinuses and the uncertainty of complete removal of all tubercular foci. It is my belief that the persistent use of the iodoform emulsion in these bad cases will make them much more amenable to successful treatment in the future. The instruments necessary to perform excision of the hip-joint are a scalpel, probe pointed bistoury, one pair of dissecting forceps, one pair of heavy scissors, two retracting hooks, half a dozen artery forceps, a periostome, a chain saw or a straight saw with a movable back, or a chisel and mallet and needles with silk or catgut for application of ligatures or sutures. It is always well to have a Paquelin cautery ready for use in case it is desirable to destroy any tubercular tissue which cannotbe otherwise removed. No better incision for exposing the joint can be made than the ordinary straight one or one made with a slight curve backwards over the situation of the trochanter major. The incision should commence at a point about two inches above the middle of the upper border of the trochanter major and terminate about an inch below the junction of the trochanter with the shaft of the femur; it should be carried with a free hand through the gluteus maximus muscle and through the periosteum of the exposed tro- chanter. The deeper portion of the incision should be inclined forward to correspond with the forward and inward direction of the neck of the bone; divide the capsule of the joint and uncover the neck and head. If the disease has not made much advance, TUBERCULOSIS. 225 by means of the elevator the periosteum should be stripped off from the trochanter in all directions, carrying with it its muscular attachments, and in this way bring into plain view all portions of the neck, head and trochanter. In all cases it is the rule to care- fully save every particle of the periosteum unaffected with tuber- cular degeneration, as by this means are preserved the muscular in- sertions and a much stronger and more useful limb insured. In many cases the disease has so far progressed in its infiltra- tion and destruction of the surrounding soft parts that it will be necessary to divide the muscles attached to the trochanter by means of the probe pointed bistoury in order to surely remove all the diseased tissues. It is best not to make any effort to extrude the head of the bone through the incision until after the tro- chanter has been perfectly freed and the capsule entirely sep- arated by one or other of the plans just described. As soon as this is accomplished the head of the bone is readily forced through into the external incision by forcible adduction and back- ward pressure, using the thigh as a lever. The diseased bone is now separated from the shaft by the use of either of the saws mentioned or the chisel and mallet. My preference is given to the use of the chisel and mallet for this purpose, for with them it is possible to regulate accurately the amount of bone removed and accomplish its removal without any injury to the surrounding soft parts. In advanced cases it will usually be found necessary to include the trochanter major in the segment of the bone re- moved. In very early cases it may be found permissible to remove only the head and neck, and this can sometimes be done without any disturbance of the tissues attached to the trochanter major. There is considerable danger of fracturing the weakened shaft of the femur during efforts at extrusion of the head of the bone unless all of its attachments have been loosened before any such attempts are made. This fracture has occurred so often during these attempts that many surgeons advise and practice the plan of dividing the bone in situ without any efforts at extrusion lifting the diseased fragment out of its bed after its severance is accomplished. After the removal of the segment of bone the acetabulum should be examined for evidences of disease. Any granulations found present should be removed by means of the scissors or curette, and if the capsule of the joint is affected with tubercular degeneration it should be dissected away in part or in whole in accordance with the degree of degeneration present. Sometime 226 TUBERCULOSIS. the destruction of manifest tubercular degeneration of the soft parts can be best accomplished by the free use of the Paquelin cautery. If any arteries are divided during the incisions described they are temporarily controlled with the artery forceps and permanent- ly secured by the application of ligatures. The limb is placed in a position of extension with slight ab- duction and external rotation. If the case is an old one the sinuses are treated as has already been described, and the wound thoroughly irrigated with a solution of 1-2000 bichloride of mer- cury or the solution of tincture of iodine in water. The external wound can be treated in either of two ways. It may be packed throughout to the bottom with iodoform gauze and partially closed by a suture, or it may be closed entirely by sutures, except at the point used for the exit of large drainage tubes introduced in such position as will provide for free outflow of the wound secretions. If the case be a very bad one with many sinuses and much suppurative action I prefer the treatment by iodoform gauze packing, permitting the wound to heal from the bottom by gran- ulation, or applying secondary sutures, to be tied about the fifth day, upon removing the packing. In either case the usual external antiseptic dressings are ap- plied and the limb maintained firmly in its normal position by the application, outside of the dressing, of the plaster cast or the use of Buck's extension. The necessity for subsequent dressings of the wound will depend entirely upon the presence of distur- bance therein, as indicated by the rise in temperature—the less often disturbed the better. The external appliances for main- taining the limb in its new position should be retained for some- time after the wounds have entirely healed, and the use of the limb forbidden until all tenderness at the seat of the operation has disappeared. It is advisable to apply Buck's extension at night for at least one year after the wound is healed. The indications for hygienic and medical treatment, such as have already been advised, should be assiduously fulfilled through- out the entire course of treatment. Results of the Operation: After excision this extremity is al- ways considerably shortened, and if the head, neck and tro- chanter have been excised the parts remaining are not such as to result in the formation of a very serviceable joint. Besides, if the destructive action be so great as to require such an exten- TUBERCULOSIS. 227 sive excision, the parts concerned are very slow in healing, and oftentimes the resulting sinuses never heal at all or remain open for years. Occasionally, owing to the continuation and exten- sion of the disease, an unseemly deformity produces an absolutely useless limb. It is certainly a question whether the majority of limbs after excision are as serviceable to the patient as the at- tainment of ankylosis of the joint, with the limb in the extended position. It is even advisable to maintain extension for a year after all symptoms of acute trouble have disappeared in order to allow of complete condensation of cicatrical tissue, to dim- inish the degree of shortening, to avoid deformity and to provide for firm fixation of the shaft of the femur in its new position. This result can be accomplished by the use of Buck's extension with sufficient weight during the night, allowing the patient to take the usual amount of exercise during the day time. Amputation: Cases which have been subjected to little or no treatment and which have been allowed to progress for years, with the extension of the disease to the os innominatum and shaft of the femur, and accompanied with much burrowing of pus, should be subjected to amputation of the hip-joint With the improved methods to absolutely control hemorrhage, and the present technique of the operation, amputation for the relief of this disease is not attended with more, if as great, mortality as excision. It promises most relief because it removes the mass of the diseased tissue and allows of free and perfect drainage, and furnishes a ready method of accurate application of remedial measures to the remaining evidences of disease. Best of all an amputation puts a stop at once to the immense drain put upon the constitutional power of the patient, resulting from an exten- sive suppurating cavity. Amputation of the hip-joint will be required in some cases as a secondary measure for deformity after excision, or for the re- lief of such cases as are not followed by satisfactory cicatrization of the cavity left and the closure of the accompanying sinuses. Amputation is best made after the plan of Mr. Furneaux Jor- dan. It consists in making a circular amputation of the thigh at a proper distance below the hip-joint. After the circular am- putation is completed the blood vessels are permanently secured with ligatures; the remnant of bone left is then dissected out of the stump through an incision carried from the top of the tro- chantermajor to the end of the fragment, along its outer side. 228 TUBERCULOSIS. The bleeding vessels are positively and absolutely controlled by carrying a rubber band across the perineum and over the pu- bis in front, and behind the trochanter and over the crest of the ilium posteriorly. The rubber is pulled as tight as possible and the ends crossed where they meet above the crest of the ilium and then carried to the opposite side of the body and securely held by an assistant. A firm pad is placed beneath the rubber across the course of the external iliac artery in such position as to actually close that vessel; it should be held securely in proper position by an assistant. Or the plan advised by Dr. Wyeth can be followed with perfect safety—pass an upholsterer's long needle through the soft tissue on the inner side of the thigh on a level with the lesser trochanter; a similar needle is carried through the tissues on the outer side of the thigh, between the trochanter major and the ilium. The needles should be long enough to project at least two inches beyond the soft parts at both ends; protect the points of both needles with pieces of cork. Encircle the thigh above the pins with a sufficient number of turns of a rubber bandage to control all the vessels. The circular amputa- tion of the thigh is now made, first forming a skin flap which is to be turned up as far as possible; then a circular division is made of the muscles as high up as the knife can safely be carried, and the bone sawed through. All vessels are now permanently ligated, the rubber band removed and the remnant of bone dis- sected out of the stump. No blood whatever will be lost while the rubber band remains in position, if either of the above meth- ods are properly executed. In my experience rapid and unex- pected recoveries have followed amputation of the hip-joint for bad cases of hip-joint disease. Tuberculosis of Bodies of Vertebrae. Mary K., 1079 Jackson St., Age 17 months. The parents first noticed some trouble with this little childs, back about three months ago. As it lies on its father's knee with its back exposed, you notice a marked convexity of the dorsal vertebrae. The little one does not walk nor stand, so we cannot illustrate the accompanying symptoms. There is a disposition toward the softening and compression of the anterior portions of the bodies of the vertebrae in this part of the dorsal region, and TUBERCULOSIS. 229 consequently the spines become more prominent. Hence we have a case of beginning tuberculosis of the spine; formerly termed Pott's disease of the spine. Now, the child does not walk, I am inclined to advise the parents not to have a cast applied but to put the child upon its back in the same manner as you would in hip-joint disease and allow it to remain in this position until it is able to walk, then the back should be supported by a plaster-of-Paris cast. The child should have a light, cheerful room, plenty of good wholesome food, half a teaspoonful of cod-liver oil three times a day, and if it will drink it, a little ale or beer; in short one should do all that can be done for its general nutrition. Tuberculosis of Ankle Joint. Case 5. Samuel W., Distant, Lasalle County, Ills., Age 12, American School boy. This little fellow came to the hospital last night. He has been troubled with his ankle for four years. I have no doubt but that he is suffering from tuberculosis of the joint. It shows that the ligaments of the ankle joint have been absolutely destroyed by the inflammation. What we propose to do is to lay it open freely both on the front and inner side and remove all the degenerated tissue and put it to rest in a plaster-of-Paris cast. If this patient were an adult I should not hesitate to amputate the foot. But being a lad the chances are much more favorable. I have seen them recover after the removal of the astragalus and perhaps the os calcis and then have a much better foot than any artificial foot which can possibly be made. I make the in- cision above the middle of the dorsum of the foot and extend it to the malleolus so as to make a free incision. The degeneration of the tissue is very great and I shall remove it very completely. With that one stroke of the hammer I removed almost the entire end of tibia. Now you will be surprised to see the boy come in here in the course of a few months with a good foot. I think the disease is confined to the bones of the ankle. The os calcis is not in a good condition to be sure. I put my finger behind the chisel to use it as a director and as a guard to the parts behind. There is danger of cutting the finger and care must be exercised to pre- vent it. You can see all the changes which we have described in 230 TUBERCULOSIS. the destruction of the bone tissue very nicely shown here in these bones. Portions of the astragalus-os calcis and cunieform bones have been chiseled away. We will carefully curette away the granulations contained in all of the sinuses. This will all fill up with connective tissue, it will draw down and make the limb a little shorter, but it will be much more valuable than an artificial limb. This will be packed with iodoform gauze from both sides and all the sinuses leading to it will also be packed with iodo- form gauze so that all parts will be aseptic. There is not much danger of septic infection if you remove all this material, the patient recovers without any rise of temperature. We do not irrigate unless there is an infected wound and then we use only the saturated solution of boric acid. Now you see that is very different from the way I have been in the habit of talking to you, but it is the result of personal experience, and hence it is to be remembered. The point is absolutely this, if you keep the mi- crobes and all foreign matter out of the wounds you are able to get along without the assistance of any irritating fluids and the wounds will heal more rapidly. Mrs. B., School teacher. 46 years of age. This is the patient whose leg we amputated at the lower third for an extensive tuberculosis of the ankle, the tarsal bones being entirely destroyed by the disease. The destruction was so great that the ankle joint was composed of a caseous mass rather than of bone and the finger could be pushed directly through the tissues. Therefore amputation was the only remedy. The wound is en- tirely healed as you see ten days after the operation. It is a very interesting case in that, as you remember, we found the blood vessels occluded through their whole extent. The limb was atrophied throughout, giving rise to this condition of affairs. There was no pulsation of the arteries nor bleeding, even after the Esmarch's constrictor was removed. We have, therefore, in this case, an illustration of the destruction of the bony, muscular, nervous and all other tissues as a sequela of this disease. In adults with such an extensive tubercular destruction of the ankle joint an amputation a little below the middle of the leg is to be preferred to a resection. This confines the patient to his bed for only about two weeks and gives him a stump upon which he can wear a very useful artificial limb. Patients who are sub- jected to an amputation for the removal of a tubercular joint usually gain very rapidly in weight and strength after this opera- tion. TUBERCULOSIS. 231 Charlotte 0., Chicago, Age, 14, Swede. Here is a typical tubercular ankle joint presenting all the characteristics which I have frequently pointed out to you. We purpose to open this joint and see what we can do for it. I shall make Professor Kocher's incision which I have described to you before, consisting in the straight transverse incision across the tip of the external malleolus, dividing the external ligaments, and bending the foot inward, so as to thoroughly expose the joint surfaces. It is not always necessary to divide the anterior and posterior ligaments, as the operation can often be successfully performed without so doing. When I cut into one of these tubercular joints and find it full of degenerated, broken-down tissues, I feel like amputating the foot above the seat of the disease. But again, when I go out on the street and meet a little schoolboy running along, with two good, sound feet, five years after having performed an operation on him for a tubercular joint as bad as this, I am encouraged in performing the conservative operation. You will thus meet both discouragement and en- couragement. I was talking to a physician friend today about a little patient on which I operated for a trouble of this kind two years ago. He tells me that the little fellow is quite well, wears a shoe, and runs about without a limp. The many results of this kind that we see convince me that the conservative work is the thing to do, and to leave a portion of the work to nature. Byre- moving all of the dead and dying tissues that you can, and at the same time leading to the occurrence of an inflammation which will cause the deposition of a large amount of cicatrical tissues, which continue to contract upon the diseased portions which were unavoidably left, you destroy by compression the com- paritively few bacilli of tuberculosis which remain. This process is, you remember, very much assisted by the use of the actual cautery. If the disease has had its origin in the astragalus, the keystone of the arch of the foot, and proceeds in the direction of the toes, one authority goes so far as to say that, even though the other bones of the tarsus are not affected, he invariably am- putates the foot. We will not say anything against this doctrine for he is a surgeon of high standing, but we will show you this foot later. We will now use the cautery thoroughly. You should uot use it hotter than a dark heat. If you get the white heat, it burns more than you desire, and does not accomplish any more. The white heat will cut blood vessels that are in the way the same as a knife would, and that, of course, should be avoided. You would 232 TUBERCULOSIS think that there would be a fearful reaction from this operation, but such will not be the case. Without some accident, the child will progress to recovery without any rise of temperature. This wound will be dressed and redressed in the usual manner and with the usual care. This little patient has a simple fistula situated on the inner side of the tarsus, leading to an abscess cavity which I have no doubt contains a foreign body. And as that foreign body must be something originating in the body, I have no doubt that we shall find carious or necrosed bone. This diseased bone will be due either to the destruction caused by the bacillus of tuberculosis or the pus microbe: If due to the former the diseased condition is known as tubercular degeneration of the joint; if to the latter, it is termed osteomyelitis. I find that this small opening leads down to dead bone, and I make just enongh of an incision to uncover the seat of the disease. If I am able to relieve the trouble by shelling out one or more pieces of dead bone from this small opening, we will do so, if not, then we shall be com- pelled to do a more extensive operation. Sometimes we are compelled to take away the entire bone. A little foot like this bears but little resemblance to the foot which you study in your anatomy. In fact the undeveloped foot is entirely different, because the progress of development or ossi- fication has not been completed and in many cases has scarcely begun. By lifting out these pieces of bone, I find that I have removed the whole focus of the disease. So I think the little one will get well without any further treatment In all such cases you should not be limited in your operation except by the extent of the disease tissue. Having removed all of the infected tissues as we have done in this case, then the patient is ready to go on to recovery. The specimens of one which we have just re- moved, is of the same oseoparotic gelatinous character which fills up the spaces between the laminae of bone and the soft parts surrounding the bone and which you have seen so often. All of this degenerated material must be removed with the curette. If this is thoroughly done and the cavity is dusted with powdered iodoform, and then packed with iodoform gauze, the case usually goes on to recovery without any further interference and without any reaction. You will never expect such results, however, unless you thoroughly carry out the instructions which have been given. It is encouraging to be able, as we are nowadays, to take these specimens of bone and after carefully searching from time to TUBERCULOSIS. 233 time, find well marked foci showing the presence of bacilli of tuberculosis; especially is this true since so many diseases are traceable to this cause. We are indebted to Prof. Koch for the discovery and description of the bacillus of tuberculosis which is recognized as the cause of this disease. Hardly ever do we find tuberculosis affecting the diaphysis of the long bones. I do not say that we never find it, but it is very rare. It is usually found in the epiphyseal end of long bones or in that vicinity. If the disease comes on slowly and an abscess forms, you may know that the trouble is tubercular in character; but on the other hand, if the disease is rapid in its progress and inflammatory in character, you may know that it is osteomyelitic instead of tub- ercular. Before dressing this wound we will wash it thoroughly with i-iooo bichloride of mercury, for the purpose of disinfection. This little patient has club foot, and has had a special shoe made which has been worn and which was supposed to originate this trouble. A careful examination would at once prove the in- correctness of that idea, for had such been the case there would have been much less destruction to the tissues. I think there can scarcely be a doubt that iodoform has a curative effect upon tubercular diseases. Just why this is, it is difficult to explain. But placed in a wound it comes in contact with moisture and perhaps separates into elements giving off free iodine which acts as a potent disinfectant. Be this as it may, iodoform has bene- ficial effects and this is why we use it, notwithstanding the fact that we read in the journals that microbes will develop and thrive in it. You must remember, of course, that the conditions are not the same in the two cases, consequently the argument is of no value, in comparison to your surgical experience conclusions drawn from experiments made in test-tubes cannot be safely ap- plied to the human body. I do not know that I have said anything in regard to the in- cision to be made in these cases. There is no regular rule in re- gard to the course of such an incision. It merely should be made in a direction leading to the avoidance of blood vessels, nerves and tendons, and with a free hand down through all of the tissues to the bone. I think this is better than trying to dissect the tis- sues separately, for you know that they are so changed and glued together that they form one tissue mass. Going through the periosteum, it can be lifted up out of the way and the chisel in- troduced without injury to the soft parts. 234 TUBERCULOSIS. The iodoform gauze packing will be removed about once a week and reapplied with the same care we have exercised during the primary dressing in order to secure an aseptic healing of the wound throughout. Tuberculosis of Knee. Wm. C, Prinenwood, Shaweno Co., Wis., Age 25, American, Laborer. This case gives the following history: His family history is good with the exception of the fact that his mother died of can- cer, but I do not think that has anything to do with this case. The patient enjoyed good health until he had a fall, hurting his knee. This seemed to pass away without any serious results. About two years ago his knee was caught between two logs, and severely crushed. From that time to the present he has suffered constantly and has not been able to use the limb; the swelling which you see has increased gradually and the knee has been held in the position of slight flexion. The case will show you all the characteristic appearances of white swelling. It is called white swelling because the skin is tightened over the part, shut- ting off the capillary circulation so that it is not so vascular as the rest of the skin, and you will see that the little veins are some- what enlarged. The landmarks have been destroyed. The sur- face is smooth and even. The same is true of the ligamentum patella. As I examine the patella I find that I can depress it. This directs your attention to the fact that there is fluid below it. It is a case of tubercular degeneration of the synovial membrane. It is impossible to say whether the degeneration began from a focus in the bone, or the synovial membrane. It is more likely to occur in the former than in the latter, and we will probably find foci in the tibia. Of course the limb has been properly pre- pared in every way. Yesterday it was scrubbed with soap and water and then shaved and washed with a solution of bichloride of mercury, 1 to 1000, and then an antiseptic dressing was applied. This is useful from the fact that it permeates the pores of the skin and renders the micro-organisms in the skin harmless. Now, of course. I am not certain what I shall find, so I shall not promise as to what we shall do. If I find no disease of the carti- lage and no very great disease of the bone all I shall do is to TUBERCULOSIS. 235 obliterate the joint by dissecting away the diseased synovial membrane, Now I have discharged from this joint a very dis- agreeable and unhealthy fluid. We give to it the name of tuber-. cular pus. This pus shows that the joint is in a somewhat ad- vanced stage of tubercular degeneration. Who would think from the external manifestations of this case, that the destruction in- side was so great as this. The surface of the condyles of the femur are eroded. The cartilage is separated and falls off in pieces. I am afraid that I shall not be able to do better than to make a resection of the head of the tibia. I will dissect down to the healthy tissue, leaving the synovial membrane behind. You can see here a focus at the upper part of the bone that I have opened into. I have expressed to you my opinion for pre- fering the chisel for removing the diseased bone and I need not repeat. The sawed surface of the bone shows some signs of in- flammation, yet I am satisfied that it is not the color of tuber- cular tissue. Here is a' large pocket of pus in a great cul-de- sac of the synovial membrane. I shall lay this wide open for I am satisfied that we cannot control it unless we do this. This is the thickened synovial membrane. We shall remove as much of it as possible. Now I drill two holes through these bones, one on either side, which is easily done, and I pass this needle armed with catgut through these holes for the purpose of holding the surface in apposition until callus has been thrown out. The holes are made obliquely from a point three-fourths of an inch from the sawed surface of the bone to a point just below the posterior edge of the sawed section. Very frequently silver wires are in- troduced. Frequently instead of catgut surgeons use ivory pegs or steen nails, sometimes the drill itself is left in the hole for the purpose of fixing the fragments. But in my cases I have used the catgut. In the majority of cases the bones will stay in posi- tion with catgut or whatever material you may use. It does not last very long but it will not cut its way through the bone as the wire often does and it does not have to be removed. There is enough exudation to fix the parts held with catgut, provided ex- ternal splints are applied, and especially if plaster of Paris splints are used. This external wound will be closed with the continu- ous catgut suture which has been antisepticised. These tissues are inserted through all the tissues. You will be able to learn much of the condition of the bone in this disease by examining these fragments. TUBERCULOSIS. James S., Chicago, Age 55, Merchant. Gentlemen;—This is a case of old tubercular trouble of the knee-joint. It had been rather dormant for a number of years, but lately it has been giving the patient trouble, so we are inject- ing it with an emulsion of iodoform. The first time he was be- fore you he was brought into clinic on the cart, not being able to get out of bed. Now, he is able to walk pretty well, after having had three injections of the 10 per cent, emulsion of iodoform in glycerine. When he first appeared before you, his knee-joint was abso- lutely stiff, and caused him very great pain. Now, you can see that there is a very perceptible amount of motion in it and the pain has entirely left it. Remember what I have told you in regard to attaching the syr- inge to the canula of the trocar with a piece of rubber tubing, as we have done here, as a guide to the amount of pressure that you are using. The amount of pressure which causes this bulb to form in the rubber tube will fill the capsule of the joint, yet it is not sufficient to rupture it. I am satisfied that the capsule is not infrequently ruptured by the application of too much force. We must insert a trocar as large as a goose quill into the joint preferably into the space beneath the tendon of the quadiceps femoris muscle. If any tuberculous pus is present it is permitted to escape through this canula. The cavity is then irrigated re- peatedly with a saturated solution of boric acid in warm water until the fluid returns perfectly clear; then the joint cavity is filled with a 10 per cent, solution of iodoform in glycerine. The quantity injected varies from one drachm to two ounces. This treatment is repeated once in two weeks at first until the irrita- tion has subsided, which can be recognised by the fact that the characteristics of tuberculosis disappear. The fluid coming from the canula becomes less flakey and is viscid and the patient is able to use the limb. Then the injections are repeated at longer intervals at first once a month then once in two and later once in three months. In our experience it has required from 2 to 12 injections We employ precisely the same method in the treatment of all the other tubercular joints. Apparently it is immaterial whether the iodoform is mixed with glycerine or with olive oil. If the former is used it is not necessary to sterilize the mixture provided it be prepared at least a week before it is used, because the glycerine will destroy any TUBERCULOSIS. 237 pathogenic microbes which may be present in the iodoform dur- ing this time. If oil is used the mixture should be heated in a steam, sterilizer for one hour. TUBERCULOLIS OF SHOULDER. John M., Age 24, Joliet, 111., Railroad employee. Four months ago this patient received a jar affecting the should- er joint. He was unable to continue his work but has noticed a certain amount of stiffness in the joint ever since. The shoulder has not been swollen to any marked degree and there has been no redness. During the past month the patient has no- ticed the development of a deformity which is now very apparent. You see the difference between his shoulders. At first glance, if you are not accustomed to seeing injuries about the shoulder, it might suggest dislocation. It is flattened, as compared with the opposite side, but the flattening does not depend upon dis- placement. I am confident that it is a tubercular disease. There is no trouble that would come on as rapidly as this; no such evi- dence of injury as this history gives would lead to so well marked atrophy as is present here. No acute injury would lead to it, other than the presence of tubercular destruction of the liga- ments, and perhaps the joint surfaces themselves. I can scarcely put the arm through any of the motions. The motion is not in the joint but in the scapula. What is to be done? Put this limb at rest and inject the joint for a short time with the 10 per cent. emulsion of iodoform. The arm should be carried in a sling fixed to keep it at rest. If no improvement follows, resection is the proper procedure. A resection of the shoulder joint is fre- quently followed by a very useful arm. The recovery is gener- ally rapid. There is one point about the deformity to which I must call your attention; it is the prominence made here by the head of the humerus. You will notice it swings forward. This comes from the weight of the extremity throwing the head of the bone down and the swinging forward by the tendency of the fore arm. You will find also a projection on the anterior surface. Here as elsewhere in tubercular joints the thickening is due to the condition of the ligaments, the periosteum and the tissues surrounding the joint and not to enlargement of the bone. 238 TUBERCULOSIS. Tuberculosis of Wrist. Wm. B., S. Halsted St., Chicago, 23 years old, Telephone op- erator. Father died of pulmonary tuberculosis. Mother and sister healthy. Seven years ago patient began to suffer from pain and stiffness of the wrist joint after a fall. The progress has been very slow but constant since that time. This patient is suffering from tuberculosis of the wrist joint. Yon notice the characteristic pufifiness of the joint. He has had two injections of the iodoform emulsion, and he says this is the first time he has been able to extend and flex the fingers for six years. You can notice also that the amount of swelling in the joint is considerably dimished. He is a private patient, and I merely bring him before you to show you the result of this treat- ment. I have had success in every case of tuberculosis of the wrist- joint that I have treated by this method. The success is ap- parently even better than it is in the ankle or knee-joints. The trochar is inserted at a point opposite the styloid process of ulna or radius a little nearer the dorsal than the palmar sur- face. It is carried entirely through _the joint to the opposite side of the wrist and withdrawn slowly while the injection is being made. Usually not more than 2 or 4 drachms can be injected into this joint consequently we use a 20 per cent, emulsion in these cases. Tuberculosis of Sacro-iliac Joint. Miss Mary G-, Age 20, American, well nourished, healthy ap- pearing young woman. Since six years has had swelling in the region of the sacro-iliac joint. This opened and left a sinus in the gluteo-femoral fold three inches below the great trochanter. One year ago the patient had some trouble in the hip joint but this has entirely subsided, The joint is freely movable without giving rise to pain. The sinus extends in the direction of the sacro-iliac joint, it can be followed by means of a probe for a distance of five inches but no diseased bone can be discovered, although this undoubtedly exists. TUBERCULOSIS. 239 The patient is so slightly inconvenienced that the radical steps necessary to ensure a permanent cure, viz:—laying open thesinus exposing and removing the diseased bone, do not seem warranted. We will advise her to return in case of further trouble or incon- venience. In the mean time we will advise the use of good food, exercise in the open air and systematic treatment with tonics and malt and cod liver oil. A patient who is suffering from a localized tuberculosis like the one before you which does not give rise to any inconvenience or pain and does not seem to affect the general condition usually recovers more rapidly and more perfectly without than with the use of operative treatment. Tubercular Abscess Connected With Sternal End of Ribs. S. B. R., Watertown, Iowa, Age 34, American, Railroad man. You see a small swelling on the left side of this man's chest, a little below the nipple. He first noticed it two years ago. During the last two months it has increased a little in size and is a little more tender. It is soft to the touch, fluctuates, and is situated directly over the apex beat of the heart, yet it does not pulsate, consequently it is not connected with any large blood vessel. The tumor is situated in the position in which we not infrequent- ly find what we term a " cold abscess " in connection with the ribs and costal cartilages. You understand that we mean a tu- bercular abscess the same as we find in other parts of the body. I will introduce the aspirator needle and see if I can get the characteristic fluid from it. I tell the patient that it is not an aneurism, or there would be pulsation in it; and if it were, the in- troduction of this small needle would do him no harm. This is, of course, the only way to arrive at an absolute diagnosis in this case. If it is a '' cold abscess," the contents will be so thick that it will not pass through the small needle to any extent, and I shall be able to get no more than a drop or two of fluid, which I have succeeded in doing and which proves to be the thick, gela- tinous, cheesy matter characteristic of the disease. The patient, therefore, has a tubercular abscess in connection with the ribs or sternum. In all such cases it is well not to make a positive diagnosis without the use of the aspirator. 240 TUBERCULOSIS. We will make an incision down to the rib evacuating all of the tubercular pus. We find that the abscess cavity is lined through- outwith a layer of soft velvety granulations. Just at the junction of the sixth rib with its cartilage we find an abraded point. The periosteum is destroyed and the bone to the depth of 1-16 inch is in a carious condition. We will remove the diseased bone and then curette the cavity in the rib thoroughly. The entire cavity will now be vigorously scrubbed in order to remove any loose particles which may remain after curetting. Then it will be dusted with iodoform and tightly packed with iodoform gauze. Secondary sutures will be introduced and left loose to be tied about the fifth day, after removing the gauze packing. The wound will be entirely healed in three weeks if nothing unexpected occurs. Tubercular Lymphatic Glands of the Neck. Miss Lizzie M., Geneseo, 111., Age 19, American. There are certain absorbent vessels in the human organism known as lymphatics. They begin in the fine microscopal lymph- capillaries all over the body wherever blood vessels are found, collect themselves finally into two trunks and empty into the subclavian veins at the junction of the internal jugular veins. They have connected with them certain lymphatic glands which are arranged in a specified position. These absorbent vessels and glands are distributed in two sets, the superficial and the deep. The superficial ones are subcutaneous and accompany the superficial veins of the body. The deep lymphatics are larger than the superficial, are fewer and are found accompanying the deep blood vessels. We have a variety of diseases surgical in nature in connection with these glands of the lymphatic system. These diseases may be classified into the acute and the chronic. A very good ex- ample of an acute disease of the lymphatic system is found in bubo through the infection with gonococcus of the lymphatic glands of the groin. We have a manifestation of the same sort of trouble in different parts of the body from syphilitic infection. You remember that we have lymphatic vessels with their glands extending from below the chin around behind the angle of the TUBERCULOSIS. 241 jaw to the side of the neck. If a patient comes to you with an unhealthy, dirty looking ulcer, circular in form with a peculiar enlargement beneath the chin it is almost a positive diagnosis of a syphilitic trouble. And of course you may have enlargement of the lymphatic glands of any portion of the body from syphilitic infection, or from the introduction into the system of the pus microbes. The gland or glands, as the case may be, enlarge and break down in pus. These are examples of acute disease of the lymphatic system. An example of chronic diseases of the lymphatic system is seen in the infection of the glands by the baccilli of tuberculosis. In this case the growth of the gland is slow and insidious and does not show the early disposition to break down. In all of these cases of tubercular glands, whether the infection is circum- scribed or is general in its character, you should seek the course through which the baccillus entered the gland. Hence it be- hooves you in all such cases to examine the mouth, throat, and nose to determine the abrasion through which the bacillus was allowed to enter. Now, this patient before you is a case of this nature. She had a tubercular infection of one or not more than two lymphatic glands at the angle of the jaw. The patient had an operation for the removal of these diseased glands at this seat four months ago. You can readily see the scar resulting from that operation. She was relieved for a time, but the disease returned and you notice that the glands situated along the posterior border of the sterno-cleido-mastoid muscle are enlarged, as well as those at the original seat of the disease. As a rule, it is not worth while to operate in these cases of recurrence if many glands are in- volved. If only three or four of them are involved they may be removed, but if there are many, an operation will not remove them all and there will be a strong tendency for them to return. Sometimes they will not return for years, at other times it will only be months. I once heard a very famous surgeon say that he was sometimes induced to operate in these cases, sometimes quite extensively, because the removal of the larger glands was followed by the absorption of the contents of the smaller. I have never seen that result in any of my cases. In most there has been a return of the disease, notwithstanding the fact that a very extensive operation was done. So far as these glands of the neck are concerned, if they are in the superficial fascia, and so long as they remain superficial 242 TUBERCULOSIS. there is but very little difficulty in their removal. Separating the tissues and coming down upon the capsule, you will observe the rule of keeping close to the tumor and by a process of emulc- tion the mass may be easily removed. The glands are always softer in the secondary manifestation than primarily and break down much more readily. So that when you reach the glands you will find that they are very soft and the corresponding pres- sure which you may put on the glands of the primary disease in their removal would destroy them, making it very difficult to allow to follow them up and remove them. You will therefore keep as close to the gland as you can, but at the same time be careful not to break into the interior. Now, here is a gland which looks as if it were superficial, but I find, as we very frequently do, that, notwithstanding its superficial appearance, it extends deeply down into the tissues of the neck. Hence, I must use a good deal of care when I come to lift out its base so that I shall not commit the error which I have warned you against. I have advised you not to pull the gland up and divide its base when the tissue is on the stretch. Because if any vessels are running along the base they may be divided in such a way that they are very difficult to take up with haemostatic forceps and you would then have a hemorrhage that would be very difficult to control. When I remove this, you will see that its ramifications extend much deeper than its external appearance would suggest. And this must be remembered when you attempt to lift it from its base, for you can never tell from what tissues and structures it has grown. It is always a very good idea to seize the base of the pedicle with a pair of forceps before you separate the tumor from its attachments. This gland which I have now succeeded in removing is a very good illustration of this point. You notice how deeply it ex- tended into the muscles of the neck and you can readily see that any pulling that would bring it up into the wound would very likely have injured the internal carotid or other important vessels. Now, instead of dividing the muscular fibres to get at these remaining glands, we will go behind the sterno-cleido-mastoid muscle. It may be necessary to divide a few of the fibres. We will make the incision very free so that the wound will be large enough to permit of easy removal of the gland. I have made the incision very near a large vein. You can see the blue pro- jecting mass. It will give you an idea of the characteristic ap- TUBERCULOSIS. 243 pearance of the large veins well distended with blood. This is the deep jugular vein. Making my incision behind the sterno-cleido-mastoid muscle, you notice that I do not make the incision through the skin and superficial fascia but also partially through the muscles as well down upon the deep glands of the region. I find that what I have told you is likely to be found in the recurrence of the dis- ease is true here. This gland is very much softer than the orig- inal first diseased glands. Hence the removal will be attended with more difficulty than either the one just removed or those removed some months ago. It is well, when you get well down into the wound, to separate the tissues with the handle of the knife instead of the blade. Quite frequently you can do more with the scissors and forceps than with the knife. You are better able to get at the parts near the tumor than with the knife and they are safer to use. There has been so much inflammation in connection with the glands and the surrounding tissue that the former show no disposition to enucleate and it will be necessary for me to dissect it from the surrounding tissue. This will cause me to open some small vessels. I have opened one now which the assistant is a little anxious about so we will apply haemos- tatic forceps to it. It is a very much more difficult operation when the gland is surrounded by this condensed tissue than when it is encapsulated. Of course, there is no particular danger so long as I am working about the posterior border of this gland for we know that the vessels of this neighborhood are not of much consequence and will not give so serious hemorrhage But when we get to the anterior part then I want to see just where every incision is made, and, hence as a rule I prefer to separate the gland from before backward getting it separated from the important vessels first. I have succeeded in getting out this large mass. We will pass them about and let you see the character of the soft glands due to the recurrence of the disease. We are operating, as you see, very closely to the base of the neck. The blood vessels are enlarged and during this act of vom- iting we might have air drawn into some of the vessels. Hence, during this vomiting spell we will pack the wound with iodoform gauze to prevent any accident. I have now found a gland so soft that the slightest pressure has ruptured it. Of course there are a good many different methods of treat- ment for this disease. Perhaps the old-fashioned method of stimulating the external surface of the neck by lotions such as 244 TUBERCULOSIS. the compound tincture of iodine has been used. The idea, of course, being to stimulate the surface so as to lead to absorption of the substance of the gland tissue. I cannot say that they have acted in that way so far as the disease is concerned. This is a tubercular gland and no doubt the microscope will reveal the baccilli the same as it would in tubercular joints but not in the same number. Not many years ago an operator in the army tried a local treat- ment for such cases. His idea was that he could cure all such infections by injecting into the parts ten or twenty drops of car- bolic acid. The treatment seemed to do good in many cases and in many other instances it seemed to be quite useless. Lately I have pursued the plan of injecting into the gland from five to twenty drops of a i-iooo solution of the bichloride of mer- cury according to the size of the gland. In one case at least, there has been very marked improvement. The manifestations were very much more marked than in this case and one of the glands had entered into the process of suppuration and after the first injection broke down. The cavity rapidly closed and we kept on injecting one or all of the glands at once with the effect of a rapid disappearance of the glands until it is now very diffi- cult to find them. Another fact in connection with the same patient is that his general health is much improved. His appetite, flesh and color are much improved. All this is in accordance with what we know about mercury. In small doses it is a tonic as well as an antiseptic. I am, therefore, inclined to treat these glands in this way. But this young lady had such an easy time with the other operation that she wishes to have these removed in the same way and we will accommodate her. If, however, there is an increase in the size of the glands after this operation we will treat them as we have many others by injecting them in the way I have suggested. You must remember that everything must be done in these cases to improve the patient's general health. Give them plenty of good food, especially those rich in fats. Often you will in- quire into their history to find that they avoid fats in their food. If this be the case, you must try to lead them back to the proper path and induce them to eat fats. Milk, cream and codliver oil should be freely used. In this way you can do much toward staying the progress of the disease if not interrupting it entirely. Usually the disease is slow and we class it among the chronic diseases of the lymphatic system. We have another disease TUBERCULOSIS. 245 which would come under the head of acute disorder if we classify them according to the rapidity of the growth and that is sarcoma affecting the lymph glands of the body. It is often found in the exillary space and less frequently in the femoral region. We had an example, in the hospital of a girl with sarcomatous lymphatic glands on either side of the neck and also in the axilla. The growth of the glands was so rapid that both sides of the neck extended out three inches beyond the normal. So rapid was the progress of the disease that within four months she actually choked to death from its effects. We have no treatment that I know of that will stop its progress in such cases. Sometimes the disposition is toward a few glands only. As in an old lady under our charge. She had two or three glands diseased, one of which had undergone colloid degeneration. Such cases are favorable for operation. Since the operation she has gone rapidly to re- covery from the disease. As a rule it is a disease over which the surgeon has very little control. You should never forget the danger which exists in operating at the base of the neck beneath the superficial veins of opening the jugular or subclavian veins and allowing air to enter. Conse- quently the veins should be compressed between the seat of the operation and the heart. The heart acts as a suction pump and unless you use every precaution to prevent it,there is much danger of air being sucked into it, resulting in death. The farther you go from the base of the neck the less is the danger. But the same danger is present in the axillary space. I show you a specimen of 75 glands which I removed from a boy's neck. They filled up the entire space between the clavicle and the neck. I show them to you for it is the only case in which there has been no tendency toward a return of the disease. It was a very extensive operation and perhaps we were able to remove all of the glands. This is much easier to accomplish in children than in adults and it is much easier in the first opera- tion than in the second. Tuberculosis of Epididymis. J. W., Chicago, Age 30, Scotchman, Machinist, generally healthy, well nourished. On examination we find that this man has a hard nodular mass occupying the position of the left epididymis. This existed for several months. It gives rise to but little pain and advances 246 TUBERCULOSIS. very slowly in an upward direction. Cases of this character and presenting this special feeling have in my experience proven to be tubercular. Based upon that belief this affection, however slight and simple it may seem to be, is of serious import to the patient. While it is present it is a constant source of danger from possible general tubercular infection. The only reasonable treatment to advise or pursue is total extirpation of the diseased organ. The patient does not consent to any such interference, and I do not expect him to, still I am quite well convinced that it is the safest procedure to adopt in this case, and it is my duty to warn him of the risks he runs with this center of disease in his system. As he will not consent to the operation suggested, we will pre- scribe such medicines for internal use as are supposed to have a beneficial influence on this disease. We will also direct the daily inunction of the diseased part with a small amount of mercury ointment. Tuberculosis of the skin. James B. F., Age 34, Laborer. This young man says that the pathological condition which you see on the left side of his chin, about the size of a dollar, first ap- peared as a small pimple, and became quite noticeable in the course of a week. It appeared eight months ago and since then has shown a disposition to extend. It has changed its appearance several times. A month' ago it projected over the surface and had light colored enlargements somewhat resembling warts in the center. The patient has let his beard grow over the growth in order to hide it. When he applies caustics it becomes irritated and pain- ful. It is a case of lupus having the characteristic granular ap- pearance advancing upon the surrounding tissues from its mar- gin and leaving a white scar after healing. It is perhaps a little tapid in its development but that is explained on the ground of stimulation of caustics. This would be a most excellent case on which to try injections of Koch's lymph. If we had some of his lymph we would try it on this gentleman, for the purpose of cure as well as of diagnosis. If it is a case of lupus there would be the usual reaction which follows the injection of lymph. There would follow also the effect, the destruction of tissues in which TUBERCULOSIS. 247 the bacillus is contained, as is reported by all who have tried it in this country and in Europe. There is no doubt it has a pecu- liar effect upon lupus at least, and no doubt upon tuberculosis in other parts of the body. But it is more evident in lupus because the effect can be seen, this being external. We will refer the patient to Prof. Hyde, and see if he confirms the diagnosis. I have no doubt he will institute a process of treatment that will relieve the patient. Many surgeons have tried to curette the surface, destroying all the tissue which is the seat of the disease. But it is said the best results have followed the use of the curette with subsequent cauterizations, scraping out everything down to healthy tissue then carefully applying the Paqueline cautery and then treating the surface as an ordinary ulcer. Of course we all hope the discovery of Prof. Koch will prove a cure for such cases. Tuberculosis of the Mamma. Mrs. Mary H., 58 Park Ave., Age 30, American, seamstress. This patient whose general appearance is anaemic, has a swell- ing in the left breast, which has increased in size very slowly, has given rise to but little pain and no symptoms of inflammation except that the patient's temperature is slightly elevated in the evening. The integment is movable over the swelling and the latter is movable over the deeper tissues. Fluctuation cannot be definitely demonstrated but the patient's general appearance and the history of tuberculosis in the family, together with the conditions present warrant the diagnosis of a tubercular abscess. In cases in which there is any doubt you should resort to the aid of the hypodermic needle. Mistakes of diagnosis have been made by almost every prom- inent surgeon in similar cases and I think it worth while to call your attention to the fact. We will lay this abscess open freely. It contains the charac- teristic liquid, granular tubercular pus. The walls of the abscess cavity are thick and covered by soft tubercular granulations. After thoroughly curetting and irrigating the cavity, we will dust it with iodoform and pack it with iodoform gauze and permit it to heal from the bottom by granulation. 248 TUBERCULOSIS. Ganglion on Extensor Tendons of Hand. Mr. J., 575 Blue Island Ave., Age 20, U. S., Druggist. This man comes with a small tumor on the dorsum of the wrist. When the hand is extended the growth is not seen, but when I flex it you see it is made very prominent. It is similar to the one you saw us remove from the hand of a woman a few days ago. It is a sac in connection with the sheaths of the tendons lying beneath it and it is filled with synovial fluid. It is termed a ganglion and usually follows a strain of some kind. Piano players and persons who make rapid movements of these tendons not infrequently have them. They are also not infrequently found in connection with tuberculosis. You remember a few days ago I opened one of these ganglions on the back of the hand of a young lady, and found a large number of "rice bodies." These " rice bodies " have been introduced into the bodies of lower animals, especially guinea pigs and rabbits and have caused tuberculosis in them which proves their connection with that dis- ease. Sometimes the sac of the ganglion is very thin and a blow or pressure will rupture it and distribute the fluid equally over the posterior surface of the hand where it is absorbed. At other times, as in this case, it is necessary to introduce the tenotomy knife subcutaneously in several places and locate the fluid in that way. You now see the tenacious, gelatinous, transparent fluid escaping through the opening made with the knife. The empty- ing of the sac is not sufficient to lead to a cure. The sac will refill unless its surfaces are pressed in contact with each other and held together. This can be best done by making a small pad from a narrow sheet of gauze just large enough to well cover the sac. A thin preparation of plaster of Paris of the consistency of cream can then be molded to the back of the hand and fitted to every elevation and depression perfectly, thus making equal pressure on all parts. This treatment frequently leads to a per- manent cure. Since the discovery of tubercle bacilli in these specimens we have advised removal of the entire swelling by dissection, thor- ough disinfection and closure of the wound. If a patient will consent to such radical treatment, it should be practiced provided the surgeon employs perfect methods of aseptic or antiseptic surgery. If infection takes place it is not confined to the sac, but spreads into the connective tissue of the synovial membrane of the tendon up and down, so that it produces an inflammation that destroys the usefulness of the hand entirely. CARCINOMA OF BREAST. 249 Carcinoma of the Breast. Case i. This patient is fifty-five years old and has had a growth in con- nection with the right breast for three years. At that time she discovered it as a small lump in the lower outer portion of the gland, which had previously given rise to no trouble. There was no pain and no tenderness, but, when first discovered, she no- ticed the character of extreme hardness belonging to the abnor- mal body. Now she comes to us with this tumor, which moves freely with the breast in the subjacent tissues as the position of that organ is changed. The skin can be moved over the surface of the tumor only around the circumference of the gland, being fixed and immovable over the greater portion of its central part. The tumor is about six times as large as when first discovered, and now approaches the size of an orange. Until one year ago, there was no discoloration of the skin; now there is plainly vis- ible a dark-red color over the tumor itself, being darkest imme- diately about the nipple and its areola. There is also a noticeable peculiarity present, in that for some distance around this brawny area there is to be seen a very marked dimpling. This corrugation of the skin and the retrac- tion of the nipple which is present are due to the fact that the growth, by its inherent power of contraction, draws upon and shortens the galactiferous tubes and the vertical bands of fibrous tissue which connect the skin with the deeper tissues. The re- traction of the nipple is not so marked as in many of these cases, because the growth surrounds rather than implicates the lacteal tubes; but the tumor shows plainly its remarkable effect on the skin covering it. This contraction and its effect upon the nipple and skin should be remembered and appreciated when seen, as its presence is a sure indication of the malignant character of a tumor, no matter how slight its manifestation. This is a tumor of rather slow growth, but shows the disposi- tion to infiltrate and take into itself all the surrounding tissues. It is also likely to ulcerate, as indicated by this blueness of sur- face, marking the commencement of interference with the circu- lation of the skin which will finally lead to its degeneration and destruction. It is evidently a malignant tumor which requires removal, and we will proceed to excise the entire mamma, as it would be use- less to remove the tumor itself. 250 CARCINOMA OF BREAST The incisions made in performing the operation should divide tissues widely removed from tne gland itself or any local mani- festation of the disease in the shape of hardness in the surround- ing tissues. There should be no hesitation in sacrificing any amount of tissue when suspicious in character, if one expects by an operation to prevent return of the disease. No regular rules can be given or followed for the directions of the necessary in- cisions. They must be made so as to go wide of all manifesta- tions of infiltration or invasion into the surrounding tissues. Neither should the question of the time expended in the opera- tion be an item of consideration. Aim always to do the neces- sary work well and thoroughly. The lower incision is usually best made first. The knife is car- ried rapidly through everything down to the muscular investment of the chest wall. The lower border of the gland being uncov- ered, the entire mamma is dissected from the surface of the pec- toralis major muscle. My plan is to remove the fascia covering this muscle, freely exposing the muscle-fibre until the mass is held by the skin-covering at its upper border, which is finally divided. The procedures thus far illustrate this method per- fectly. The fascia of the muscle is removed with the tumor, be- cause experience has shown that a manifestation of the return of the growth is extremely apt to occur in this tissue if it is not removed. Bleeding vessels are caught by forceps as soon as divided, so that comparitively little blood is lost even after very extensive excisions. Now, 1 carefully examine every portion of the fresh surface to ascertain whether any hardened tissue has escaped removal; if any is found, it is unhesitatingly and widely removed, even if it becomes necessary to sacrifice the muscles of the chest. It is seldom that a malignant tumor of the breast is unaccom- panied by infiltration of the lymphatic glands of the axilla in some degree, perhaps unrecognizable from external examination, but still certainly present. Hence, it is necessary to open the axillary space by prolonging the incision across it just below its anterior border, divide carefully the superficial and deep fascia forming its floor, and uncover it at once. The axillary vein as a guide to the situation of the vessels and nerves on the outer wall of the axilla. Here, as elsewhere during any operation, first uncover the point from which most danger is anticipated. When the vein is uncovered and held out of the way, all other important structures go with it, and the axilla can then be easily cleared of CARCINOMA OF BREAST. 251 the enlarged glands embedded in loose fat. This should be done thoroughly in all directions, leaving nothing behind that shows any evidence of disease. You remember that in this case I could feel no enlarged glands before the space was opened, and now you see that I uncover several concealed by the pectoral muscle and beneath the clavicle. The space between the pectoralis major and minor muscles is es- pecially liable to contain infected lymph glands. In removing a malignant tumor always avoid cutting into the growth. Also avoid pressure upon it, for I am satisfied that harsh manipulation often leads to direct infection, followed by rapid return of the disease. By care all the loose tissue in the axilla is cleared out and with it such glands as may be contained in it. Here, you perceive the search has been rewarded by obtaining quite a number of all sizes, although none were found by careful external examination. It is needless to say that many glands, enlarged sufficiently to be an evidence of the extension of the malignant process, cannot be found without this exploration and the operation is not com- plete without the removal of all the fat contained in the axilla. This mass of dense fat in the region of the wound is a source of danger, and hence it is dissected out. The borders of the axillary space should be examined carefully, because enlarged glands are apt to be found in this region. In order to provide for drainage through this lower portion of the wound, I shall thrust a pair of scissors or a knife through the tissues at the most dependent part. This will be the direction in which the drain will naturally flow, as the patient will be on her back most of the time during the process of repair. Having removed all evidences of the disease, the wound is closed by approximating its edges with the continuous catgut suture applied in two rows. The first row of stitches is introduced some distance away from the edges of the wound and rather far apart, to act as stay sutures; and the second row, for close ap- proximation, is introduced in the intervals between the first. A large external dressing of iodoform-gauze and borated cot- ton is applied, and held in place by a body bandage. This dress ing is left in place for a week or ten days, unless the patient shows a rise of temperature. All going well, when the dressing is removed, the wound will be found entirely healed, as you have seen many times in cases shown you. In some cases we have a little flow of serum, but not so much 252 CARCINOMA OF BREAST. as we had a year ago when we used antiseptic solutions. You know that we now use no washes or solutions of any kind, hence we do not irritate the surface of the wound and consequently have less discharge. The vessels are all secured and there is no bleeding from the veins, and there is no reason why the dressing should be removed for a week or ten days. Changingthe dressings much less frequently than formerly, makes less work for the surgeon and is much better for the patient. If, after the first dressing is removed, the wound be not absolutely dry and perfectly healed, but shows signs of redness along its edges, we shall apply for a few days a wet antiseptic dressing made of a few folds of steri- lized gauze saturated with a three per cent, solution of carbolic acid and covered with some impervious substance, such as oiled silk or rubber tissue. This same cloth dressing is to be used for the relief of inflammation in the wound earlier in its course, provided infection has inflamed its edges and necessitated earlier disturbance of the dressings. It is well to prevent motion by bandaging the arm to the body, but let me impress upon your minds the uselessness and cruelty of insisting on your patients being absolutely still. They will obey your requests and will lie still for hours. Try lying in one position for an hour, and you will soon become impressed with the disagreeable feeling, no matter how comfortable was the posi- tion at the beginning it soon becomes an actual torture. A slight movement of half an inch will rest the patient materially. I have sometimes found that patients have kept still for 24 hours, and a slight movement relieved them of the consequent suffering al- most instantly. Now,let me examine the tumor itself. As you see, the discolora- tion is not entirely lost, even after the flow of blood has stopped. You must not notice the hardness, which is characteristic of this variety of malignant tumors, and from which the name of schirr- hus is obtained, stone-like. It constitutes a pathognomonic sign. You will notice the little depressions which show the fixation of the tumor in the investing skin, also the freedom of movement of the breast on the deep tissue and beneath the skin. The degree of mobility of the tumor on the chest walls is always a sign for which you look in case you advise an operation. If the mass is immovably fixed to the chest walls, an operation will do no good whatever and should be discouraged. In order that you may not be deprived of examining the char- acteristics to be noted in the tumor itself, I will open this speci- TUMORS OF BREAST. 253 men in such a way as not to destroy them before passing them up to you. You will notice the juice which flows out of the incision upon pressure; it is milky in color. Notice also that, instead of the cut surfaces bulging and being convex, they are concave. There is one point always to remember, the extreme hardness of the mass always present in this variety of malignant tumors of the breast. It is remarkably evident in this specimen. Fibro-Cvstic Tumor of Breast. Case II.—M. Mrs. Jas. S. Casapolis, Mich., Age 37, American, housewife. The patient before you is the one who was here a few days ago with the large tumor on the breast. It is the largest tumor that I have had the opportunity of seeing. It is an innocent tumor in every way, growing as a knot grows on a tree, between the trabecular of the gland. It is an illustration of a large cystic tumor of the gland. We know that it is not malignant from its history, it having been in progress of growth for ten or more years. There has been no increase in the size of the lymphatic glands. There has been no disposition toward the discoloration and infiltration ot the skin over the tumor. I have never seen but one other case like this and I think in that case the tumor was nearly as large as this. It came under my observation some two years ago. It was a wonder to me how this lady carried the tumor around and concealed it. While I was talking with her I was surprised that I could not see where it was. I finally dis- covered her plan of concealing its presence; it was by carrying it under her arm. This had stretched the skin, forming a pedicle, in this position and she was able to carry it and hide it from view. Of course, these veins are very large and having no valves they give rise to a good deal of bleeding and will give a spurt of blood as large as the radical or ulnara arteries. Not infrequently you will find that a growth like this which is an outgrowth from the gland, does not implicate the entire gland but is from some portion and spreads over the healthy part with- out implicating it. You can see the fluid running out of the tumor as I cut it, showing that it is composed of cysts closely applied, the same as multilocular cysts anywhere. You remember that I called your attention to the manner in which the skin was drawn by the tumor, and by its being carried under the arm. Now that the tumor is removed, you see the skin has drawn up on it so that I have left comparatively a small portion of the sk 254 TUMORS OF BREAST. compared with the size of the tumor. The edges of the skin fall apart and this illustrates its elasticity. This elasticity of the skin is a feature that must be remembered in the removal of tumors, especially in portions of the body in which the skin is loose; unless care is exercised you will remove more skin than you can cover. These vessels are tied with silk ligatures. We have found that silk is as harmless as catgut if the wound is not infected. The edges of the wound are approximated by means of the silk sutures. In sewing a superficial wound do not take a stitch too deep or the edges of the wound will turn inward and will not unite. The stitch should not be more than y inch in depth unless you have a deep wound in which you use deep ten- sion and superficial coaptation sutures. I see that my assistant is going to use the interrupted suture. You know that it has an advantage over the continued suture in that, if a suture breaks the other stitches will hold the wound, whereas, if the thread of the continuous suture breaks the entire suture is loosened. The continuous suture is the easiest applied and acts very well in many cases in which you do not expect to have much tension. Here, as well as in the interrupted suture, it is wise to put in deep stay stitches, and especially in wounds about the breast. This is a case in which you follow the rule of keeping near the tumor in its removal. In malignant tumors you keep away from the tumor cutting through the healthy tissue, removing every portion of the diseased tissue. With the wound in this position the skin can be drawn down from the shoulder or up from the abdomen and held in place by deep stay or quilled suture while the edges of the skin are approximated by the interrupted sutures. Then deep stitches will be left in for a week or ten days until the edges have adhered. There seems to be a little oozing, so we will introduce a small drainage tube. Fibro Adenoma of Breast. Case III. When speaking to you about tumors of the breast, I called your attention to fibromata and told you that they are apt to make their appearance in the mammae about the time of puberty. Their position is usually to one or the other side rather than in the center, as you see is the case here. This tumor is situated a little to the inner side of the middle line of the mamma, and TUMORS OF BREAST. 255 just below the left nipple. It is freely movable under the skin, and does not implicate the tissues of the gland sufficiently to necessitate the removal of the gland. The skin is freely mov- able over it and the growth has all of the characteristics of a fibroma or of a fibro-adenoma. You notice that the nipple is not implicated in the growth. It is not inverted or retracted as is so often the case in tumors of the mammae malignant in character. Palpation detects a peculiar firmness; not the so-called " stony hardness " of the schirrhus variety, but it is firmer than the nor- mal glandular tissue. Usually, you will have no difficulty in diagnosing these cases, and you will be able to remove them through an incision directly over their most prominent point without difficulty. Not infrequently they can be turned out of the incision without doing much damage to the glandular tissue; I think I will be able to do so here. This tumor, you see, had a capsule of its own composed of connective tissue, and I have succeeded in removing it without doing an)' injury to the gland- ular tissue. As it is passed about, you will see that it is princi- pally made up of glandular tissue, hence it is an adenoma. At its base you will see quite an amount of fibrous tissue, hence it is a fibro-adenoma. Of course, your patients with tumors of the breast will be very anxious about the character of the growth and the prognosis, because malignant tumors are so frequently found in this situ- ation. Families are very much concerned when the slightest tumor manifests itself, and you must be able to tell them that a tumor of this character, freely movable in all directions under the skin and on the deeper tissues, in a woman of this age is not a malignant growth. You can say positively that if it is removed, it will be followed by a prompt and permanent recovery. This is a patient from whose breast we removed the fibro-ade- noma ten days ago. The wound has healed perfectly, you see, and you would not know from the appearance of the patient and the breast that any operation had been done. This is the first time that the dressings have been disturbed since the operation The patient has shown us no constitutional disturbance whatever and she should not. If her condition had not been aseptic from the first, and throughout the course of healing, it would have been evident that some one had infected the wound, during the operation. 256 TUMORS OF STOMACH. Carcinoma of Stomach. This patient complains of some difficulty in the abdomen, the nature of which we are not at all positive about after examination. There is to be found over the abdominal surface, especially in the upper portion, a mass with a sort of irregular surface to the touch, nodulated, as we call it, in the course of the transverse colon. Also upon the left side in the neighborhood of the cardiac ex- tremity of the stomach an enlargement that can be followed across the abdomen in the epigastric region, so that we are enabled to determine his difficulty. The symptoms rather indicate it to be of a malignant nature. It concerns some portion of the aliment- ary track. There is interference with the patient's nutrition. We have concluded to make an exploratory laparotomy. Nothing can be promised the patient, except that the operation will de- termine whether relief can be given. No benefit has been ob- tained by the use of medicine, and so we will try this means to determine whether any surgical interference will bring relief. There is a condition here which is not present usually in the ab- domen the veins running from the lower portion upwards are in a varicose condition, calling attention to the probable presence of some obstructive disease in the abdominal cavity. We have a superabundance of peritoneal fluid, which of course flows out as soon as the abdomen is opened. I find we have a malignant growth in the stomach extending over its left side. By turning the stomach up and pulling it a little towards the right side I un- cover the infected portions of the stomach walls, the infiltration extending across the anterior surface. Here we have the edge of the omentum containing quite a number of nodules, turning up the stomach I immediately bring into view a portion of the in- testine which I know to be the transverse colon, on account of its lobular shape in that it has a distinct wide band of fibres running longitudinally. As I turn the stomach upwards and tear through this omentum I can get into perfectly healthy stomach, soft and uninfiltrated, whereas the upper surface is hard and dense from infiltration. There is no well marked evidence of obstruction of the pylorus. The passage of food from the stomach into the small intestines is not interrupted, hence I question whether very much would be gained by doing in this case agastro-enterostomy. This man has an absolutely incurable disease and so extensive that I TUMORS OF STOMACH. 257 cannot remove it, without removing two thirds of the wall of the stomach. But it is rather surprising that in many of these cases the patient is relieved by the operation notwithstanding the fact that nothing is done beyond an exploratory incision. The testi- mony is so clear and positive upon this point, from so many sources, that we must believe whatever unexpected relief follows the attempt has been due to nothing more than opening the abdominal walls and manipulating the contents of the abdomen. We do not known whether any such effect will be produced in this case. He will certainly be relieved by the loss of the peritoneal fluid and the distention caused by its presence, and for the time being he will be benefitted. These beneficial results do not follow simple tapping. This is particularly true in the cases of tubercular peritonitis. You can tap those cases as often as you desire with only temporary relief, but when a lapar- otomy is done many of these cases pass on, to permanent re- covery. There is no reformation of the accumulated fluid and the evidence of disease in the shape of nodules disappears. We cannot expect any such effect from this operation. In this loca- tion carcinoma is an incurable disease. It is always, as in the days of Velpeau a disease that never surrenders, that never gives sympathy at all to its victim, but always kills. Hence, this opera- tion will possibly give this patient the relief mentioned, but it will not cure the disease. If I had found the disease moderate in extent and confined to the stomach even had there been no complete obstruction to the passage from the stomach to the bowels, I should have made the operation of gastro-enterestomy the junction of the small intestines and the stomach. It is com- paratively a simple operation and one which can be done quite rapidly. It is not necessary to have any special material or ap- paratus to perform it. It is practically nothing but a vestibule formed between these two portions of the alimentary canal. Of course you are well aware of the great advance that has been made in all operations for the relief of disease in the abdominal cavity, and the surgeon is tempted to do many operations that in fact confer no benefit upon the patient; they merely prove the fact that when you unite portions of the intestinal tube and make an opening between them the course of the contents will follow the opening. That was proved many years ago, and if we resect large portions of the tube the ends may be brought together and a continuity restablished. But that does not remove the disease. In hundreds of cases that have been done there are few indeed 258 TUMOR OF TONGUE. in which the recovery has extended over a period of three years. We will close the abdominal cavity in the usual manner, it will heal in as short a time as in cases not complicated with malignant growths. Carcinoma of the Tongue and Mouth. John W., Scandia, Wis., Age 40; U. S., Farmer. This case is a very unfortunate one and I do not expect that its treatment will be followed by a great amount of satisfaction, However the patient is in such a sad condition that he is not able to eat and is in constant misery, so that I shall do what I can to relieve him by removing the entire chin, the floor of the mouth, a portion of the superior maxillary bone and a portion of the tongue. We shall leave a portion of the tongue, for the laity believe that if a portion of the tongue is left the patient can talk better than if the entire organ is removed. We have seen cases which disprove this, however, in persons who have had the tongue removed at the base. Such persons talk with a remark- able degree of clearness after a sufficient time has elapsed in which to train the organs of speech. In order to control the hemorrhage from the tongue we will transfix it near its base with a needle armed with heavy double silk ligature and tie in halves. The diseased portion is now removed freely and the margin of the tongue is closed by means of interrupted sutures this will con- trol the hemorrhage permanently so that the temporary ligature can be removed. Remember, when doing an operation about the tongue which severs the anterior attachments of the genio-hyo- glossus and the genio-hyoid muscles, that you have also destroyed the anterior attachment of the tongue. There is, therefore) nothing to prevent the tongue from falling back into the pharynx, closing the glottis and choking the patient. It is very necessary then for you to secure the tongue by passing a ligature through it so that you are thus enabled to hold it forward. The mylo- hyoid artery is enlarged and bleeds very freely. We will now re- move the side of the face, including the upper and lower jaws, as rapidly as possible, following the methods we employed in the cases operated upon a few weeks ago. Very frequently you can stop hemorrhage from an artery which runs through the bone by seizing the bone in this manner with the lion jaw forceps and compressing the bony canal. There has been so much tissue re- TUMOR OF TONGUE. 259 moved that it is very difficult to say how much of a mouth we shall be able to get. The tissue which remains will be utilized to the best advantage remembering that the tissues of the face unite very kindly on account of their great vascularity. We have succeeded in getting very good proportions now, as you can see. The anterior jugular vein bleeds every time the patient breathes, so we will ligate it. Now, until he gets control of his tongue, we shall have to fasten it outside. This is, I think, all that I shall close the mouth to-day, leaving him a good sized mouth. We should have been able to make a much more cos- metic appearance of the mouth had we been able to leave a por- tion of the chin. You can see that the patient has a very fair color now, and is in a very fair condition. Having operated rapidly the patient will not suffer from shock. Carcinoma of Tongue. Case I.—Thomas D. We nearly had a death from the anaesthetic in this patient be- fore bringing him before you. The air passages are very much obstructed by the disease in his mouth. The man has been here before, and we then delayed operating to determine, if possible, whether his trouble is specific or a malignant disease. We have examined it under the microscope and there is no doubt of its being of a malignant nature. The growth is under the tongue, filling the entire floor of the mouth and gums and affecting the bones of the lower jaw; it has destroyed a part of the tongue's attachment. Consequently the tongue dropped back into the pharynx as soon as he became partially anaesthetized. The man's face was cyanosed and he had stopped breathing. We opened the mouth and removed the mucus and finally grasped the tongue with a pair of vulsellum forceps and pulled it forcibly forward The head was also placed low and then by resorting to artifi- cial respiration, we revived the patient. This is a very bad case and will take a good deal of time. I am encouraged in this case, notwithstanding its unfavorable nature because to-day I have received word that a patient on whom we operated ten mouths ago for cancer of the face and from whom we removed a large portion of the face, replacing the removed portion by a flap from the neck, has entirely recovered from the operation 260 TUMOR OF TONGUE. and there is as yet no evidence of return. Now this man will die very soon if something is not done for him. The lymphatic glands are much enlarged. We shall tie the lingual arteries be- fore attacking the disease in the mouth and in that way stop the bleeding from the tongue, although it will not have much effect on that coming from the floor of the mouth. Even here in the line of incision there is considerable hemorrhage for the lingual artery supplies only a portion of the blood which the tongue receives. It is my aim to find the upper extremity of the hyoid bone, and finding that, I shall have the guide for the hyo-glossus muscle. The artery will be in all probability just behind it on the upper border of the bone. Of course, this is all obscured by the infiltration and increases the difficulty of the operation in every way. Here I pick out one of the little lymphatic glands which obscures every thing. It is not the simplest thing to do an operation of this kind with everything clear, but when you have the entire field obscured the difficulty is greatly increased Both lingual arteries are tied in the usual way, close to the pos- terior border of the hyo-glossus muscle and the wounds tempor- arily packed with gauze. Now in order to get to the diseased tissues in all parts I will divide the lower jaw through the sym- physis mentis with the metacarpal saw, completing the operation with the bone cutting forceps. Now that it is divided and some fibres of the mylo-hyoid muscle severed, you see the two halves fall widely apart giving a good view and way of reaching all dis- ease. First I will fix the tongue close to the hyoid bone with a strong silk ligature passed entirely through its substance. This enables me to control the stump entirely after the tongue is re- moved so that 1 can catch easily any bleeding vessels, provided they have not been secured by the ligatures already placed, and serves a useful purpose in enabling us to prevent suffocation after the operation. This stay ligature in the tongue should always be used after division of the anterior attachments of the tongue in operations. The tongue is now cut away and also all loose and diseased tissues in the mouth. All that I cannot reach with the scissors I will now destroy with the actual cautery. Hav- ing finished all this, the ends of the separated bone are perforated with the drill, and a silver wire drawn through the openings thus made. This enables us to bring the separated jaw fairly and closely together again. The external incisions are now properly closed with interrupted sutures and dry antiseptic dressings ap- plied. The stay suture through the remnant of the tongue is TUMOR OF FACE. 261 brought out of the mouth and fastened to the outside of the dressing. The chief danger to the patient after this operation comes from shock and from the tendency to acquire a pneumonia form in- spiring the discharges from the wound in the mouth. The shock is limited greatly by a rapid operation and by placing the patient in a thoroughly warmed bed after the operation. The latter danger is disposed of by elevating the foot of the bed 12 to 18 inches and making a depression in the mattress for the head so that the larynx will be higher than the mouth. Packing the wound in the mouth thoroughly with iodoform gauze also aids very materially in decreasing the likelihood of the occurrence of an inspiration pneumonia. Carcinoma of Lower Jaw. J. W. M., Canton, 111., Age 49, American, Cigar-maker. This man has a tumor of the lower jaw, a malignant growth extending down upon the neck. We will be compelled to remove half of the lower jaw, together with the submixillary and sub- lingual glands and all infiltrated tissue. The jaw is partially ex- posed by the incision along the lower border of its body. A tooth is extracted and the jaw is divided with the chain-saw close to the symphysis and just in front of the angle. In this way the main mass is removed. A straight incision down the neck allows us safely to remove the neck infected glands. The incision closed with interrupted sutures. You see there is a small opening here which has been cauter- ized and will soon be healed. Exposed in the wound is the hyoid bone, the hypoglossal nerve and the side of the tongue with its attachment to the lower jaw. When you have to do an operation involving the muscles of the tongue you must fix the tongue by running a thread through it to retain it, for sometimes it falls back into the mouth and chokes the patient. We made a curved incision beneath the body of the jaw, that, when it heals the scar will be on the under side of the jaw. The man has a luxuriant growth of beard and will cover it. The prognosis in this case is unfavorable on account of the extension of the disease into the lymphatic glands. The wounds which we have made will heal by first intention but we can be 262 TUMOR OF FACE. quite positive of a recurrence, consequently our efforts will result only in temporary relief. Epithelioma of the Eye-lid. E. D., Hillsborough, Wis., age 55, American, farmer. Here is a case of epithelioma of the upper eye-lid and eye- brow. The disease first made its appearance about 16 years ago. The progress has been delayed by the application of escharotics. He says that he would be inclined to have nothing done for it if it were not for the fact that it troubles his eye. There is but one thing to do for it, and that is to remove it widely with the knife, going into healthy tissues in all directions, and perhaps taking off a scale of bone covering the frontal simus. That would be quite an extensive operation, but not a formidable one. I should make no attempt at closing the wound with stitches, but would either transplant at once by Thiersch's method, or, what I think better, after removing the disease deeply, to touch it at all points with the actual cautery and trans- plant later on. It is a popular idea that escharotics are always more beneficial than the knife. If a wound, as large as the one we are compelled to make in this case, were left to heal by granulation, a marked and very troublesome extropion of the Upper eyelid would be sure to follow as a result of cicatricial contraction, but this is avoided by the use of Thiersch's skin transplantation. Epithelioma of Lower Lip. W. B., Dayton, O., aged 66, American, nurseryman, family his- tory good. Thirteen years ago this patient had a growth in connection with the lower lip. A year ago it was removed, as he thought, by the application of an escharotic plaster or salve. Three or four months after this application the tumor began to grow, and has continued in its development until it has reached the size which you now see. I think we could not have a better illustra- tion than this of the harmful effects of escharotics in such cases. There is no doubt that you can remove superficial malignant growths by such escharotics as the Vienna Paste. But in order CARCINOMA. 263 to do this it must be used very freely. If only the superficial portion is removed, the tumor is stimulated into more active growth, as it has been in this case, leaving the patient greatly deformed. The lower lip has been entirely destroyed, and a large portion of the cheek and the tissues of the lower jaw are infiltrated. A large tumor has also formed inside the mouth. We shall there- fore be obliged to remove a large portion of the face, and then the likelihood of a cure will not be nearly so great as it would have been had we removed the growth at first with the knife. I am satisfied that the best treatment for these malignant growths is the early use of the knife, going wide of the disease. Usually the lip and cheek are so movable that you can remove large portions of them and then be able to unite the parts. Be- ing so vascular the union takes place without any difficulty. All ulcers about the mouth are very apt to be foul, especially those which are malignant; and this case is not an exception. I will now tie these vessels before making further incisions, in order to get the forceps out of the way. You can not help being a little cruel in these cases, as it is impossible to keep the patient per- fectly asleep during all stages of the operation. The mouth is a little one-sided, but the important part of it is that it is large enough. I have no doubt that it will pull around in a few weeks without any difficulty, for we have a sufficient amount of tissue. If you were close enough you would see that I stopped the incision just short of the jugular vein. Had the diseased tissues made it necessary, I should have divided the vein. Carcinoma of the Uterus. This woman complains of pain in the inguinal region and of leucorrhcea. This is all that we get from her, and it is as much of a history as you will often get from your patients. Making a digital examination I find the cervix wide open, its edges forming a rough surface, with lacerations extending back on its sides. It is friable and is nothing but a broken down mass. A bad odor comes from it. It is an epithelioma of the cervix. There is too much infiltration of the surrounding structures to justify the radical operation consisting in the removal of the entire organ. We will advise the patient to come back and we will remove the trouble as completely as possible with the cautery. It will check 264 EPITHELIOMA. the disease, give her comfort, and will not put her life in danger. In performing this operation we will be careful to destroy the tissues for a distance of half an inch beyond the visible margin of the disease in every direction in which the anatomical structures will permit this. We will destroy the entire lining of the uterus, leaving this organ in the form of a thin shell. The cavity will be packed with iodoform gauze, which will be left in place for two weeks; after its removal the patient will receive two or three warm douches daily until the wound is en- tirely healed. Epithelioma. Here we have a very good example of epithelioma of the clitoris and principal part of the labia minora, not implicating the urethra, I think, as yet. The patient tells me that there is some involvment of the cervix, which I doubt very much. At least there is no manifestation of it, except the little discharge that comes from the parts. She is in that condition now in which she has very irregular menstruation, and is about the time of life when it ceases, so that she does not know when it will manifest itself. 1 find the cervix perfectly smooth. Epithelioma in this situation, in my experience, does better than in any other portion of the body, except the lower lip. I have had some cases in which I have been compelled to remove the entire vulva some of the clitoris and part of the vestibule. In all these cases radical removals were performed, and the earliest manifesta- tion of the return in any case was after three years; and some of them have had no return in an interval of seven years. That is very good history and we feel justified in advising radical removal in this case. P. H., Plainville, Wis., Age 33, American, farmer, previous family history good. This patient has some trouble on the left side of the penis. On examination I find a hard body about the size of an old-fashioned three-cent piece, situated under the skin and connected with the corpus cavernosum. It feels exactly like cartilage. I have met another case similar to this. The other one I saw two years ago on a patient having fully an inch of the organ affected; the mass extending beyond the midline. I removed the growth and the EPITHELIOMA. 265 parts repaired without any difficulty. It would be very interest- ing if this hard body should prove to be cartilage, because the organ in some of the lower animals is supported by cartilage. I think that I shall be able to make the incision in such a way as to avoid the large vessels of the organ. Of course this hardening of the tissues of one side of the organ will have the effect of changing its position under certain circumstances. I think the removal of the growth will largely obviate that trouble. Some portions of this mass are almost as hard as bone. It has developed in the connective tissue of the corpus cavernosum, but the erectile tissue is not disturbed. Not infrequently surgeons in operating on the penis are obliged to open into the erectile tissue, and when this is the case, it is very difficult to control the hemorrhage. This is especially true in such operations as the amputation of the organ in some malignant troubles. The hemorrhage in such cases may be stopped by applying the actual cautery to the stump. The heat should only be that of a " cherry red." If you do not succeed in stopping the hemorrhage in this way, then introduce a needle armed with a ligature just above the urethra at the root of the organ and tie a figure-of-8 with the ligature over the ends of the needle. You will succeed in this way in compressing the vessels and in stopping the hemorrhage. Epithelioma. You recognize this patient as being the one from whom we re- moved the epithelioma from the penis by the removal of a por- tion of that organ. He has had no difficulty in urinating; the skin is pulling very nicely over the corpora cavernosa; there has been no constriction of the urethra and the wound has healed perfectly from the first. I think the operation which you saw me do is the best one for amputating the organ. Instead of dividing it straight across and allowing the urethra to retract so that the cicatricial tissue would form over it and cause a stricture as it naturally would do, I divided the corpora cavernosa a half-inch behind the point of division of the corpus spongiosum and the urethra, then split the two latter, antero-posteriorly, I stitched them to the integument with a stitch or two. In this manner you are able to get a much better result than is possible from the other method. 266 EPITHELIOMA. Epithelioma Developed in a Scar. John M., Victor, Montana, Age 36, American, prospector. This patient is a very interesting case; came a longdistance, nearly a thousand miles, to have us treat a bad limb that has been troubling him for three years. The limb was injured eight or ten years ago, and has been a source of much annoyance since that time. Two or three years ago it took upon itself this peculiar horny growth, which you see. The disposition for the growth to develop deeper and deeper, as well as to increase in circum- ference. It is of the same character as the trouble on the old lady's arm and that of the man's knee, both of whom were before you a short time ago. It is an abnormal growth due to the long continued irritation of scar tissue. It is apt to take upon itself the character of epitheliomatous tissue. In the case of the man's knee mentioned the growth was papillomatous. This may prove to be of the same nature. I am confident that an amputation would lead to a rapid re- covery, and that it would be the best treatment in this case. First, however, I shall try if possible to remove the growth super- ficially. If we can remove it without going too deep into the tis- sues, we shall do so and then cover the raw surface by Thiersch's method of skin transplantation. Of course it is well to save the limb if possible, for it will carry him about, if it can be saved, much better than any artificial limb that he could get; hence we will expose and see what we can do for it. It is very foul and of- fensive, as most of these conditions are. We will apply the Es- march constrictor for the purpose of controlling the hemorrhage. I am told that the patient prefers having an amputation at the thigh to having an operation which will be likely to confine him a long time; and I think he is right. I find the bone destroyed and an amputation is the best thing to be done for him, so we will accommodate him by amputating the limb at the thigh. It is always well, however, to make such an examination as I have made first, so that you will not be disappointed in showing the limb after its removal. Many times, good and famous surgeons make mistakes by failing to do this. To illus- trate, a noted surgeon was called on to remove an angioma, which he thought to be too deeply seated to be removed, except by am- putating the thigh. A surgeon friend happened to be present, EPITHELIOMA. 267 and would not consent to the amputation until the tumor was opened. This was done, and the angioma peeled out of its cap- sule without any difficulty. But in this case we have satisfied ourselves that there is no local operation that will remove the disease, because it has extended to the bone and a recurrence is certain to occur in the near future. There is not enough healthy tissue below the knee to make the flaps, so I shall have to go above the knee, keeping as near the joint as possible. It is al- ways well to have the limb extend over the end of the table, and if you are right-handed, always stand on the right side. We shall make the partial skin and partial muscular flap which we have illustrated to you so often. Operators not infrequently make the posterior flap too short. You will remember that when you make the posterior flap you begin a little in front of the angles of the anterior flap, and make it in the same way that you make the an- terior flap. Give the knife a little sawing motion and it will cut bet- ter than it will if you give it a straight pull. These flaps should be reflected back to the point at which you expect to divide the muscles, and a little farther, including the superficial and deep fascia. You seize the limb just above the point at which you desire to make the flap, make the tissues tense, introduce the knife, make a few sawing motions in this manner and bring the knife out in this way. Introduce the knife in the same manner on the pos- terior surface and make the posterior flap. Now, reflect the tissues back far enough so that the flaps will cover the stump freely, make a circular incision through the periosteum an inch below the point at which you intend to divide the bone and shove the periosteum upward beyond this point. The periosteum and the flaps should be protected by means of retractors made of aseptic muslin while the bone is being sawed off. Then, having sawed off the bone, you search for the blood vessels. I think it is al- ways well to separate the artery from the vein, although it has been shown that they do very well when both are included in the same ligature. Remember that the nerve should always be sought for, separated back into the tissues and cut off; you will then k now that there is no likelihood of the occurrence of an amputation neuroma or pain from a compression of the nerve trunk in the cicatrices of the stump. The assistant, you see, is doing good in holding the soft parts well in place and not allow- ng them to retract from the stump. There is one objection to this kind of a flap, and that is that it does not allow the artery to be cut squarely off. The vessels are all ligated and the wound 268 EPITHELIOMA. will be closed in the manner you have seen so many times. There is a considerable amount of hemorrhage from the bone. This can usually be controlled by pressure with a sponge. You see that these flaps come together very nicely, without any trouble whatever. In a wound of this size in the thigh there will be a considerable amount of serous exudation, hence we will in- troduce a rubber drainage tube. Epithelioma of Face. J. W. V., Plymouth, Ind., American, carpenter, age 75, has epitheliomatous ulcers on the face. How long have you had these? About twenty years. How old are you? 75 years. Well, gentleman, you see the roughened character of this man's face and the disposition it has toward ulcerating and breaking down, especially in these three places. He has exhausted all of the remedies that he could hear of and that had been given him, and he had been far and near all over the country to see different physicians in vain for a cure. Lately these spots have taken upon themselves the disposition to destroy the skin, and show a well marked infiltration around the edges. They do not heal, and I am inclined to believe that as far as internal or external use of medicine is concerned he will not be cured. Next comes the surgical treatment. His age militates against the operation which would require extensive incisions, and he refuses surgical interference. I have no doubt but that he would recover from the operation, but he does not wish to be operated upon. Then we must do something for his comfort. There are various things that we may do, and many things have been recommended. Salicilate of sodium applied externally in the form of a salve, always keeping the face per- fectly clean, is one of the best applications he can make. Then I must not fail to call your attention to another remedy which may be beneficial to this man, and that is some preparation of arsenic. He can take it without impairing his digestion, and it will have some beneficial effects if any medicine will. EPITHELIOMA. 269 Epithelioma of Lip. W. S. S., Hoopston, 111., age 44, American, shoemaker. This patient has an ulcer of the mucous membrane of the lip on the outer side of the mouth which shows no disposition to heal. There is not the disposition to crust over in this case, as there frequently is. These ulcers gradually increase in size not rapidly in depth, but in area. If an ulcer of this kind has existed only a month or two you will not be able to feel the hard- ened infiltrated edges, but if it has existed for three or four months you will be able to feel them in all parts around the ulcer. These conditions and the disposition to infiltrate the tissues in all directions are present here, so that the patient has an epitheliomatous infiltration of the lip. He has tried the usual remedies which are supposed to be of service, but they have failed. He has also applied two plasters which caused a slough. The glands of the neck became swollen from the irritation of the plaster. From the disease and from the plasters together the man has lost a large portion of the lip. The scar made by the plaster limited the growth of the ulcer for the time, but finally went on in its development, and broke down and has reached the condition which you see. Of course, he comes at rather a bad stage for the operation, much worst than if he had come before anything had been done for him. So much of the lip has been destroyed that it will necessitate some special operation for its relief and at the same time to provide for a lower lip. It is not necessary for me to say that this is a variety of carcinoma which it is possible to relieve. In operating you will go wide of the disease, not only of the ulceration, but of the infiltration as well, going into healthy tissue in all directions. This is absolutely necessary if you do not wish a return of the disease. I shall make a curved incision from the margin of the lip down over the chin and around on the cheek to a level with the angle of the mouth, going wide of the disease. All of the tissues are now removed down to the jaw. Then I shall make a second incision below the chin and parallel with the first incision and an inch and a half lower and slide the skin up after dissecting it away from the deep tissues, forming a lower lip and leaving the open space below the chin. This flap is held in its new position by catgut sutures extending through the subcutaneous connective tissue of 270 EPITHELIOMA. the flap and the periosteum of the lower jaw. The flap is very vascular and the size of the vessels is increased by the disease. You can see that these parts are coming together and will make him a very good lip. The parts are very loose and that is a good feature of the operation. The raw surface below the chin will heal very well by granulation, or if it is large it can be covered at once with Thierchs' skin flaps. In doing any operation about the mouth like this put your patient in a position so that you are able to control him. The best plan is to anaesthetize him on a table. You are then able to manage him. In order to prevent all trouble do not undertake an operation of this nature without a sufficient number of assistants, and do not begin the operation until everything is favorably prepared. This makes a very good looking lip. It will be dressed with iodoform gauze and sterilized cotton. A pad of gauze will be placed over the newly made lip and held in position by means of bandages in order to prevent it from sliding down. Epithelioma of Lip. Peter R., Rochville, 111., age 70, American, farmer. This old gentleman was before us last clinic for advice. He has a secondary manifestation of an epithelioma originating in the lip. We will remove the diseased tissue. I am making this incision into healthy tissue; so far, I have not opened into the diseased mass. I have now uncovered the entire submaxillary space. You can plainly see both bellies of the digastric muscle, the facial artery and the mylo-hyoid muscle. I have removed the submaxillary gland entirely. It is a comparatively easy matter to remove all the diseased tissue after exposing the muscular tissue in this manner. By examining the mass, now that it is removed, you will see portions of the healthy fibres connected with it, showing you that all of the diseased tissue has been removed. The prob- ability is that in removing the submaxillary gland you will divide the facial artery. You will notice again, when examining the mass, that there is a smooth, grooved surface on its posterior part, which rested against the lower jaw. I am satisfied that it is infiltrated. There is, therefore, a very great probability that the disease will return in connection with the lower jaw. There is so much tissue to be supplied here that I scarcely EPITHELIOMA. 271 know where it will all come from. I desire to save as much of the mucous membrane as possible. The most of the hemorrhage comes from the opposite side of the face; some of it is from the internal maxillary and some from the transverse facial, but I do not think that it is important. You see the auricularis magnus nerve showing very plainly as it passes over the sterno-mastoid muscle. The result of these extensive secondary operations is some- times very surprising. I remember a case upon which I operated some three years ago, removing the entire cheek for carcinoma as I have done here. I transplanted skin over it. A few days ago the patient sent me his picture, and in the photograph you can scarcely notice any deformity whatever. Of course, hair will grow on this face and it will largely hide any deformity that may be produced. I shall now unite this portion of the flaps by applying the sutures transversely across the neck, preventing too much ten- sion on the flaps by so doing. This surface will be thoroughly washed and dressed with iodo- form gauze and sterilized cotton and the head will be bent over toward the side from which the tumor was removed, so as to prevent too much tension on the flaps. You can see that the parts look a little white. But these parts are so vascular, that after dressing the wound in the manner I have described, it will heal without difficulty. Notwithstanding that we sacrificed so much tissue, we have, as you see, succeeded in covering the wound completely. We also have a half inch or more of redundant tissue at this point which will draw down into the flaps and relieve the tension which exists. You would not be able to cover this large area with the same amount of integument if it were on a patient less than 30 or 35 years of age, as the skin would not be so pliable as it is in this old gentleman. Sarcoma of Thigh. S. J. Elliot, Iowa, Age 26, American, druggist. This man has a tumor on the thigh which grew rapidly, reach- ing the size of a hen's egg, and was removed. That operation was performed about a year ago, and now the patient comes with 272 EPITHELIOMA. another tumor about the size of a hen's egg in the cicatricial tissue. He has another complaint now; another tumor in the groin just above the femoral vessels. lean lift it up, yet it is rather firmly adherent to the deeper tissues. It is not separated into nodules, as it would be if it were made up of enlarged lymphatic glands. There is another evidence showing that it is not composed of en- larged lymphatic glands. There are enlarged superficial veins which you can see from quite a distance running over the surface of the tumor. Thus far it has the appearance of a malignant growth. When it was removed before it showed no evidences of infiltrating the skin, and was supposed to be a fibroma. The patient had all of the appearances of being entirely relieved of the disease. The stimulation of the operation evidently caused a re- turn of the disease, making it malignant or semi-malignant in character. Its return has been rather too rapid to be what is termed a "recurrent fibroma." This form of tumor has the property of a malignant growth in that it has a tendency to re- turn locally and in the skin. It has no tendency to infiltrate the lymphatic glands. I am inclined to believe that it is a sarcoma. The proper thing to do is to remove it. You will find that it requires very careful dissection to remove a tumor of this size lying in this anatomical location, and en- dangers the large vessels of the part. I have now exposed the course of the femoral artery. At this point the sheath has been taken away. The same rule is observed here as is always ob- served where large vessels are endangered by the incision in the removal of a tumor. The structures,which are in danger of being injured, are first exposed and then the dissection is made away from these structures. In this case, I determined that the femoral vessels lay to the inner side of the tumor, and consequently I ex- posed the inner side of the tumor first. Had I removed the outer side first, the probability is that I should have wounded the vessels. It is impossible to prevent the division of these small arteries, given off from the main artery near the saphenous open- ing. Being divided so near the artery the hemorrhage is profuse, even from the small arteries, and requires a ligature. The mass has a very different character internally from what it did ex- ternally. You see that it extends very deeply into the substance of the muscular tissue, and I must follow it to the bottom. Its external appearance was that it was confined to the scar tissue and deep fascia, but the incision showed that it extended deeply into the muscular septa. Of course the patient would not have SARCOMA. 273 been benefited by the removal of the superficial portion of the mass. The only thing to do was to follow it. as we did, to the bottom and remove it completely. If any projections from the growth are left, there will in all probability be a return of the tumor. Sarcoma Pressing upon Brachial Plexus. F. S. S., David City, Nebraska, Age 40, American, carpenter. This patient was before you last clinic suffering from a loss of function of some of the nerves of the brachial plexus from press- ure produced by a small tumor located beneath the plexus. The nature of the trouble we do not fully understand yet. WTiat we purpose doing today is to uncover the tumor, ascertain its character and remove it if possible. It is a peculiar case in that it has been aspirated and a whitish fluid withdrawn from it. We have the shoulder depressed as much as possible and the head turned to the opposite side, so as to give us as much room in the triangle as possible. I now have the tumor pretty well uncovered. Those near by can see its conical appearance very plainly, the base extending downward and the apex upward. Here we have issuing from it one of the large trunks of the brachial plexus, and you can readily see how the tumor is causing pressure on this plexus. Whenever I touch the substance of the tumor, you notice that the nerve is stimulated, causing a con- traction in the muscles which it supplies. This is evidence of the intimate connection between the nerves and the tumor. I am obliged to go well down into the axillary space to get to the bottom of the tumor. Now that we have the mass exposed, what shall we do with it? I have succeeded in removing the nerves uninjured from the surface of the tumor and find that the tumor has caused a separation of the nerve fibres. I am satisfied that this is malignant in character from the manner in which the tissues are infiltrated and from the character of the fluid which came from it. I find that it projects down into the axillary space some distance, and I shall have to follow it. The tumor is developed from the anterior sur- face of the transverse processes of the cervical vertebrae. Growing outward from this situation it presses against the under surface of the brachial plexus, separating the fibres and interfering with the function of the nerves, giving rise to the 274 SARCOMA. patient's symptoms. The deep seated character of the mass has made it necessary to go down through all of the tissues to the cervical vertebrae at the base of the neck. I got behind the sub- clavian artery and vein so that I could press them out of the way; lying as close as these vessels did to the mass, it would have been a serious operation if this could not have been done. Fibro-sarcoma of the arm. This lady has a tumor on the anterior surface of the arm, ex- tending from the axillary fold to the bend of the elbow. I have made no previous examination. It has been four or five years in reaching this degree of growth. It is regular, smooth, and even and painless, and is one of those growths which resemble the tissues in which they are formed. It is perhaps a deep connective tissue growth, on the anterior surface of the arm proper, lying directly in the course of the biceps muscle. The skin and super- ficial fascia are not implicated, and it is exceedingly movable on its deeper surface. It is probably a fibroma, and is so large that it interferes with the motion of the arm. So we will make an in- cision and remove it. It does not implicate the skin, which is perfectly movable over it. It is not connected with the super- ficial fascia. We have now gotten down upon the biceps. I am rather inclined to believe that it grows from a deeper muscular tissue. I work slowly here as I wish you all to see. It would be interesting if it should prove to be a fatty tumor, as it would prove to you what I have often said, that lipomata will grow any- where there is fat. I saw one once, as large as a potato on the end of a man's tongue; he was in the habit of carrying the tumor in his mouth. It was interesting to see him put it out, and to hear the peculiar sound he made in talking. One of the most noted surgeons, Prof. Von Bergmann, of Ber- lin, examined this patient, and was unable to make a positive diagnosis until he cut into it and the fatty tumor rolled out. While talking we have exposed the tumor, and it is one with peculiar characteristics. It grows in the biceps muscle. It is not fat, and I shall let you see microscopic sections of it next week. It looks like fibro-sarcoma. Here we have a deep wound in which the different layers of tissue will be united separately by three continuous cat-gut sutures. The wound ought to heal with- out any pus, unless some accident occurs. SARCOMA. 275 Lympho-sarcoma of Neck. Frank, 5138 Wentworth Ave., age 7, American. You have heard the story of this case. The boy, seven months ago, first noticed a small tumor on the neck below the angle of the jaw. You notice how rapidly it has increased in size. It now lifts the lobe of the ear and extends downward as far as the clavicle. A close examination discloses the fact that the mass is made up of a number of lobes. The largest mass is immedi- ately below the ear. It is a case of acute lympho-sarcoma with an enlargement of the lymphatic glands of the neck. It is unusual to have such a mass form in two months. As a rule the disease which leads to this is chronic and slow in its manifestation. A very rapid course has been pursued in this case. There is a question here as to whether this may not be a common difficulty. We are apt to say that such troubles are due to the same pathogenic organisms which cause tuberculosis anywhere in the body, but a growth so rapid is much more like a lympho-sarcoma. The fact that the glands are so movable under the skin and that there are so many of them would rather point toward tuberculosis of the glands. Of course, there is but one thing to do surgically, and that is to remove as many of the glands as the eye can see and the finger detect. Yet it is an operation which is not likely to prove success- ful. In many cases, I have removed all of the glands that could be detected, and still there was a recurrence. This is due to the fact that the disease has already attacked some of the glands which can not be detected either by sight or touch and can con- sequently not be removed. It is absolutely necessary to make a very extensive incision in these cases, in order to make the glands freely accessible, lest some of the smaller ones might escape detection. It will be necessary to lay bare all of the important arteries and veins from the angle of the jaw to the clavicle. Sarcoma of Leg. W. F., 635 W. Van Buren St., Age 37, U. S., bookkeeper. This patient was before you a few weeks ago with a tumor on the right leg the size of two fists. It has been growing for a year 276 SARCOMA. and a half, slowly at first and more rapidly later on. You remem- ber that we explored the tumor and got nothing but a bloody fluid from it, and we pronounced it malignant. The situation of the tumor is on the fibula just below the knee, and the clinical symp- toms are very plain as to the nature of the trouble. First, we have the rapidity of the growth; we note next that it grows deeply into the soft tissues and has no connection with the epi- thelial cells. The man has no other disease, so that it can be a secondary infection, it is therefore a primary trouble. The sur- face shows elasticity of the mass, not fluctuation, but a softness which makes it elastic. The surface, you notice, is covered by arborescent appearance of the veins showing that the deep veins are interfered with by the pressure of the tumor, and that their function is carried on by superficial veins, causing their much increased size which you see. Hence, the tumor presents all of the characteristics of a sarcoma, growing from the embryonal connective tissue cells of the periosteum. Originating in the peri- osteum, it is called a periosteal sarcoma. If its origin is in the bone it is termed an osteo-sarcoma. Situated as this tumor is, its pres- sure upon the veins of the leg interferes materially with the re- turn circulation from the lower part of the leg and the foot which accounts for an oedematous condition of those parts. Palpa- tion shows that the tumor is somewhat nodular, it is softer about its center and perhaps has broken down or undergone colloid degeneration. Believing that it is a sarcoma, there is no treat- ment permissible but to amputate the limb above the segment in which the tumor is found. The tumor being in the leg, the am- putation should be through the thigh. Were it in the thigh, the amputation would be at the hip-joint. The operation should be as early as possible before there is much extension. Now that I cut into the tumor, you see that it is entirely broken down, and nothing but this blood and chocolate colored fluid comes from it. Not infrequently a sarcoma connected with the bone is filled with fluid of this character. It is interesting to note how nature has formed a limiting covering for the growth, by throwing out calcareous matter which intermixed with the tissues, forms a dense capsule. SARCOMA. 277 Fibro-Sarcoma of Abdominal Wall. Mr. J. N. V., Clarence, Iowa, Age 50, married, carpenter, Amer- ican. Habits and previous and family history good. Fairly nourished, muscular man. Eighteen months ago, patient noticed a tumor in his right in- guinal region. This has enlarged constantly and since the first four months very rapidly. It has given rise to much inconven- ience and some pain. The right leg is oedematous. The tumor is hard and apparently pulsating in an upward direction, this, however, being due to proximity to and fixation over the external iliac artery. There is no aneurism. The femoral artery can be felt pulsating plainly below Poupart's ligament. An incision 7 inches long and down to the transversalis fascia is made directly over the center of the tumor parallel to Pou- part's ligament. The tumor, as large as a fist, is thoroughly ex- posed by a careful separation of the layers of the transversalis fascia and found lying upon and surrounding the external iliac vessels and covered by the iliac fascia. Its gross appearance is that of a sarcoma. After dividing the iliac fascia over it the tumor is easily dissected out, exposing the peritoneum and the external iliac vessels and leaving an enormous cavity. The wound is sponged out carefully and united throughout with deep catgut and superficial silk sutures. An iodoform, iodoform gauze and borated cotton dressing will be applied, and the wound will remain undisturbed for ten days, when the superficial stitches will be removed. Sarcoma of Face. J. M., Charles City, la., Age 37, American, farmer. This is the case that was before you at last clinic with the tumor on the side of the neck. He comes now for its removal. He had a tumor removed seven or eight weeks ago, and it has now returned very rapidly. It is a sarcoma. This will, of course, be a bloody operation. The tumor being a secondary growth will not shell out as the first growths do. The operation will be principally in the submaxillary triangle of the neck. Your ana- tomical knowledge tells you the structures here to be avoided. You notice how prominent the external jugular vein is made by pressure of my assistant's finger. I shall probably divide this vein in the operation, and I have directed him to compress it 278 SARCOMA. immediately with his finger, to prevent the entrance of air when a deep inspiration is made. You see here now, very plainly, the submaxillary triangle exposed to view. In this location it is always best to expose the deep jugular vein first and then to work from within, outward, instead of going in the opposite direction. I have removed the bulk of the tumor. I must work very care- fully for I am very near the pharynx, and as I do not wish to make a fistula here, I shall remove the slight amount of diseased tissue that remains with the cautery. You noticed that when I divided the facial artery, one part of it was in the tumor and the other upon the face and that the hemorrhage from each end was about equal. I have punctured a small opening in the in- ternal jugular vein. I shall not try to ligate the entire vein, but shall lift up the portion containing the puncture and ligate it, in this way, ligating the vein laterally. Several years ago a paper on this subject was read before the American Medical Associa- tion in Philadelphia, in which ligation above and below and the removal of the perforated portion of the vein was advocated. I advocated that the procedure was more formidable than neces- sary, and that where the vein is situated in loose tissue, it could be ligated laterally in the manner mentioned, and I cited ex- amples of successful cases. The idea was not taken to very kindly but I have gone on, nevertheless, doing the operation with success ever since and within the past year or two this method has been adopted by a number of surgeons both in America and abroad. You see the pulsation of the external carotid artery very plainly. I have now cleaned this wound so that I see healthy tissues in every direction, except the little point which I cauter- ized, and here I have destroyed as much of the tissues as is safe. There is no doubt as to the nature of the disease. In order to prevent the accumulation of blood beneath the skin, we will pack the cavity with iodoform gauze, which will be removed on the third or fourth day. In a small portion of the wound, the sutures will be left loose until the gauze packing is removed. Then they will be tied, and a pad will be placed over the skin to hold the raw surfaces in coaptation. ANGIOMA. Congenital Angioma of Face. Gracie S., 291 S. Morgan St., age 1 year, American. We have a little babe with a red mark, three-fourths of an inch in diameter, on the right malar bone. It has been growing grad- ually from the birth of the child, when it was about the size of a pin's head, until it has reached the size which you now see. The growth has been more rapid of late. If you were to pass your finger over its surface, you would find that it is raised. It is of a port wine color. What is it? (Students answer): A naevus. We shall destroy these veins composing the growth absolutely by the use of the cautery, i.e., the hot needle, making a number of punctures. This is so large we may not be able to destroy it all at one sitting. Sometimes, where the naevus is large, it takes a number of sittings. You should never attempt to cure a naevus by injection of a coagulating fluid into its substance, for there are records of instantaneous deaths resulting from injections. The burnt surface will be dressed by a film of flexible collodion. This will come away with the eschar in about two weeks. After this time the surface will be anointed with vaseline. Venous Angioma of Upper Lip. Eva A., Dixon, 111., age 19, American, housewife. It never rains but it pours. It is not many days since you had before you a case similar to this. This lady has a tumor on the upper lip. She has always had it. It is of a bluish color, and a close observation of its surface will show that it belongs to the blood vessels of the face. It is an angioma, smaller than the one which we removed, although this has been growing from birth, also. If I were able to turn the lip back, you would see that the mucous membrane is affected. You see that it has grown by dis- placement rather than by absorption of the surrounding tissues. The vessels of which the tumor is composed have developed, and have pushed the tissues out of the way. It is a venous angioma. If I were to compress it between my fingers, I could reduce its size materially. This can be very readily removed. I will make a conical excision, being careful to make the incision in the healthy tissue beyond the region of the angioma. 280 ANGIOMA The two portions of the lip will be united by means of three deep silk-worm-gut sutures, which will include the entire thickness of the lip. Six or eight superficial sutures of fine silk will serve to adjust the skin and mucous membrane accurately. The superficial stitches will be removed on the third day, and the deep ones after a week. Angioma of Face. Sylvia M., Floyd, Iowa, age 14, American, school girl. Fam- ily history and previous history both good. This case is that of the young lady who was before you a few days ago with the large angioma of the cheek. A careful exam- ination shows that it extends up under the eye and down below the angle of the mouth. It is soft, and is made up of extremely dilated veins, implicating all of the tissues of the cheek. You see the bluish color of the veins through the skin, and when you turn the cheek outward, you can see the blood vessels through the mucous membrane in the same manner. The pressure of the blood vessels has destroyed all of the soft tissues of the cheek, so that the cheek in its entire circumference and thickness is but a mass of dilated and tortuous veins, limited on the outer surface by the skin and on the inner surface by the mucous membrane, both so thinned out that the bluish color of the venous blood shows through them very clearly. In addition, this is demonstrated by the fact that pressure displaces entirely the contents of the tumor, which returns immediately upon its release. In itself, dilation of the blood vessels is not a dangerous condition, but in this instance, with this thin covering and the large sized blood vessels, the child is exposed to the dangers of a fatal hemorrhage upon any slight accident, which might sever their covering; besides, the deformity is great, and should be relieved, if possible, because so marked. As it is in such an exposed position, it is a source of constant annoyance and remark. There are three methods of treatment which might be adopted, all having for their object the absolute destruction of all the dilated vessels making up this tumor. First—Subcutaneous ligation in sections around the circum- ference of the tumor, which I think would fail because the base of the tumor could not be reached by the ligatures. Second—The actual cautery plunged into it in many places all ANGOMIA. 281 over its surface, which I think would fail to act on account of the size of the tumor and the size of the veins. Third—Complete excision of the mass, making the incision outside of the dilated blood vessels in sound tissues. This will be sure and safe, and entail the least amount of deformity. It is the method which we will adopt. There is one structure passing through the cheek that we must try to avoid, and that is Steno's duct, extending from the anterior portion of the parotid gland through the cheek, and opening in the mouth opposite the second molar of the upper jaw. This should be done, if possible, in order to prevent the formation of a salivary fistula. So we will make an attempt to isolate Steno s duct, but we are not sure that we shall succeed. If we fail, the result is nothing as compared with the present condition of the child. Treatment. — What I propose to do is to get as far away from the margin of the tumor as possible into healthy tissue, and lift it up from its attachments. The tumor will have to be dissected out piecemeal, and it will consequently be a slow operation. There is no use to think of doing rapid work in a case of this kind. I have gotten below the mass now, and very likely I can follow it up. I am trying to dissect the mass from the mucous membrane, because it will enable us to shut off the cavity of the mouth at once. If I succeed in saving it, it will be of great advantage, but it is so very thin that I may not be able to do this. I am trying to save this little portion of skin to help cover the wound; we will need every bit of it. Here is a little projec- tion of flie tumor that we shall have to dissect out. I find here under this little portion of the skin, directly beneath the lower lid, the nucleus of the original trouble. I think I have succeeded in avoiding Steno's duct. I shall unite these edges of the mucous membrane in the same manner as you would a wound of the intestines, turning the edges inward. There is not much to say when a man is doing an operation of this kind, for he has about as much as he can do to attend to the operation. When you undertake a thing like this, you must take all the time you need, and be sure to stop the bleeding as you proceed. This patient has not lost enough blood to do him any harm. I did not know but that we might have severe bleeding, so I made preparations for treatment in case we did, by having a saline solution made. It is ready and would take the place of blood, temporarily. You can make a satisfactory solution by putting 282 ANGIOMA. into 1000 parts of water, six parts of sodium chloride, two parts of sulphate of sodium and one part of bicarbonate of sodium. This makes a solution which may be injected into the veins or subcutaneous tissues with impunity. It should be at the tempera- ture of about 98 degrees. I do not know that it is necessary for you to remember these proportions, for I am sure that a tea- spoonful of the ordinary table salt to the quart of water is just as good. It is well to keep such a solution ready whenever undertaking an operation in which the patient is likely to lose much blood. It is a harmless fluid but should be injected into the body at the normal temperature of the body. In all cases in which you have serious loss of blood and you are in fear of your patient's condi- tion you will remember that the use of this fluid is followed by great benefit, and it is taken up by the subcutaneous tissues very readily. About a year ago I removed the entire cheek of a man who had a sarcoma developed in connection with the cheek. We were obliged to remove a large flap of skin and also more tissue than we have done in this case. So far there is no evidence of this return and there is but very little deformity. He did very well indeed. He had a fistula for a little while but that healed and he is well. In his case the entire mucous membrane was re- moved. Notwithstanding this fact, the patient did very well indeed. In this case I have saved so much of the skin that I shall not try to make any transplantation. Of course, these edges must be very carefully adjusted so as to get union as quickly as possible and in that way get vascularity of the parts estab- lished as soon as possible. I shall turn this flap across in this manner so as to avoid any tension. Each one of these flaps has a broad base and I am sure that the circulation will be maintained without any difficulty. I will put a little drainage tube in so as to drain off any bloody or serous discharge which is likely to form. You see that we have united this wound without causing much deformity of the face. There is a small pucker at the corner of the mouth which will be smoothed by the process of healing and the lady will have a very pleasing appearance. At any rate her appearance is much better than it was before the operation. POLYPUS. 283 Nasal Polypus. In this man's nose you can see a growth forcing its way to the anterior nares. He is unable to breathe through either nostril and you notice as he speaks his voice has a muffled sound. He is suffering from nasal polypi, a form of myxomatous growth de- veloping usually in the mucous membrane covering the middle turbinated bone, and as they grow drawing into and occluding the nasal fossa. We will remove them en masse if this pair of forceps which is introduced along-side the septum of the nose will open so as to include the growth. It will be carried up to its base which is grasped firmly and the polypus twisted off and withdrawn, Now, sir, I shall not hurt you much, take hold of the chair. This is a case in which there are a half dozen nasal polypi hanging in a bunch like grapes to their stem. Rectal Polypus. John C, age 5, American, Chicago Lawn, 111. This is a very interesting case, and one that is of practical in- terest to you because you will frequently be called to treat just such cases. Some months ago this little patient would have a discharge of blood following the evacuation of his bowels, but it does not continue now. The mother noticed at times a pro- jection from the bowel after his going to stool. I asked her if it appeared at the center or margin of the bowel, and if the child strained much to get his bowels to move. I have an object in these questions, for in children, although they may have hemor- rhoids there is another trouble which will produce these symp- toms perhaps more markedly than the piles. It is the presence of a growth in the rectum perhaps no larger than a cherry or the end of your finger, connected to the lining of the bowel by a long pedicle and is called a polypus. This disease is not infre- quent in children. You will be helped to the diagnosis by the history given by the friends of the patient in that way learning whether or not the protrusion is centrally or laterally located immediately after the bowels move. You may be able to place the child over a vessel of warm water and be enabled to examine the parts yourself before they return, and in this way get a view of it. I do not suppose that I can see any growth of the nature 284 TUMORS. of a polypus now. By spreading open the nates and everting the anus I am unable to see anything but a small hemorrhoid. I am therefore inclined to believe that it is hemorrhoids that has been troubling him. The treatment will be the same as in adults which you have seen so often. If it were a polypus, you would be able to feel it by introducing your finger in this manner- When a patient complains of these symptoms you cannot say at once that it is piles. You must make a differential diagnosis between piles, polypi, malignant growths and prolapse. Tumor of Terminal Filaments of Plantar Nerves. John Mc, 605 Congress St., American, steamboat agent, age 71. This patient has a small tumor on the sole of his foot. It is now the size of a large walnut, having reached this size from the size of a pea when he first noticed it twelve years ago. Some days it is more painful than others; and it is more painful in the morning than at night. It is perfectly soft to the touch; there is no infiltration of the tissues. It is not a neuroma, for it is not hard and oval in shape, hence. I believe that it is an adventitious growth in connection with the terminal filaments of the nerves. It is not a callosity from the friction of the shoe termed a corn. It should be removed freely. Neuroma on Back of Hand. Miss E. A., Chicago, age 32, American, musician, general health good. This patient presents herself to us with a small, exceedingly painful tumor as large as a bean, on the back of the hand, be- tween the second and third metacarpal bones. It has developed within the last six months, after prolonged piano practice. It is a neuroma, and requires removal. The lady bravely con- sents to having it done without taking an anaesthetic. It is ex- posed by a short incision directly over it, picked up with a pair of forceps and dissected away. Two catgut sutures, and the ap- plication of an iodoform, iodoform gauze and borated cotton dressing complete the operation. TUMORS. 285 Lipoma of the Back. Mary F., 90 Damon St., American, age 19, clerk. (Q) What is your trouble? (A) I have a tumor in my back. (Q) How long have you had it? (A) Five years. (Q) Is it painful? (A) It has not been so except duringthe last few days. (Q) How large was it when you first noticed it? (A) It was about as large as it is now, and does not seem to grow. As the lady has told us we find a little prominence on the left side of the spine. It slides under the skin and hence is not attached to the skin. The back is a favorite place for fatty tumors. This one as you see has been compressed by the clothing and has been prevented from rapid growth by bands of the clothing: we will see if it contains pus. In considering the kind of a tumor, always bear in mind the fact that all primary tumors of the body are made up of similar tissue to that in which they are found except in cases in which a portion of an embryonic layer has been included in one of the other layers. In trying to introduce the needle or knife into the back, remember that the skin in this region is thick and somewhat difficult to penetrate. We will make an incision through the skin and superficial fas- cia directly over the center of the tumor. Now this mass of fat as large as a child's hand can be removed from its bed of loose connective tissue with perfect ease. We will close the wound completely with a continuous cat-gut suture and seal it with collodion and iodoform gauze. It will not be dressed for two weeks when it will be perfectly healed. Papiloma of the Skin. W. A., Naperville, 111., age 21, American, student. This young man comes with a small fibrous growth developed from the skin. We will clip it off with the scissors. When dividing a growth of this nature from its point of attach- ment, it is always well to lift it up firmly so that you divide the pedicle down in the deeper tissues. The patient has, also a small tumor on the side of the neck just below the ear. I can lift it up between my thumb and finger. It is a collection of sebaceous matter which has accumulated as a result of closing of the duct. W7e shall open it and scrape it out 286 TUMORS. as he is desirous of being rid of all his ailments. The tumor is so small that I am not sure that I have removed all portions of the lining, and as that is absolutely necessary, I now touch it with 95 per cent, carbolic acid to destroy any portions of it that have escaped the knife and curette. Not infrequently you will meet patients with fibrous growths attached by a long pedicle, as in this case, which may be de- veloped from any portion of the body. They are not always pedunculated, but sometimes are attached by a broad base. When they are pedunculated, as was the case here, they may be very readily removed by tying a thread about the pedicle. The thread will soon produce a slough and the tumor will drop off. You can employ this means when your patient is afraid of the knife. Cystic Tumor of the Breast. Mrs. J. M. S., CassOpolis Mich., age 36, American, housewife. How long have you had this tumor? Nine years. I shall not hurt you. I shall be as careful as possible. This lady has a tumor of the mammary gland. It has been growing for nine years. When she first noticed it it was about the size of a hickorynut. It is now as large as a man's head. It is rather irregular in character, showing no disposition to ulcerate except at a few points where the clothing irritates it. I imagine that you will practice a long time before you see anything like this. This is an innocent growth as shown by its external appearance and its history. It shows no disposition to infiltrate the skin and it has been long in growing. It is a multilocular cystic tumor, of the breast. There is but one thing to do in this case and that is to have it removed. It is attached by a mere pedicle and will be very easily removed. We will advise the lady to have it removed be- cause it is a source of great inconvenience and because non-malig- nant growths often become malignant if left undisturbed. Epiphyseal Exostosis at Upper End of Tibia. A. T. J., Chicago, American, age 23, drug clerk. This young man presents himself with a swelling as large as a good-sized potato and very similar in shape, on the posterior sur- EXOSTOSIS. 287 face ot the upper part of the leg. The growth evidently pushes all the muscles of the calf in front of it. It is hard and irregular to the touch where it can be felt underneath the edge of the muscles. It causes no pain or inconvenience, except from its size. It evidently is an outgrowth, bony in character, from the posterior surface of the upper part of the tibia, growing from the epiphysial cartilage. It belongs to the class of innocent tumors, and is technically called an exostosis. I cannot advise any operative procedure so long as it is harmless in its manifestations Should it at any time become a source of trouble through increased enlargement, I think it can be safely removed. Exostosis. Robert R., 30 Austin Ave., age 19, Welsh, blacksmith. How long have you had this trouble with your arm? About two weeks. I used the sledge and had worked a little harder than usual the day that I first noticed it. I have not been able to work since, but it is getting better. I suppose a veterinary sur- geon would call this a splint. You have seen horses that were lame from splints. We have here a localized periostitis on the posterior border of the ulna which has been more painful than it is now, and more painful at night. It is possible that the young man gave it a slight blow without noticing it at the time. He looks like a healthy young man. I have looked into his mouth, and have examined him sufficiently, and shall not ask any ques- tions. This is not a gumma. They are more apt to come on in old sinners than in young ones, and more apt to come on the long bones, and especially on the clavicle. They are soft and fluctuating to the touch, and increase slowly in size, causing more pain at night. Treatment.—The thing for this young man to do is to apply hot fomentations to the arm, and above all things else give it rest. We will secure rest by applying a light, angular splint, and ad- vising the patient to carry the arm in a sling. Enchondroma. Mary N., 869 55th St., Hyde Park, age 42, American, house- keeper. Family history and previous history good. Duration of present disease, 15 years. EXOSTOSIS. You have a lump on the side of your face. How long have you had it? It has been coming for fifteen years, and causes pain. How large was it when you first noticed it? About the size of a pea. It is very sensitive. (Just above the angle of the jaw and below the ear). It is two inches in diameter and one inch thick, and is movable under the skin. There is no inflam- mation. The lymphatic glands are not enlarged. It is very close to the parotid gland. Not unfrequently you will find cartilaginous tumors of the parotid gland, and I should not be surprised to find that this growth contains cartilage. It is an enchondroma, and we would advise the lady to have it removed. I will make an incision over the center of the growth in the direc- tion of the nerve fibres in this region, in order to limit as much as possible the resulting facial paralysis. I work carefully here, because it is so dark in the room. You can see the cartilaginous character of this tumor, and here is the parotid gland. I have uncovered the internal jugular vein. I am quite sure that you will meet with cases like this one, demanding your treatment, much more often than those requiring a formidable operation, and hence the minutiae should be well mastered. The rule for the removal of all innocent tumors, and one that will carry you safely through an operation, is to keep the knife or the scissors, whichever you use, to the tumor. All innocent tumors are en- veloped in a capsule, and if you keep close to and in the capsule, you will not sever any important vessels. You may also remem- ber this: that all tumors that are movable are removable, and the greater the mobility the easier are they removed. This is a very important locality. There is the facial nerve which, if severed, would result in paralysi of the face. The jugular vein, the loca- tion of which you can fix in your mind by making pressure just above the clavicle, should be avoided. If you cannot avoid cutting it, ligate it and cut it between the ligatures, beginning the operation. You have here all the important structures of the neck, so you must keep close to the tumor, and so long as you do this it makes no difference where you are, you will not injure any vessels. Malignant tumors, on the other hand, you know have no capsule, except in some sarcomata. They invade the surrounding tissues in all directions', and hence, you would not expect to remove them without doing some injury to the nerves and vessels. You will make this fact known to your patients, and thus warn them of any trouble that may come from the operation. FIBROMA. 289 Fibroma of Pharynx. Joseph V., Muskegon, Michigan, age 42, French, lumberman This patient is suffering from a tumor of the pharynx. Prof. Ingals performed a tracheotomy on the patient, and he is wear- ing the tube now. The tumor occupies the entire upper half, at least, of the pharynx. It projects forward under the soft palate so as to be seen through the mouth, and it projects upwards so far as to occlude the nasal passages, hence you see that it in- cludes that entire cavity. The tumor is, therefore, a very formid- able one to remove. If we can reach the tumor from the mouth, uncover it, and re- move it in this way, it will be so much better for the patient. Quite frequently the operation through the mouth fails, then we have to separate the upper jaw entirely. This makes a very formidable operation, and is to be avoided, unless the surgeon is compelled to do it. In order that the hemorrhage may be stayed, and the patient thus prevented from being choked from the dropping of the blood into the larynx, all these operations for the removal of large tumors of this character are proceeded by tracheotomy. This permits of the packing of the lower portion of the pharynx with gauze to shut off the hemorrhage. I find that I shall have to separate the palate before I shall be able to remove the growth. I have now gotten the posterior nares open, and I find that the tumor is made up of a rather soft mass, which it is impossible to remove completely without thoroughly curetting it. I am now removing some portions of the tumor from the base of the skull, which I can not reach quite so easily as I do the rest. I can put my finger into the posterior nares without any difficulty, and I am sure those passages are free. I now have the tumor removed from the anterior surface of the spinal column. These pieces that I am removing now come from the roof of the pharynx, which you know is from the body of the sphenoid bone. You can now readily see how ex- tremely difficult this operation would be without first doing a tracheotomy. I have succeded in removing the mass through the mouth, a very much less formidable operation than the one I mentioned of separating the jaw. I am afraid that this disease is one which this operation will not cure. It will, probably, only give him a breathing spell. I 290 EPULIS. fear that the microscope will confirm the diagnosis of sarcoma. At the bottom of the wound the anterior common ligament of the spinal column can readily be seen. I am closing the soft palate which I was compelled to divide. This tumor has come down so low in the pharynx that it has implicated the tonsil. I merely mentioned this to call your attention to the fact that in removing tumors in the locality of the tonsil, you must be very careful not to injure the internal carotid artery. This vessel is separated from the tonsil by the walls of the pharynx only. Of course, if you should open this vessel it would be a serious acci- dent. It would at least require the ligation of the common carotid artery, for there is no packing that can be applied which will stop the hemorrhage. The current is so direct that no pressure can be applied except that of the finger, and that directly to the opening, to control the hemorrhage. I have dis turbed the mucous membrane of the nose a little, and we have a little bleeding from the nose, which will soon cease from the pressure of a little iodoform gauze. My assistant tells me the long continued use of the gag in the mouth, together with the motion required in the removal of the tumor, has caused a dislocation of the lower jaw. It is a very easy matter to reduce a dislocation of this kind by putting the thumbs in the mouth of the patient, pressing downward with them, and at the same time pressing upward with the finger on the chin. It is quite possible, as you readily see from this operation, to remove quite a large fibroma from the pharynx by dividing the soft palate, and, if necessary, the hard palate and the jaws. Then, dividing the coverings of the tumor, seize it with the Vol- sella forceps and peel it out of its capsule. You know that fi- bromata here, as well as in other parts of the body, have their own capsule of connective tissue, and they can be enucleated even easier than fatty tumors. We will cauterize the entire surface to which this tumor was attached with the Paquelin cautery, and then pack the pharynx with iodoform gauze. Epulis. Mrs. S. E. S., 329 Flournoy St., age 47, American, housewife. This patient was before you at the last clinic, but we did not have time to perform the necessary operation; so she comes to- EPULIS. 291 day to have a tumor in connection with the roof of the mouth removed. There is not much to be seen in an operation of this kind. We will place the patient in Roser's position, which we advise in all operations about the mouth, nose or pharynx, i.e., in the dependent position of the head, so that the roof of the mouth is the lowest portion of the respiratory or alimentary tracts, thus giving the blood a chance to flow out of the mouth instead of flowing into either of these passages. I think that by holding the mouth in this position the most of you, even at quite a distance, can see the nature of the growth quite plainly in the mouth. It is as large as a quail's egg, and is growing from the under surface of the hard palate. It is hard, glistening and smooth in character, and I am satisfied that it is an innocent growth, which we shall probably be able to remove without any great difficulty, and which we shall find to be composed of dense fibrous tissue. The upper portion of the tumor is really attached to the alveolar process; hence I am satisfied that it is of the na- ture which I mentioned to you the other day—that of an epulis. There is quite severe hemorrhage. This tampon of antiseptic gauze which we will pack into the cavity, will soon become fixed n the cavity, and in that way stop the bleeding, and at the same time will make a sufficient dressing for the wound. Now, that I have opened the specimen, it does ]not look so pleasant as it did before. You notice that the growth is some- what cystic, made up of a number of cavities, the trabeculae of which are composed of dense fibrous tissue. This may possibly prove to be malignant, but a microscopical examination will be made and will determine the character of the growth definitely. Epulis. Mary D., 26 Allington Place, age 12, Irish, school girl. This little girl has a growth springing from the alveolus, ex- tending from the canine back as far as the last molar. One molar and a bicuspid were extracted. The margin of the gum is three times its natural width, and has an appearance peculiar to epulis. It grows down on the outer side of the gum. The thing to do is to extract the teeth and remove the growth. It is an epulis, and is classed among the innocent connective tissue tumors, and if removed completely will not return. The tumor grows from the periosteum covering the alveolar 292 CYSTS. process. It is, consequently, advisable to remove this process together with its periosteum by means of a chisel. The wound bleeds freely, but the hemorrhage can be easily controlled by packing the space tightly with iodoform gauze. The patient will be advised to rinse her mouth every hour or two with a solution of one part of alcohol in three of warm water. The wound will be entirely healed in two weeks. Sebaceous Cyst below Ear. H. E., 632 Adams St., Chicago, German, age 28, engineer. Family history and previous history good. Well, sir, what is your trouble? I have a lump on my face. How long has this lump been growing? Seven years. This pa- tient conies with a little lump at the angle of the jaw. It is very movable under the skin and does not give him pain. It has some of the appearances of a sebaceous cyst. You remember that sebaceous cysts are caused by the closure of the ducts of sebaceous glands. From the fact that this tumor has been here so long, and has been of such slow growth and does not give pain, I am inclined to believe that it belongs to the class of in- nocent tumors. The treatment indicated is to uncover it by an incision directly across its highest part, and to dissect it out of its bed. Picking the tumor up between my thumb and finger, I find that it is freely movable, and that it is connected with the skin by an elongated attachment. This is one of the tumors in which it is absolutely necessary to get out all of the cyst wall. If you do not succeed in removing it all, the tumor re-forms. When these growths are situated on the scalp, there is no difficulty con- nected with their enucleation, for they are developed in the loose tissue of that region, and you can separate and remove them without any difficulty whatever. When they are found on the face or neck, they are removed with more difficulty, because all of the subcutaneous tissue must be dissected away from the cyst wall. We have now dissected all portions of the sac from the tissues in which it is imbedded. The wound is closed by stitches, and dry dressings are applied. CYSTS. 293 Sebaceous Cysts of Scalp. C, Richland, 111., age 72, German, farmer. This old gentleman has a number of small tumors upon his scalp, as you see. They are smooth and soft to the touch. The skin is not implicated in the growth. They have been growing for many years, and have caused him no trouble, except by their disagreeable appearance. They are sebaceous cysts, caused by the occlusion of ducts of sebaceous glands, causing an accumula- tion of the secretions of these glands. I have told you that they are easily removed when they are found in the scalp, and that in this position they are not attached to the tissues except at the very top of the tumor. The method of their removal that I have adopted is to pass the knife through them, splitting the cyst in two, to introduce the director at the base and pull it around be- tween the sac wall and the skin. You can quite readily do this; then grasping the deepest portion of the sac with forceps, the en- tire mass can be lifted out. I think this is a much better way than to undertake to dissect them out. When you incise the skin over a small cyst, it falls out quite readily, as this one does. This is a large one, but I shall not attempt to remove any of the skin. It will all contract. The contents of this cyst is partially fluid in character. It is of the kind that frequently ulcerates on its external surface, and assumes the appearance of a malignant tumor. You are to remember that every portion of the cyst wall must be removed. This man has another trouble which concerns him more than these cysts. He has a tumor just below the left ear. It has been removed once, but shows a disposition to return. We will have more difficulty in removing it than we have in re- moving the cysts. It will not separate from the skin, and shows a disposition to grow and to infiltrate the surrounding tissues, havirg all of the manifestations of a malignant growth. It is in an unfortunate position. Just above it is the facial nerve, which, of course, we desire to avoid, but we may be obliged to injure it. I am not at all positive that this growth will not return. In fact, I expect it to return. Now we have removed it, and I think we have missed the nerve. Ranula. Mrs. O., Austin Ave., age 30, American, housewife. Family history and previous history good. Duration of the present dis- ease, eight months. 294 REMOVAL OF THYROID GLAND. Some of you will recognize this lady. She was before us last Tuesday, and presented a very beautiful case of ranula as large as a walnut. It is a large cyst formed by the occlusion of the duct of some of the mucous glands underneath the tongue. It had grown so large that the tongue was pressed against the roof of the mouth. The tumor was a little discolored. I made a large open- ing into it, allowed the fluid to escape, and then packed it with iodoform gauze, as much as would represent the size of a walnut. The patient became nauseated, and she removed the packing about 8 o'clock that evening. This is the first time I ever heard of iodoform acting in that way. It was quite unfortunate for the patient that the gauze was removed. She was very much fright- ened by the operation, and the discomfort from the gauze would have soon passed away. Treatment.—There are different methods of treatment, but the tendency is for the cyst to refill. But in all cases in which I have removed a piece of the wall, and had the packing left in the cavity until this has healed from the bottom by granulation, I have secured a cure. Practically this is well. The walls of the cyst have adhered, but the accumulation may return. Removal of P^nlarged Thyroid Gland. Preceding my remarks, I shall show you a patient from whom we removed the gland and shall also show you a number of glands which we have removed. The specimens which I pass about will give you an idea of their size and appearance when enlarged. In the first place it may be well for me to say a word about the Surgical Anatomy, in order to impress upon you its importance !n avoiding the nerves and vessels during an operation. You know that the arteries supplying the glands are the superior and inferior thyroid arteries. The superior thyroid supplies the upper portion of the lateral oval mass of the gland and the in- ferior, the lower portion of the mass. These arteries anastomose freely with each other in the side which they supply but not with the opposite side. In other words the two sides of the gland are distinct, unless the third artery, the thyroideaima, which usually arises from the arch of the aorta, passes up the anterior surface of the trachea and is lost in the substance of the gland, unites the two sides. When the gland is enlarged the division of any of the REMOVAL OF THYROID GLAND. 295 vessels, which are also enlarged, gives rise to hemorrhage which is difficult to control. The other vessels are the veins. I do not call your attention to the common carotid artery, for all of your operative procedures are so far away that there should be no danger of injuring it. Of course, on either side you have the anterior jugular and the laryngeal veins running over the surface of the tumor. The veins will concern you more than anything else, because they will be immensely enlarged. Veins having no name, anatomically will have formed and will be of large size, oftentimes as large as a lead pencil. These veins not only have greatly distended walls, but the walls have become attenuated and brittle, so that the slightest touch will break them; and once broken, you will be sur- prised at the great amount of hemorrhage from them. Before the day of haemostatic forceps, when the surgeon had to depend on skill and dexterity, the majority of these cases met with death, from hemorrhage. This shows you the difficulty of con- trolling hemorrhage, and warns you against undertaking an opera- tion without providing yourself beforehand with all necessary apparatus for any emergencies which may arise in the course of the operation. Besides the veins mentioned you will bear in mind the internal jugular. Now, with reference to the superior thyroid artery, you know that when the gland is contracted and of normal size, the vessel enters its upper portion, but when the gland is enlarged, all is changed, instead of entering the superior portion it enters from below, altogether different from the re- lations which you find in your dissections. The inferior thyroid artery you remember is the guide to the recurrent laryngeal nerve. It is a branch of the thyroid axis, and the subclavian artery, from which it arises, is just beyond it. As the inferior thyroid artery ascends to the gland it becomes in- timately associated with the recurrent laryngeal nerve. This nerve you remember supplies the muscles of the larynx, and is very important; if it be divided, the muscles on the affected side are instantly paralyzed. The division of the nerve causes collapse of the glottis. You will remember, too, that the point where the artery turns to run across the gland is the point where the in- ferior thyroid is ligated. Another nerve of importance is the superior laryngeal, which supplies the pharynx with sensation. It lies in the course of the superior thyroid artery and of course should be avoided. When the gland is enlarged and it is necessary for you to remove it, 296 REMOVAL OF THYROID GLAND. you will usually be able to prevent much hemorrhage, by finding the vessel in its distribution and seizing it with forceps, then the next division in the same way, and the next, and so on before their division. You will also prevent hemorrhage by keeping outside the substance of the gland. You remember the trachea in its relation to the gland. You know that the gland is made up of two lateral masses and a cen- tral portion uniting the two, called the isthmus. Not infrequent- ly the enlarged masses of the gland extend around the sides of the trachea and become adherent to its surface, as you can see was the case with this specimen which I show you. This speci- men also illustrates the fact that the lobes of the gland develop in such a way as to make pressure on the walls of the trachae, almost shutting off respiration. The trachea is very loose and care must be exercised in manipulating the gland, that pressure is not made thereby on it and respiration interfered with. Perhaps this is all that is necessary for me to call your attention to in regard to the anatomy of the gland, unless it be to the coverings of the gland. We have first, of course, the skin and superficial fascia. Below this is the platysma myoides muscle, then we come down upon the deep fascia, and upon removing this obstruction we reach the sterno-hyoid and the omo-hyoid muscles, very thin muscles termed "ribbon" muscles. When, however, they are enlarged as you will often find them, it is al- most impossible to recognize them. Finally you come to the fibres enclosing the gland, itself. It is very important that you bear in mind all of the relations which I have mentioned every moment of the time while you are operating. You can divide the tissues immediately over the gland with extreme care, avoiding the important structures already mentioned. This ^patient comes before you showing the result of an opera- tion in which the entire thyroid gland was removed. She was suffering from difficulty in breathing at all times, but especially when lying down. She had been troubled for 25 years in this way, gradually growing worse notwithstanding almost constant treatment until, unable to bear it longer, she came and had the enlarged gland removed. You notice the nature of the incision in this case, it was sufficiently extensive to enable me to enucle- ate the mass without any great difficulty. The patient is now entirely relieved of her disagreeable symptoms and is cured. Now that I look at this tumor, I have called to mind another complication, and that is, that these growths are very likely to be REMOVAL OF THYROID GLAND 297 supernumerary. In this specimen which I have in my hand, you see its " spread eagle " shape. After removing, it there popped out of the neck on the under surface of the gland, this great mass which could not be diagnosed at all before it made its appear- ance, because it was underneath the sternum. The mass was readily removed and on its under surface was a distinct groove which had been made by the arch of the aorta. That case also recovered without difficulty. Again, we have what is sometimes called a supernumerary gland, some distance from the original gland. Here is an example of this kind. Some time ago I re- moved a tumor from behind the sterno-cleido-mastoid muscle, and upon microscopical examination, it was found to be composed of tissue resembling that of the thyroid gland. A number of similar cases have been observed by other surgeons I do not know that it is necessary for me to say anything about the pathology of the organ. Your comprehension of the path- ology of it will depend largely upon your knowledge of its mi- nute anatomy. The gland is made up of a capsule and a stroma. The capsule sends down trabeculae which divide and subdivide the stroma into lobules which, in turn, are made up of vesicles lined with a single layer of epithelium. The vesicles may become filled with a colloid material which may lead to pockets of the same. Very frequently they become arranged in nodulated masses as a result of the cicatricial tissues which form about them. The gelatinous, viscid fluid sometimes becomes more liquid, collects, forms an extensive cavity and is surrounded by its own cicatricial tissue, forming a cystic condition of the gland. The trabeculae take upon themselves an enlargement and you have a fibroma resulting. It may be adenomatous, or the blood- vessels may take upon themselves a peculiar condition giving rise to the vascular variety. However they are produced, a careful examination will usually tell their nature, and whatever be their effect is what concerns you most surgically. When they increase to a large size, and are hard, they make pressure on the trachea and interfere with respiration, the voice becomes husky, and deglutition is also im- paired. But the most pronounced symptom is the interference with respiration. When the gland reaches this large size, sur- gical interference for its relief is necessary both to relieve the symptoms and for its cosmetic effect. The neck is exposed to view, and every one sees it, causing not a little annoyance to the sensitive woman. 298 REMOVAL OF THYROID GLAND. Many cases of enlarged thyroid glands are of a nature which are apt to reach the extreme size of the true hypertrophied gland. These glands are amenable to such treatment as the ex- ternal application of the tincture of iodine and the iodide of potassium internally. Certain good surgeons report excellent results by exposing tumors to heat, as that of a fire or the hot rays from the sun. Then, again, certain injections with hypo- dermic s) ringe, or the trocar and canula, of fluids like carbolic acid, ergot and alcohol, or a 10 per cent, solution of iodoform in glycerine, have been followed by relief, and in some instances by cures. Of late years, the hypodermic injection of five per cent, carbolic acid has been my favorite remedy for this variety. You will always try these remedies before rashly undertaking an operation, but you will sometimes be surprised to find that these remedies will have but little or no effect, and it will be necessary to resort to an operative procedure. When you have decided upon operative treatment, there are a number of things to be borne in mind. Until a few years ago> when antiseptic precautions were adopted, operations on the thyroid gland were considered the most formidable, and were frequently followed by death on the table. The operation had to be done quickly. Great, strong, waxed linen thread, such as shoemakers use, was employed to ligate en masse, and great strength was used in tying it. Infection was of common occur- rence in the cases which did not succumb to shock. A septic mediastinits was likely to follow, and cause the death of the patient. The formidable operation of removing the entire gland is be- gun by making an incision over the surface of the gland in such a way as to give plenty of room to control the tumor. The most convenient incision is a bilateral one, extending down the lateral mass on one side, across the mass below, and up the other side through the skin and superficial fascia. The deep fascia is then carefully divided, and you come upon the fascia covering the tumor itself. You divide it on the grooved director, and separate the tissues from the tumor with your fingers, first on one side and then on the other. The superior thyroid is seized and controlled with haemostactic forceps. Remember that the thyroid gland is exceedingly vascular, and that both ends of the artery must be tied. Follow down the side of the lateral mass of the gland, find the inferior thyroid artery, and secure it. Turn the tumor over carefully, sever its attachments with the trachea on that side, REMOVAL OF THYROID GLAND. 299 then do the same thing to the arteries and attachments of the other side. This is done when you remove the entire gland. It is not always possible to do this, however, and you may enucleate a portion of it, after reaching it in this way, by making one or more incisions into it, and removing, with the finger or curette, all of the loose material. Hemorrhage may be controlled by the use of a constricting band, applied as you have seen us do some- times in cases of a fibroma of the uterus. If a cystic tumor has reached the size of a hen's egg, it will have its wall, and can be turned out. The cavity is then packed with iodoform gauze. That is the method of enucleation, and a cyst may be removed entirely without hemorrhage. The same process is carried out by the use of the actual cautery. There is another condition which I should mention, and that is an enlarged condition of the blood vessels, giving to them the appearance of an aneurism. The tumor pulsates as does an aneurism. This condition is found to be attended with a nervous trouble. There is a protrusion of the eye-balls and palpitation of the heart. This form is termed exophthalmic goiter. It has been treated by the removal of the entire gland. I have told you that the great danger in removing a thyroid gland is that of hemorrhage. However, this can be prevented. There is not a man in this room who can not control hemorrhage during the removal of a gland. This is done by securing each vessel before it is divided, then you will be able to do this formidable operation with the loss of but an ounce or two of blood. In case hemorrhage should occur during the operation, notwithstanding the fact that these precautions have been taken, it can be temporarily controlled by grasping the gland between the thumb and fingers and elevating it until the vessels can be caught in haemostatic forceps. The next danger is that of sepsis, simply because you are obliged to open the large, loose cellular spaces in the anterior portion of the neck which communicate with the mediastinum. Infective germs are likely to find their way into the mediastinum, and the patient dies of acute septic poisoning. Therefore, you will never approach an operation of this kind until you can swear that you have carried out all of the rules governing an antiseptic opera- tion. I have already mentioned the danger of dividing the in- ferior laryngeal nerve. The other laryngeal nerve might carry on its function in a degree, but if the greater accident of dividing both nerves should occur, the result would prove fatal. Of 300 GOITRE. course, the large vessels are in danger. If you should injure the internal jugular vein, you would ligate it at once, of course. It being large, you would ligate in two places, above and below the injury, and cut it between the ligatures. The pneumogastric nerves are to be avoided, of course, as their division might be fatal. In regard to the cosmetic effect, we may say that your incision should never be transverse, for such an incision will always show. But if you make the incision which I have mentioned, it will leave the least scar, and at the same time will give you an abundance of room. Now, with reference to that dreadful disease called myxcedema, or cachexia strumipriva, associated with a degeneration of the nervous system, a loss of intellect, and a general physical weak- ness. Myxoedema was first described by Sir William Gull, and later by Sir William Ord, both of London. It has recently been studied with great care by Prof. Kocher of Bern. These men discovered that in the lower animals the disease is due to a de- posit of mucin in the connective tissues. The human subject with this disease becomes thick lipped, and his tongue and cheeks also become thick; he has the appearance of anasarca, but his tissues do not " pit on pressure," hence, there is a difference. It is said that the entire removal of the gland is followed by myxoedema. This is not true in my experience, however, you should always leave a portion of the gland if you can find a sound and healthy portion which may be left. Goitre. The six patients now shown to you are all illustrations of the enlargement of the thyroid gland, technically termed goitre, or bronchocele, or struma. The points in diagnosis are, first, its position in front of the neck; second, its shape, spread eagle, a small body in the center and large wings on either side; third, it rises and falls with each act of deglutition, as I illustrate with this patient, because it is normally fastened to the trachea. The growth may be unilateral, bilateral, or central, according as one or both lobes or the isthmus, or all three are the site of the manifestations of the disease. The growth may be cystic, TREPHINING. 301 single, or multilocular, adenomatous, vascular, or fibrous; or the tumor may be a sarcoma or a carcinoma of the thyroid gland. Again, we are often called upon to treat cases of enlargement of the thyroid gland associated with bulging of the eyeballs and dis- tressing pulsation of the large arteries of the neck. Such cases are termed exophthalmic goitres. The cases before us are all examples of cystic or adenomatous enlargement of the thyroid. We have fallen into the habit of treating these cases by the weekly injection into the substance of the gland of a drachm of the 5 per cent. sol. of carbolic acid in water. This treatment is followed by a rapid diminution in size in many cases, and a perceptible improvement in all who have regularly returned. I have added to this treatment the use of 5 drop doses of Donovan's sol. and 10 drop doses of Tr. stro- phantus three times a day, with what benefit I am not yet able to state. I do not know the exact number of patients we have treated by means of hypodermic injection of 5 per cent. sol. of carbolic acid but it must by this time exceed one hundred cases and you have all noticed the improvement in the different cases from week to week. The percentage of complete recoveries is large. Trephining for Epilepsy. B. G., Utica, 111., Age 36, American, mechanic. The patient before you is a man 36 years of age who is suffer- ing from a complication called epilepsy, a sickness which is char- acterized by a loss of consciousness and motion and a peculiar spasm of the muscles. There is always present in these instances an excitable nervous center in the brain and a second factor is a periphoral irritation- cortical excitability. It has been proven clearly by repeated ob- servations that a certain irritation of the brain will produce epi- lepsy. But I merely mention this as a fact in passing as a point which seems to justify surgical interference. There are cases on record in which the removal of such irritating causes has relieved the epilepsy. Other cases of epilepsy are on record which re- covered from their disease after operations upon other portions of the body, for instance after removing necrosed bone of the tibia in a case of osteomyelitis. The amputation of extremities 302 TREPHINING. the opening of abscesses, removal of ovaries, removal of scars and many other operations have been followed by similar results. Surgeons have long known that injuries about the head lead to this condition of epilepsy. It is not an infrequent sequela of frac- ture of the skull, and particularly certain kinds of fractures of the skull, such as a punctate fracture in which the edges are accentuated and circumscribed, as from a fall on the corner of a brick or nail. Here the force is circumscribed, is confined to a small area and the pressure is directed internally upon the mem- branes of the brain and often lead to inflammation. Again, sur- geons know that epilepsy is a sequela of a thickening of the bone by an abnormal development of it without the occurrence of a fracture. The cancellous diploeand inner plate lose their normal appearance, becoming thicker and harder, sclerosed, if I may use the term, and more bony tissue projects into the sulci of the brain than normally. Another change which may take place is a thick- ening of the bone which at the same time becomes very porous and spongy, producing a condition known as osteoporosis. Any of these conditions may go on developing in the interior of the cranium. Such conditions occasionally form osteophytes, small bony developments sometimes an inch in length, which irritate the tissues with which they come in contact. When this is the case the seat of the trouble comes to be the point of periph- eral irritation and any surgical interference which does not re- move the osteophytes will fail. This unfortunate man has an injury of the skull which he re- ceived when a boy by a fall from a tree. Seventeen years after receiving the injury he began to suffer from epilepsy, since which time it has been increasing in severity. He has already been trephined without obtaining any relief. He is now in such a lamentable condition so far as the epileptic seizures are concerned, that he wishes to undergo another operation. We feel inclined to let him have an operation for the reason that the first opera- tion did not elevate all of the portions of the skull which were depressed by the fracture. If you undertake one of these opera- tions, you should be provided with means to elevate all portions of the depressed bone, for there is nothing that will tell you which portion of the depressed bone is causing the irritation, or is the cause of the trouble. Here is a very well marked depres- sion marking the opening made by the button of the original trephining. TREPHINING. 303 Running upward and outward from this depression is a well- marked sinking in of the skull, showing that this was not a punc- tate fracture, but that a considerable portion of the skull was depressed. So we will not predict that the patient will be abso- lutely and positively relieved, but from our knowledge of such cases we have every reason to believe that his condition will be improved. Instances of this kind are on record resulting in a cessation of the epilepsy by removing the irritation with the tre- phine after the disease has existed 20 years. In order that we shall be satisfied that a cure has resulted from the operation of trephining, it will be necessary for us to wait a considerable length of time, for it is a strange but apparent fact that almost any oper- ation for a trouble of this nature will give the patient relief for the time being. The new irritation on the nerves due to the operation seems to take the place of the old. Hence, the per- manent benefit must be verified by time. It is best in these cases to make the horseshoe flap incision. The flap is made large enough to embrace a little more than the entire depressed area of the skin and the incision goes directly down upon the bone through all of the tissues. I have a little more difficulty here on account of the cicatrices of the original trephining than I otherwise should, and I must therefore be more careful in separating them, lest I might injure the coverings of the brain Now you see, with the use of the chisel I have succeeded in removing this large piece of bone without any difficulty and with- out any injury whatever to the brain or its membranes, and it has been just as surely done as with a trephine. We trephined a case before the students in this amphitheater a year or two ago in which we found the bone so osteoportic and so thick, that the trephine would not reach to the bottom of it. So that we had to remove the first button and then substitute the chisel in order to complete the opening. That condition not infrequently follows injuries of the skull, but not to such a degree, except in rare in- stances. I have come to more evidence of disease just here at the posterior inferior angle of the wound than in any other part. Here is an outgrowth of the nature of an osteophyte growing directly into the membrane in this position. One has to use a considerable amount of care in lifting it out not to tear the mem- brane. Ot course, the patient's trouble may come just here where the cicatrix has been found as a result of the old operation, and I have to go carefully or I may tear into the brain. As it may be the source of the convulsions, I am now loosening it up thor- 304 TREPHINING. oughly. You must listen to the sound of the chisel as well as to notice carefully regarding the amount of force used. When one has separated the continuity of the bone, the sound given off indicates this having been done. The membranes fill up the cavity that I have made in all directions. I can feel the pul- sations of the brain very distinctly. If we were trephining for an abscess, the membrane of the brain would bulge up into the opening, would be changed in color, being lighter, and would not show this pulsation. Now, I intend to remove a portion of the cicatrices which have formed in connection with the dura mater and the pericranium, in this way getting rid of a series of convulsions which might come from irritation from these cica- trices. Not infrequently such cicatrices are the cause of the trouble. Under these circumstances the patient will complain of signs or premonitions of a burning sensation in the scar or a darting pain or flashes of light etc: Immediately following which there will be a convulsion. This man has a premonition of a flash of light before his eyes and then the convulsion immediately follows. Others have premonitions in the form of certain muscular spasms as, for instance of the little finger, wrist or hand. These are found in what we call the Jacksonian epilepsy. In this form of epilepsy the indications are always to trephine, for you have a certain seat for the disturbance, which in the supposed case above would be in the ascending frontal convolution of the brain. Now, I have removed all of the cicatricial tissue resulting from the healing of the original wound and I am now smoothing off the edges of the opening so as to be sure that there are no spiculae of bone extending from the internal table inward toward the membrane. You see that this area is very considerable in extent and it will certainly relieve the pressure to a greater or less degree and will in that way be a benefit to the patient, especially if we have gotten away all of the osteophytes that have formed. The probability is that we have succeeded in this and that we shall be rewarded by a recovery. This flap is made in such a way that its widest part is most dependent when the patient is in the recum- bent position, and a good condition for drainage is thus effected. Of course after such an extensive operation there will be a good deal of oozing. The manner of making your flaps, as I said in the beginning, will depend on whether or not you return the but- ton to the wound after the operation. If you have the wound open and do not return the button, then the incision should be TREPHINING. 305 made directly down upon the skull through all of the tissues in- cluding the periosteum. By the use of the periosteum the flap is elevated from the bone. But if you expect to return the button, it is best to leave the periosteum attached to the bone, so that the periosteum of the button will furnish attachments for the surrounding bone. In a number of these cases where the button has been returned there has been sloughing and a portion of the bone came away with the slough. But of course, if there is a part of the bone which remains, it is a benefit. We shall not try to return the fragment of bone in this case, but what we shall do is to introduce a few strands of aseptic catgut under the flap to act as a drain for the serum and blood which will accumulate be- neath the flap. Another benefit from this kind of a flap is the good support which it forms. I will catch this bleeding vessel in the line of the suture and shut it off. This method will stop the hemorrhage in every one of these instances, so it is not necessary to tie the vessels separately which are found in the line of the in- cision. However, if the bleeding troubles you in your work, then it is well to tie the vessels. I have used the chisel today, for I was satisfied that it would be more expeditious and by its use I could remove just the amount of bone I desired. Had I used the trephine, I should have been obliged to use it two or three times unless I had used the larger trephine and then should have been obliged to use the chisel in removing the triangular portion of bone left between the openings. This might have been done well with the bone forceps. This kind of forceps which I hold in my hand allows you to pick up any little spiculae of bone which may be projecting from the under surface of the bone. The fact that the inner surface of the skull is irregular and uneven makes these little projections very prone to appear. In using the trephine, you make the incision in the same man- ner as I have made this one. I think that this is the best incis- ion to make, for it makes a perfect covering for the skull and if you desire to return the fragment of bone it forms a species of support for it. If this operation is done with the trephine it is necessary that you hold it still until a groove is made. This would be a difficult task if it were not for the fact that in each trephine is inserted a center pin which projects from 1-8 to 1-16 of an inch. The puint of this pin holds the trephine until the saw is made to hold. As soon as the groove is deep enough to hold the barrel of the trephine, the pin is removed; otherwise 306 INAESTHESIA. it would pass through the skull first and would injure the brain. I do not mean to say that such an accident would be a fatal one by any means. We know that the brain and its membranes may be injured to a considerable degree without any very serious re- sults, but of course we must avoid any unnecessary injury to it. Remember that this circular saw, the trephine, is not applied to a plain surface, and it is impossible to make it break through the inner plate of the skull evenly and at all parts at once without tipping the trephine in all directions. At first there will be but little discharge of blood. When the trephine has passed through the outer table of the skull there will be a considerable amount of hemorrhage calling your attention to the fact that you have reached the diploe. Your anatomical knowledge tells you that the diploe is very cancellous, soft and vascular; therefore the trephine will pass very readily through it and come down upon the inner table of the skull. It is now that the saw must be ma- nipulated very carefully indeed. All the time from the beginning you will carefully measure the distance sawed from time to time, but especially careful will you be in passing the inner plate, that you do not go down suddenly upon the brain. As soon as the button is loosened all around, the probability is that it will come away with the trephine; if it does not, the additional help of the elevator will enable you to lift it out without any difficulty. Then you apply the trephine again in the same way, if the case is an extensive one, embracing the depressed bone between, in this way making the incision as large as is necessary to accomplish your purpose. In all of these cases the large openings are the best. They should be large enough to uncover all portions of the depressed bone which should be elevated. It is well in most instances to replace the fragment of bone. I have replaced frag- ments of bone an inch long and three-quarters of an inch wide in two instances, with the result of having them grow, with the exception of one of the halves of one. It is an advantage to the patient, of course. There is an opinion among the laity that the openings in these cases are covered by a piece of tin or a piece of silver. This is not done nowadays unless we try to close the opening with the bone button which was removed by the trephine. Anaesthesia. It has always appeareed to me to be of paramount importance that the surgeon should bear in mind the fact that complete ANAESTHESIA. 307 anaesthesia, induced by an agent, chloroform, ether or any com- bination of these or any other lethal substance, is always, and must always be a dangerous condition for the patient. Death is so near in this state of abolition of consciousness, sensation and motion that it becomes quite easy to believe that, even a "little thing," may divert the balance and precipitate the patient into his arms. I am inclined to the conviction that surgeons generally fall into the habit of giving the administration of an anaesthetic second- ary consideration in the items of operative work, familiarity with its use, and long periods of freedom from accident are apt to lead one to forgetfulness of the time expended in an operation or the methods of giving the anaesthetic, intrusted as it is, almost en- tirely to a second person, during the care and perhaps annoyance of a prolonged operation. The surgeon who has had a death from the anaesthetic, or one who has come so close as barely to escape, never gives up en- tirely to any one his watchfulness over his patient's actions under the anaesthetic. A careful vigilance should be maintained by every surgeon over the hazardous condition without reference to comparative suppositions as to the safety of different agents or methods. The time is within the memory and practice of some of the surgeons still among us, when operations were compulsory with- out the benefits of anaesthesia and when certainty of action and rapidity of execution, was one of the most desirable accomplish- ments of the surgeon. After the introduction of anaesthesia the habit of delibera- tion and absolute slowness seems to be taking the place of haste and even skillful rapidity. One hears this expression "Time is of no account, operate de- liberately and slowly." Is it not well to ask the question "Has not the pendulum swung too far to the side of deliberation?" It does appear fair to state that time is of great importance to a patient profoundly anaesthetized and, in my opinion, when pro- longed beyond an hour, the administration becomes a matter of serious hazard to the patient. So that in operations requiring a longer period of time the agent should be given with greatest care, drops should be begrudged and every known means of re- suscitation, support and restoration be ready at hand for use in order that there would be no delay in their use in case of necessity. 308 ANAESTHESIA. It is certainly a pernicious habit, no matter how brought about, or for what reason practiced, to heedlessly prolong an operation, simply because the patient can feel no pain. It is well known that the vast majority of hospitals in foreign countries adopt chloroform as the agent used to produce anaes- thesis. No doubt surgeons in private practice all over these countries use the same agents. It never fails there, is not disagreeable, is portable and so sel- dom harmful that they do not ask for anything better. They do not deny that a patient is occasionally lost by its use, but they say death also comes as the result of the use of ether or any other agent. They are honest enough to say that perhaps greater care and attention to the details of the administration of the agent and to the condition of the patient to whom it is given would lessen materially the present low death rate. At least, American sur- geons cannot teach them that ether is safer than chloroform. For instance, a prominent surgeon from one of the large eastern cities visited a foreign hospital and chided the surgeon in charge for using such a dangerous agent as chloroform, although years of use in daily operating have given him confidence in it. The visitor is politely asked to illustrate how a patient can be safely put to sleep and kept asleep with a moderate amount of ether. The ether is being given with the hospital surgeon quietly waiting to commence his work; he notices s.ome change in the patient which causes him to be anxious and ask the visitor if he is sure every- thing is all right. The reply is a prompt and assuring affirma- tive. He still waits and in waiting becomes more anxious, he takes hold of the patient's wrist and finds it pulseless—he insists on discontinuance of the ether in the midst of the reassuring utterances of the visitor. The inhaler is removed and the patient found dead beyond all possibility of reclaimation in spite of pro- longed efforts. This was certainly an unfortunate accident to happen under such circumstances, proving the danger of overcon- fidence here, as elsewhere Personally, my sympathies are with the use of ether, first, be- cause I have always used it and have been associated with those who have always depended upon ether, second, because I have never witnessed a death during its careful administration. On the contrary, I have seen four patients loose their lives during the administration of chloroform, and with no other cause acting to produce their death. TREATMENT OF WOUNDS. 309 There is no doubt in my mind that death may result from the administration of ether, but my experience with it makes me bold enough to say that an unfortunate result comes from ether, the bad condition pathologically of the kidneys or the lungs, or from faulty or careless use, or a combination of both. The danger with ether, principally, is from suffocation, almost invariably the result of carelessness. Usually the suffocation is caused by permitting the closure of the pharynx by the falling back of the tongue or by an accumulation of mucous. The dan- ger of chloroform is from a seeming sudden and absolute paraly- sis of everything vital which so far appears to be unexplainable aswell as irremediable. Further, complicated inhalers, however simple be their con- struction, fail to give any security or ease in administration and after a fair trial have been discarded in my practice for a simple apparatus made fresh for each case out of a towel. They are always clean and hence free from the mouthings and slobberings of many patients, which make the shop inhaler an abomination. They can be had anywhere and allow of most perfect adjustment to the face. The safest inhaler for chloroform consists of a frame made of wire and covered with thin cloth. This should be placed over the patient's nose and mouth and the chloroform should be poured upon this continuously, drop by drop, in order to secure a uniform amount. The thin cloth will permit the vapor of the chloroform to be thoroughly mixed with air. During the stage of excitement, it is well to remove the chloroform entirely until respiration becomes regular. Preparation of Patient for Operation. Before the patient is brought into the amphitheatre, I desire to make a few remarks about the arrangements necessary previous to the performance of any operation, and thus answer the ques- tions asked. During the past six months or more, we have not used any sort of antiseptic fluid as a wash to aseptic wounds. None for any purpose whatever other than a one per cent solution of carbolic acid in water in which to place the instru- ments. We are perfectly satisfied with thoroughly boiled and thus sterilized water as cleaning material, cheap, efficacious, easily obtained and reliable. We do not believe that antiseptic fluids 310 PERFORA TION OF PA TIENT are harmless in fresh wounds, and do not think their use at all necessary when proper and careful preparation has made the site of the operation surely aseptic, and the similar preparations have placed in the same condition the hands of the operator, those of his assistants and all instruments to be used. We try to impress upon ourselves and upon every one having anything whatever to do with the patient or his surroundings, the fact, that the patient's life is positively endangered by the slightest relaxation of vigi- lance in maintaining a thorough asepticism in all things. How is the condition secured? The site of any operation is first thoroughly washed and scrubbed with soap and water. If any hair grows upon the surface have this shaved off. Then it is again washed with soap and water. Secondly—The surface is thor- oughly washed and bathed with a solution of mercuric bichloride i-iooo if near the outlets of the body; 1-2000 anywhere on the general surface. If any natural creases or puckerings exist these must be carefully opened out and cleansed in the same way. After these washings, the surface is sprinkled lightly with iodo- form and a large compress of sterilized gauze soaked in a two per cent, solution of carbolic acid in water is bound on the surface, covered with an impervious material such as gutta percha tissue, and left on until one is ready to make the incision. By carefully carrying out these processes the surface of the body at the site of any operative procedure is rendered absolutely aseptic and the danger from infection of any wound through microbes from the surface rendered practi- cally impossible. Absolutely the same procedure in cleaning the hands and arms is carried out by myself and every assistant and nurse, in order to render them aseptic. Particular and special attention being given to the finger nails. During an operation the hands are frequently washed in sterilized water only, if the operation is an aseptic one, if not, in some antiseptic fluid. The clothing of every one about the patient is prevented from carry- ing septic materials to the wound by having the person enveloped in a clean white muslin gown. The arms should be bare, long sleeves are frequently carriers of all kinds of infectious matter into wounds. The immediate surface surrounding of the point of incision should be covered with dry towels then again covered with towels wet in a two per cent, solution of carbolic acid in water as a means of safety. The instruments are sterilized by being thoroughly scrubbed in soap water, then rubbed dry and then kept in boiling water, to which a tablespoonful of baking TREATMENT OF WOUNDS. 311 soda for every quart has been added to prevent rusting, for one half-hour, after which they are placed in the one per cent, solu- tion of carbolic acid, in which they are kept until used and to which they are returned when out of use during the operation after being washed clean with hot water. All instruments should be so constructed that they can be easily taken apart so that all joints and irregular surfaces may be cleaned. The only sponges used are pieces of sterilized gauze and this is rendered sterile by subjecting it to prolonged boiling in hot water after which it is kept in tightly stoppered bottles dampened with a two percent solution of carbolic acid in water, taken out as used and thrown away. When used they are squeezed as dry as hand pressure will make them, Sea sponges are used in ab- dominal operations and here only because they are more easily managed and accounted for. The ligatures used are either cat- gut or silk prepared so as to be positively aseptic according to the following method: The silk is boiled in water for one-half hour and then preserved in 5 per cent carbolic acid solution. If any piece of silk comes in contact with any external object it is discarded or again sterilized by boiling. The catgut is immersed in sulphuric ether 48 hours in 5 per cent carbolic acid in alcohol 48 hours in 1-1000 bichloride of mer- cury in strong alcohol for one week, it is then preserved for use in strong alcohol or in equal parts of strong alcohol and oil of juniper. We use silk and catgut indiscriminately for either of the pur- poses mentioned when thus prepared, and always cut the ends short. The dressings after the wound is closed as you have fre- quently seen are always dry, iodoform, iodoform gauze, and borated cotton. No solutions of any kind are ever put into an aseptic wound. The idea being to add in no way to the irritation always produced by the use of the knife and other instruments. If the wound is not much irritated there will not be any greater flow of serum than the absorbents are able to carry away, hence, you seldom see a drainage tube used. If one is necessary the ster- ilized perforated rubber drain tube answers every purpose. Now if the wound is already septic how will you proceed? Carry out exactly similar methods as have been already de- scribed for an aseptic operation. Then the septic or suppurating surface should be thoroughly irrigated and cleansed with some of the antiseptic fluids recommended for such purposes. For instance, a saturated solution of boric acid in hot water or one teaspoonful of Tr. iodine to a quart of hot water, or a five per 312 TREATMENT OF WOUNDS. cent solution of carbolic acid in water or less strong, or a solution of mercuric bichloride not stronger than 1-3000 in water. The last mentioned is the most popular antiseptic agent and the one most commonly used because it is the most powerfully destruc- tive agent as regards micro-organisms. But, gentlemen, I begin to believe that thoroughly sterilized hot water is as efficacious as any of these and has, I am sure, the advantage of being harmless to the patient. All the others possess some poisonous properties, many of them are dangerous when used in large quantities and to be of any use under the circumstances we are considering, the quantity must be large. If the suppurating surface is large and old, holding a considerable quantity of free pus, this can be all washed away by the water alone. If it is lined by a dense mem- brane of granulation tissue, the old Pyogenic membrane, I doubt the probability of the strongest and most deadly of antiseptics being able to destroy micro-organisms lodged in it, in fact I some- times think that the coagulating properties of these fluids are likely to fix the micro-organisms in their breeding places, quiet- ing them for the time but a menace and perhaps a real harm for the future. The best method, in my opinion, is to scrape away with the sharp spoon, as you so frequently see me do, all this unhealthy and septic lining down to the health)' tissue underly- ing it and then use only the sterilized water for washing. If the scraping is done I am sure the strong antiseptic fluids are harmful. They never should be used about the brain or abdominal cavity. After the septic surface has been treated as suggested, the fur- ther operative procedures are executed as already described ex- cept that it is very seldom that the wounds are entirely closed by sutures, it is usually best to pack the cavity with iodoform gauze to be left in until loosened by developing granulations. In this way the wound can be kept perfectly aseptic for any length of time, provided the external dressings are changed at proper in- tervals and the same care practiced at each dressing that was carried out during the primary operation. I am sure if you follow out religiously in every detail the minutest direction now given you, adding to their perfection if you can, in the matter of clean- liness and the avoidance of the entrance of any foreign substance into the wounds made, that you will seldom, if ever, be troubled with suppurating wounds. The wounds you make or treat will heal kindly and rapidly and firmly, without much pain and with- out abnormal temperature. You have repeatedly seen me' make the most extensive wounds, and subject patients to prolonged and INFRA-SCAPULAR AMPUTA TION. 313 severe operations, and I have just as repeatedly shown them to you at the end of a week or two with wounds soundly healed and the patients free from any signs of suffering or exhaustion. So, gentlemen, I have some right to speak confidently about these things and to ask of you confidence in the procedures advocated. I like to see the rule which I have given you regarding sup- purative cases carried out here. This case is not exactly a suppurative case, but I was not quite ready to have it brought into the arena. It is the case you remember that was before you with an extensive suppurative osteomyelitis. We opened it, care- fully cleaning out all diseased tissue, and packed the cavity with iodoform gauze. It has done very well. There are no extensive manifestations of inflammation. We will have it dressed outside. Do not operate upon suppurative cases or cases that have been suppurative, until you are through with all of your other cases. Those of you who have attended our clinics for some time have noticed that we are as careful in arranging the order of our cases for dressings as for operation, never dressing septic wounds until all of the aseptic wounds have been disposed of; not that we consider it impossible to completely disinfect our hands after manipulating septic wounds but because we desire to eliminate every possible source of infection. A Precise Method of Excision of Clavicle, Scapula and Humerus* I am induced to present this case to you this evening both be- cause of the rarity of such cases, and because it affords a very good example of the recover)' of the human body from terrible injury. I will at the same time show you the specimen, which displays the disease in situ, and the amount of affection there was present. Before doing this operation, I, unfortunately, had not inquired very carefully into the subject; had not read much about it, and hence, did not know much of the history of the operation, nor the circumstances under which it was adopted. But I have since been enabled to collect a little history of this operation, and will read what I have collected, mainly an abstract from a paper read before a society in Berlin by Professor Adelmann. These cases *Read before the Chicago Medical Society, January 21, 1889. 314 INFRA-SCAPULAR AMPUTA TION. come to the attention of the surgeon under three circumstances: first, the operation is done for the surgeon by machinery or some accident previous to the patient coming under his charge; second, the surgeon does a series of operations, removing first one part of the member, then another part, and finally a third or fourth part, until the patient dies of recurrence; and third, the primary removal of the entire extremity as soon as the disease is recog- nized—the heading under which this case will be placed. Professor Adelmann addressed the Surgical Society of Berlin, June 4, 1888, concerning the operation for the removal of the upper extremity, together with the scapula and a part or whole of the clavicle. His address contains the history of the operation placing the date of the first reported case at 1808. The operation was next performed, between 1830 and 1840, five times; between 1840 and 1850, five times; during the next decade, three times; during the next, seventeen times; during the next, thirteen times; and since 1880, twenty-six times; making in all 70 reported cases. He discusses the statistics of Paul Berger, comprising 51 cases, and his method of operation. Adelmann makes three classes: (1) cases in which the operation was performed after traumatism; (2) cases in which the operation was performed for benignant tumors; (3) cases in which the operation was performed for ma- lignant tumors. In the first class are 14 cases with 9 recoveries; in the second class, 3 cases with 3 recoveries; in the third class, 50 cases with 24 recoveries. This third class is subdivided into sarcomata, of which there were 26; enchondromata, 7; encephaloid tumors, 4; the remaining number bearing different names in different lan- guages. Of the 50 cases with malignant tumor, in 25 the entire opera- tion was completed at one sitting, among these 25 cases there were 10 recoveries. Of the 25 cases having more than one oper- ation each, 19 cases were operated in two sittings with 10 recov- eries, 4 cases had three operations each with 3 recoveries. Of 2 cases with six operations each 1 recovered. These recoveries apply simply to the operation itself; deaths from recurrence after healing of the wound are not counted in the statistics. Among the 25 cases in which several operations were performed there are 17 in which the arm was primarily removed, but having recur- rence it was found necessary to remove the scapula and clavicle. Professor Adelmann remarks that this should induce us in the future to perform the entire operation at once, as these cases were INFRA-SCAPULAR AMPUTATION. 315 all seen early, and the chances for radical cure must necessarily have been good. As it was, only five of all these 25 cases re- mained free from recurrence for years after—one after 30 years, one after 20 years, two after 6 years, and one after 3 years. In the 15 cases of death after one operation, 7 cases were due to the operation or to the low condition of the patient at the time of operation; 2 to shock; 3 to hemorrhage; 1 to gangrene of the flaps; 1 to purulent pleuritis; and 1 to secondary hemorrhage. In 8 further cases in which the wound was entirely or almost entirely healed, the patient died from recurrence, five times in the lungs, the time of recurrence varying from three years to four months after the operation. In view of the frequent occurrence of secondary tumors in the lungs, the author advises careful ex- amination of this organ, and considers an evidence of the pres- ence of tumors in the lungs as a contra-indication for operation. The percentage of recoveries from this operation for malignant tumor is a little less than 50. Many methods of operation have been adopted by the different operators, but the plan of ligating both the subclavian artery and vein primarily seems to be ad- visable. I will show the case as rapidly as possible, in order to let the patient get out of the room. You see the wound is healed, ex- cept this one spot of granulations. The boy, from his general appearance, is much healthier and stronger than previous to the operation. You will notice that there are quite a number of little pleats here, as if the sewing had not been very well done; there is apparently a superabundance of flap at the upper part which might have been used to close this gap of ulceration. This re- sulted because I had not a plan in view before the operation and made my flaps a little too redundant, so that when the lower flap was brought in contact with the upper one its fullness caused the foldings during the apposition. This case came before the clinic at Rush Medical College; a boy much reduced from pain, displaying merely an enlargement of the upper end of the humerus, implicating the shoulder-joint. The growth surrounded the bone, but was not uniform in devel- opment. Manipulation showed seeming fluctuation, both on the anterior and posterior aspect of the tumor, so much so that friends who sent him supposed that to open an abscess would be all that was necessary. But the appearance of the patient and the gen- eral aspect of the tumor rendered me suspicious, and, therefore, I introduced an exploring needle; instead of pus, I got only 316 INFRA-SCAPULAR AMPUTA TION. blood. The exploring needle went through the soft tissues to the bone, calling attention to the fact that there was not only implication of the soft part, but also disease of the bone itself. It seemed evident that it was a case of sarcoma of the shoulder joint itself, probably commencing in the capsule and passing from it to the tissues around it, and that it would be very likely to recur after amputation, or other simpler operation upon the shoulder-joint. I explained to the father that as it was a malig- nant tumor, the only thing that seemed to me feasible was the complete removal of the shoulder. He consented to the opera- tion. From the report I have read, you will understand that the im- mediate danger of the operation is haemorrhage. There is an- other danger—the introduction of air into the veins as they are divided. In all operations about the large vessels of the neck or axillary space, where the veins are apt to be patulous, there is a source of anxiety to the surgeon from this cause. To over- come these immediate dangers, primarily to any incision for am- putation, the circulation must be controlled by ligation of the subclavian artery and vein. This vein contains a large mass of blood, and if divided without control of it, much blood is lost, aside from the danger of the introduction of air. Not having seen the reports of Paul Berger's method, I proceeded with this idea in view, and made the first incision above the clavicle, un- covering the subclavian artery, which was ligated close up to the side of the scalenus anticus muscle. The incision was then carried directly over to the top of the shoulder, the same as for ampu- tation at the shoulder-joint. This incision was prolonged to the axillary space and along the line of the axillary border of the scapula. As soon as the axilla was opened, the pectoralis major and minor muscles were divided and the axillary vein was included between two haemostatic forceps and divided—the main trunks of the brachial plexus were then divided. The arm was then drawn over the front of the body and this incision adopted for excision of the scapula—following the spine of the scapula- so that the posterior flap was divided into two poitiors. These two flaps were dissected off until the posterior part of the scapula was uncovered; raising it from the chest wall, the muscles were divided and the extremity removed. All bleeding points, to- gether with the axillary vein, were now ligated and the flaps united. This operation was not made upon any specific plan. Follow- INFRA -SCA P ULA R A MP UTA TION. 317 ing the suggestion of Mr. May, who, in the last issue of the Annals of Surgery, reports two cases of this operation, I have looked through all the books in my library and have not found any specific method given. It remained for Paul Berger to give a plan for it. He was led to the plan he suggests after several trials upon the cadaver. The quickest and easiest method of doing the operation and securing the blood-vessels is according to his plan of procedure. He makes his first incision from the inner extremity of the clavicle outward to the top of the shoulder, immediately uncovers the clavicle and turns it out of the way; this leaves the subclavian vessels exposed so that they are easily secured. You all remember well as a result of past experience that as the front of the axillary space is uncovered there is always to be seen a ridge across it produced by the raising of loose tis- sue upon the external thoracic nerve. It is easily found, and I call attention to it because passing outwards this nerve leads directly to the interval between the artery and vein, and hence to them. With the clavicle out of the way the vessels are super- ficially situated, easily isolated and free from diverging branches. The artery should be tied in two places, an inch apart, and divided; and the vein also; then the circulation is absolutely under control. May advises that just before the vein is tied the arm should be elevated for a few minutes to allow the venous blood to drain from it, thus saving as much blood as possible for the patient. In my second case I applied the Esmarch bandage up to the axilla. As soon as the arteries are secured in this position, by a rapid cut with the scissors, the brachial plexus can be divided and the pectoralis major and minor be severed. The flap portion of the operation is done in this way: Com- mence at the center of the anterior incision and carry the knife directly across the anterior part of the axilla and inner arm to the lower angle of the scapula; then from the outer edge of the incision, posteriorly, carry the knife behind the joint to the same point; rapidly reflect the posterior flap; then all the muscular attachments should be divided and the extremity removed with- out any trouble. This gives a perfectly even anterior and pos- terior flap, coming together easily and nicely, and avoids the unseemly appearance of the anterior part of this wound, which was caused by the too redundant anterior flap. This operation was done six weeks ago, and after the first few days there was no time when we felt particularly anxious about the patient's recovery. The patient's perfect recovery has been 318 INFRA -SCA P ULA R A MP UTA TION. interfered with by an accident, the effect of which you notice, the sloughing of the flaps, leaving this ulcer. In dissecting up the flaps one is compelled to keep close to the surface, diminish- ing greatly the nourishment of this immense piece of skin. The danger is increased if the post-scapular artery is wounded; so it is necessary to bear in mind the direction of these incisions in order to secure as neat a stump as possible. Prof. Adelmann goes on to show that an artificial extremity can be applied in these cases, which overcomes the lack of symmetry, and which can also be made quite useful. The second case came in about two weeks after this first, demon- strating the assertion that all cases come in couples. A man 37 years old came in one afternoon, with a tumor on the top of his shoulder, occupying the situation of the supraspinous fossa. It had all the indications, so far as external appearances, of a fatty tumor. A surgeon in charge of a clinic labors under this disad- vantage in all his cases; he has no opportunity for previous examinations, and hence is apt to go into a case without as com- plete an examination as it is entitled to. This tumor was examined hastily and the history hastily passed over, and the suggestion made that, in all probability, it was not a fatty tumor but, from the rapidity of its growth, would prove to be malignant, and that it was connected with the superficial tissues of the spinous fossa. As soon as the incision was made and it was exposed we saw the mistake. It proved to be a tumor that grew primarily from the shoulder-joint, and particularly from some part of the capsular ligament, crowding out from beneath the supra-spinous fossa and developing as large as a cocoa-nut upon the man's shoulder. The man had not consented to so radical an operation as entire abla- tion of the upper extremity, so only a temporizing operation was done; the removal of the tumor so far as external manifestations were concerned. He afterward had the nature of the growth explained to him and, after consulting with his friends, decided, in about three weeks, to submit to the operation. It was done; but he died fifty-six hours after the operation. He was slightly shocked by the operation, but recovered from that and for twenty- four hours was quite well, with only a slight elevation of tem- perature and pulse; he was then taken with delirium and died in a comatose condition. I do not know exactly what was the cause of death, but I am inclined to think that it was poor policy to do this severe opera- tion as soon after the primary interference. The man was still AMPUTATION OF LEG. 319 depressed and in great fear of the severity of the second opera- tion. All these facts were against him. In this case the operation, after the method I have described as advocated by Paul Berger, I am sure was more quickly done, and with more satisfaction to the operator and, if he had lived, to the patient. This second case properly comes under the head of secondary operations. It is quite noticeable from the report read that the cases done by machinery are all reported as recovering, and it is question- able whether they have a place at all in the classification of this operation; because the deaths after such accident are not reported at all. Amputation of Leg for Gangrene Due to Traumatism. This young man came into the hospital last night. His foot was injured five weeks ago by compression in a hay press. Both the direct and return circulation were cut off, and as a result of this the parts have dried up and we have dry gangrene. In most cases gangrene comes on as a result or failure of return circula- tion. In this case the entire nutrition to the part is shut off. It has destroyed the tissues and ligaments of the heel. Infection has taken place since the occurrence of the injury and we have a septic ankle joint, and I propose to amputate above it. I do this because the tissues of the ankle are destroyed as well as those of the heel, and to secure healthy flaps it is necessary to go above them. The Syml amputation removes the foot by a section through the leg just above the tips of the malleoli, a flap being made from the tissues of the heel. It is impossible to do this operation in this case, and as the young man is in a septic condi- tion I am sure that his chances are better to make the amputation above the ankle. If he were in a condition to improve I should wait with the hope of being able to do the Syml operation. In doing this I shall make the skin flaps anterior and posterior from without inward, dissecting these up a little beyond the angle of the flaps, and then make a circular incision through the muscles. You will remember the rules I have given you regarding the flaps. They need not be repeated here. With this flap you take up the skin and facia; the sweeps of the knife should be trans- versely to the limb and not obliquely, because if the knife is held parallel with the skin it is likely to cause a splitting of the ves- 320 AMPUTATION OF LEG. sels. Now the flaps have been formed, I retract them freely, so as to make the division of the bone a little above. I reflect the muscles and periosteum to a point a little above the prospective line of division of the bone. I then introduce this retractor made of gauze, so as to protect the muscles from the saw. Make the furrow with the heel of the saw and saw the smaller bone first. Then feeling for any irregularities on the ends of the bone, these are removed by means of bone forceps. Be careful when you pick up a blood vessel to pick up the nerve accompanying it and dissect it back and divide it so that there will be no danger of tying it in the ligature. Tie the ligature by passing the thumbs down close to the vessel, then tie as tightly as you can with- out breaking the ligature or cutting through the walls of the vessel. In order to prevent the sharp edge of the tibia from burying itself into the tissues of the anterior flap and producing an ulceration, I usually saw it off obliquely so that there is no sharpened edge of bone to irritate the skin. It is best to hold sponges to the surface of the wound and remove them gradually as you take up the blood vessels after loosening the Esmarch constrictor. Usually you are not likely to have any bleeding if the main vessels have been tied before the Esmarch constrictor is removed. Here is a little bleeding from a small vessel running down on the inner side of the fibula, or a smaller one running down along the tendo-achillis. The flaps will be brought into position and will be united by silk sutures. You notice that this wound has not been washed, and as a result of this there will be but a small amount of serous discharge, consequently it will not be necessary to employ a drainage tube; but irritating the surfaces with antiseptic solutions will give rise to exudation of serum in considerable quantities and you will have to use a drain- age tube, A large dressing of iodoform gauze and aseptic cotton will be applied and held in position by a carefully applied roller bandage. The pressure made upon the flaps in this manner will be gentle and uniform and will keep the surfaces in perfect apposi- tion. The limb will be kept in an elevated position for a few clays in order to prevent congestion or cedema. AMPUTATION FOR TUBERCULAR ANKLE. 321 Amputation for Tubercular Ankle. Duncan, Mc. 425 S. Western Ave., age 24, American, clerk. Here is a man with a diseased ankle. It has been a source of great trouble to him for a great many years, and he comes with the request that the foot be amputated. He says that there is no use for me to operate on it and remove the dead bone and dis- eased tissue, and try to make a good foot out of it. He further says that unless the amputation is made that he will have nothing done to it, because he has had much sad experience with conservative treatment. We will accommodate him by removing the foot. You see that the foot is smaller than the normal one on the other side, and it has been diseased so long that he may be right in his opinion. And now that I come to examine it more closely, I am inclined to believe that he is right as to what should be done, for I think this could not be made to answer the purpose so well as an artificial limb. In children the repair in these cases is much more rapid and complete, and the conservative operation should be done. The patient came accompanied by the artificial limb maker. They had concluded between them as to the place at which the limb should be amputated. It is a rule among artificial limb makers that a stump six inches long is the best to which to attach an artificial limb. Consequently the patient and his friend had fixed upon the length of the stump, and so we shall accommodate them again by amputating the limb according to their wishes. The assistant has a very important duty to attend to, and that is the holding of the limb firmly. When you use the Esmarch constrictor it does not matter which flap you make first. Ordinarily it is best to make the posterior flap first to prevent its site from becoming obscured by blood, but as we have secured a bloodless condition, I shall make the anterior flap first. I shall make the old fashioned skin flap. This-limb is full of varicose veins which will have to be ligated just the same as arteries for they will bleed very freely. I find here along the line of the vessels what is often the case in tissues which have been inflamed for a long time. The vessels are agglutinated so that it is almost im- possible to separate them. There is not a particle of skin too much on this stump. The flaps are all the better for being long and loose. The skin will contract and make a perfectly smooth surface. It is very important not to have any tension upon the flaps, in 322 AMPUTATION FOR TUBERCULAR ANKLE. order to secure primary union throughout. The periosteum is retracted for a distance of about an inch, so that the sawed end of the bone can be covered. This prevents the end of the bone from adhering to the skin, which makes the end of the stump much less tender, and less likely to become irritated. The sharp point formed by the spine of the tibia is removed before the periosteum is drawn down over the end of the bone. We will ligate the anterior and posterior tibial, and the peroneal arteries, and the internal and external saphenous veins and their en- larged branches. The posterior tibial nerve is now drawn down and resected to the extent of about two inches in order to prevent the formation of amputation neuroma. We will unite the flap throughout. Drainage is not necessary for this wound, because every precaution has been taken to pre- vent infection and the tissues have not been irritated by the use of antiseptic fluids. The application of the ordinary dressing of iodoform gauze and absorbent cotton, and the fixation of the stump by means of a posterior splint will complete the operation. Amputation of Leg for Tuberculosis of the Ankle. Mrs. H., Benton Harbor, Mich., age 45, American, housewife. This is the patient whose foot we amputated a week ago to-day. It has not been dressed since the operation. There has been no rise of temperature at all and we naturally expect to find the wound in a good condition. This is a peculiar case in that it is the first one that I have seen in which there was absolutely no arterial bleeding from the stump after an amputation. I have seen bleeding that was very small in amount, as in the old lady's limb after the amputation for senile gangrene some time ago. There was but little haemorrhage in that case, but there was a little. In this case there was none whatever. Perhaps there is but one explanation for it in this case, and that is that the limb has not been used for years and years. There is a general atro- phy of the limb and the arteries are diminished in size, so that the blood just flowed through them as it does through capillaries. This condition of affairs being present, you would suppose that there would have been some interference in the nutrition of the stump. Yet there has been no rise in temperature whatever. there is a partial ankylosis of the knee-joint, as you remember, AMPUTATION FOR TUBERCULAR KNEE. 323 which prevented our elevating the stump in anyway. The stump is not in as good condition as I expected to find it. Here is a little spot along the margin which has not healed. This is prob- ably due to pressure from the dressing rather than from infection. There is a little necrotic condition of the cuticle, the epidermic layer, which does not extend entirely through the integument. To avoid pressure upon the tissues and to prevent infection we will have applied to the stump a fomentation of 2^ per cent, car- bolic acid, rather than the dry dressing. It will be more grateful to the patient and at the same time will correct the disposition toward the destruction of tissue. You notice that I have washed it freely with alcohol, instead of water. The alcohol is an anti- septic in itself and it is a little stimulating. Any washing that is done on the surface of the wound is done with alcohol. The stump looks well in every part except at this one spot. The drainage tubes are no longer doing any good and we will leave them out. The openings made by them will remain open long enough to allow the escape of any fluid which may remain between the flaps. Amputation for Tubercular Knee-Joint. Gentlemen: The first patient that I show you to-day is a child with an old tubercular trouble of the knee-joint for which a resection was done some time ago. But the disease was not arrested by the operation and the only thing left for us to do in order to eradicate the disease is to amputate through the thigh. This brings up, therefore, the subject of amputations. Amputat- ions are done both for injury and disease. Oftentimes it becomes necessary for the purpose of staying the progress of the disease to amputate above the diseased portion in the healthy tissues, as in this case. The progress of the disease is so positive and of such a malignant character that we must interrupt it by removing the seat of trouble by means of amputating in healthy tissues. When you come to examine the case of an injury there should be no hesitancy as to what you should do. If the injury is con- fined to the bone and the large blood vessels and nerves are un- injured, no matter how serious the injury to the bone may be, under no circumstances are you justified in performing an ampu- tation. If the circulation is good below the injury, as ascertained 324 AMPUTATION FOR TUBERCULAR KNEE. by the pulsations in the larger arteries and the color of the skin there will be no doubt about your ability to save the limb if the tissues are maintained in an aseptic condition. But on the other hand, if the larger vessels are destroyed the amputation will be necessary. After you have concluded that an amputation is nec- essary, then you will need certain instruments which must be carefully prepared according to the methods I described to you at the beginning of this college year. You will need a good heavy scalpel, a catlin (this small size will do very well in this case), this saw, or a butcher's saw, and bone forceps. Usually there are spiculae of bone present after the section, which must be bitten off by bone forceps. You will also need a half dozen or more of these haemostatic forceps for stopping haemorrhage. Besides these forceps you will need a pair of dissecting forceps to enable you to pick up and dissect tissues. Then you must have catgut or silk ligatures and sutures. The catgut thoroughly sterilized is perhaps best and we generally use it. When all of these in- struments, the limb, yourself and assistants have been made aseptic you are ready to begin the operation. You will first make the limb bloodless by elevating it a few minutes and allowing the blood to flow back into the body; you maintain the limb in this condition by means of the elastic band fastened high 'up about the thigh. You decide upon the kind of operation —whether you make flaps by transfixion, partially skin flaps and partially muscular, or whether you make the circular amputation. In the circular method the stump will be covered only by the skin and superficial fascia, these being divided by a circular sweep of the knife, dissected up, reflected back, and the muscles divided by a similar circular sweep of the knife to the bone. If you amputate by the method in which the flaps are partially skin and partially muscular — by the way, I think this is the better method—you choose the seat for the section of the bone, seize the limb between your thumb and fingers and estimate the length of the flaps, which, of course, should be a little longer than half the diameter of the limb, so as to provide for the retraction of the integument. The skin flap is made first by an oval incis- ion through the skin and superficial fascia down upon the muscle. It is then seized with the fingers and dissected up the desired distance. During this part of the operation you will always be very careful to hold the knife squarely across the tissues of the limb. If the knife is held parallel with the skin it is likely to plit some of the vessels, which will give rise to troublesome AMPUTATION FOR TUBERCULAR KNEE. 325 bleeding. It makes no difference whether you make the anterior or posterior flap first. The anterior flap is made a little longer than the posterior one in order that the scar shall be drawn a little behind the stump, thus avoiding pressure upon it by the artificial limb to be worn. As soon as these superficial flaps are made, a circular incision is made down through the muscular tissues to the bone. In a thigh of this kind I should not think for a moment of trying to amputate by the transfixion method, but would make the flaps through the muscles to the bone in the same way that the flaps of the integument are made. You see the assistant making the incision straight down the muscle in the manner that I have indicated. Always remember to guard the direction of the knife as suggested. The knife is nothing but a microscopical saw and it is designed to make the incision with a free sweep of the knife. As soon as the bone is reached, the entire mass, together with the periosteum, is retracted to a distance that will allow the section of the bone to be made a little higher than the base of the flaps. Then the flaps are brought down over the bone, representing an inverted cone with the base at the integ- ument and the apex at the junction of the flaps. Before sawing the bone, place a piece of gauze around it and press the soft parts back out of the way of the saw. When you saw, stand directly over the work. As soon as the section is made you search for the blood-vessels. Finding the femoral artery first, you separate it from the surrounding connective tissue a little, so that the walls of the artery are all that will be contained in the bight of the ligature. The femoral vein is next tied in a similar manner. Usually you will be able to find the other vessels and ligate them. We will use the silk ligature for tying the artery. If you are sure the cat-gut is aseptic it answers just as well, and you will not have the subsequent bother of an abcess and the discharge of the thread through a sinus as is so frequently the case when silk is used. The assistant did not follow the directions exactly, and he has what might be termed the oval flap. This flap, however, is a very good one and will answer every purpose. Taking the constricting band off, and removing the gauze, the bleeding vessels are caught with forceps and ligated. I know that the assistant has secured the femoral artery in this case, for I can see it pulsating. I think it is well at this stage of the operation to wait a little and be sure that all the vessels are caught and ligatures applied, whether the vessels spurt or not. As soon as the bleeding has been controlled by the application 326 AMPUTATION. of ligatures you are ready to close the wound with sutures. You may adopt one ot two methods: you may close it by a series of deep cat-gut sutures, sewing the periosteum and fascia near the bone, then the muscles and tissues a little away from the bone, then the deep fascia, and finally the integumental surface. In this way you have the surfaces of the tissues brought closely and firmly into apposition, and you avoid using the drainage tube, which is a disadvantage in any wound, because it leaves a fistula for a time at least. In closing the wound you must be very care- ful not to include the artery nor to prick it with the needle. You see that this child has not lost an ounce of blood in the operation. The time was when an operator was supposed to be able to am- putate a limb in three minutes. This was before the day of anti- septic surgery, and also before anaesthetics were used. The idea was to do the operation without shock by rapidity of action. In this day of anaesthetics time is not of any consequence in compari- son to the suggestions which I have mentioned to you in getting a good stump. If you are not in a hurry in doing an operation the probability is that you will do a good one. This limb should heal by first intention. There is scarcely any irritation, and the temperature will perhaps not reach 101 degrees F., and this will be because there has not been any septic material introduced into the wound. If there has been any septic material introduced into the wound there will be pain in the stump, and a new dress- ing will be required in a day or two. If not septic, the dressings will not be changed for a week or ten days. Then, as you see, it is well to try to do the aseptic operation by prophylactic preparations of yourself, your instruments, the patient and your assistants in avoiding the introduction of septic material into the wound. If you do this, the worst of operations may be done without result- ing in much pain or discomfort to the patient. When you use the continuous suture, I think it is well, after you have gone over the entire surface, to begin again and go over the surface, intro- ducing interrupted sutures between the continuous sutures, so that if the latter give way the former will hold the flaps in position. When the flaps are separated for any reason, the healing will be by granulation. The ordinary dressing of iodoform over the surface, loose iodo- form gauze and borated cotton will be applied extending well up on the buttocks. A bandage will be carried up to the waist to secure the dressings, and the thigh will be kept in the flexed posi- tion. The child will be comfortable with the thigh in this posi- AMPUTATION. 327 tion. It will interfere in a degree with the direct flow of blood in the femoral artery of the stump, and it also assists the return circulation. Elevation should always be practiced for this reason. Amputation of Thigh for Charcot's Knee. J. C. H., Stonington, 111., age, 48, American, farmer. Family history good, patient well until he entered the army at the age of twenty. This patient has had slowly but constantly increasing symp- toms of locomotor ataxia, probably caused by exposure during three years service in the war. But he appears before us to-day for relief from disabling dis- ease of the right knee-joint, which you can plainly see is very much enlarged and misshapen. Fourteen months ago he first noticed an unusual snapping and grinding in the knee during motion. The knee and the leg below, as far as the ankle became swollen. The swelling of the leg gradually subsided, but the knee remained swollen and its distortion gradually increased, until now an examination shows it to be completely disorganized, movable in all directions, the ligaments apparently destroyed and every motion made in it accompanied with harsh, rough grating. It is also filled with fluid, which upon aspiration is shown to be reddish serum. He has had amazingly little pain in the joint itself, when one considers the amount of apparent destructive change that has taken place. Yet he has complained, and does complain, of severe shooting pain throughout the leg, and es- pecially in the upper third of the tibia, which you can plainly notice is much enlarged. The shooting pains spoken of are common to, and characteristic of this general disease, for I take this to be clearly a case of Charcot's disease of the joint, a con- dition not infrequently present as a complication of tabes dor- salis. It is so named because Professor Charcot, of Paris, was the first one to thoroughly describe it. The most noticeable peculiarity about the disease is well illustrated in this case, in which the most destructive changes have taken place without correspondingly severe manifestations of their progress. Believing the patient will be best relieved of his trouble by an amputation of the thigh through the middle, we will proceed to do that operation. 328 AMPUTATION. The limb was removed by forming the ordinary long anterior and short posterior flaps by transfixion. No antiseptic fluids or washes of any kind were used on the stump; it was dressed with dry dressing, iodoform, iodoform gauze and borated cotton. The thigh had been rendered thoroughly aseptic before the operation. The joint was opened and displayed to the class; it displayed the characteristic appearance of a Charcot's joint—the fluid was sanguineous, the articular ends of the bones enlarged, that of the tibia being worn off as by a grindstone. The ground surface showed extreme hardening. Amputation at the Hip-Joint. You have seen this patient before. We removed the limb at the hip-joint a month ago and the patient went on to complete recovery from the first. We have a perfectly healed wound, with the exception of this little point of granulation which would not be there had it not been for the fact the the upper edge of the flap was a little prominent and pressed against the dressing, which gave rise to decubitis. You will always have gangrene if any part of the flap is subjected to undue pressure. Even the weight of the dressing is sufficient to cause death in the super- ficial layer of the skin over a prominent portion of the wound, and if a slight gangrene thus takes place, it delays the healing process, of course. You remember that this patient has done a great deal for the benefit of surgical instruction. When first I saw her, she was quite a young girl with a tumor as large as a hen's egg in the popliteal space, which I examined. Aspiration showed a bloody fluid, and I looked upon the tumor with suspicion, pronouncing it malignant, and advised its early removal. The parents thought the advice rather harsh and took the patient away without an operation. Later, the patient returned with the tumor developed to twelve times its former size. This time it was found to be a sarcoma developed from the sheath of the sciatic nerve, having a connective tissue capsule out of which it could be shelled. We amputated the limb at the middle of the thigh. The patient re- covered from the operation and went home well three weeks after the operation. W7e confirmed the diagnosis of sarcoma by a microscopic examination. Eighteen months afterward, she AMPUTATION. 329 came back with a well defined, circumscribed, hard tumor on the posterior flap of the thigh. It'was a malignant growth and there was nothing to do but to amputate at the hip-joint. This was done in this amphitheatre four weeks ago and the patient is before you to-day to show you the success attending the operation. Knowing that the tumor grew from the sciatic nerve, I took the pains to fix the nerve, d issectit up, and cut it as near the sacral foramena as possible. This is the ninth hip amputation that you have had before you, only one of the nine was primarily fatal, and that case not from hemorrhage. And I should be ashamed if any one of you who, having absolute control of the patient, should allow him to die from hemorrhage in such an operation, if he had not previously lost much blood from accident, for you have been taught how to control the hemorrhage completely. This can be done as successfully as in the lower part of the thigh by carrying a large elastic rubber drainage tube over the tuber- osity of the ischimn, over the anterior superior spine of the ilium, over a roller bandage 2 inches long and \y2 inches in diameter placed directly upon the femoral artery, then extending over the crest of the ilium where it meets the other end of the tube. This tube is tied and then stretched up along the side of the body by an assistant, and the roller bandage is held in place by another assistant. We now make the flaps and saw off the femur several inches below the great trochanter. The large vessels are now caught and ligated; then the bandage compressing the femoral vessels lifted by- the assistant, and any bleeding points are caught and ligated. This done the con- strictor is removed entirely and the slight amount of hemorrhage which follows is controlled. In order to remove the remainder of the bone a large individual incision is made over the great trochanter, and then the head is dis- articulated without difficulty and without causing any hemorrhage. It is, of course, necessary to place the rubber constrictor and the roller bandage which compresses the vessels in the hands of reliable assistants. Chopart's Amputation. John; Chicago; age 40, American, printer. This is the man who had a double Chopart's amputation for gangrene following frost bite. I must say that this Chopart's 330 AMPUTATION. operation finds no favor with me. I have been called upon a num- ber of times to amputate the foot after this method. There is al- most always some difficulty with the stump. In some the stump, has not healed at all. The condition is frequently such that you are not able to leave flap enough to prevent tension on the stump. and unless this can be done the Syme operation had better be done, or better, the amputation of the lower third of the leg. Then with the aid of an artificial limb the patient will have no more trouble. This man has the remains of a slough resulting from his decu- bitus in his long confinement during the process of healing. You should always remember this effect of pressure. This sloughing is not an unfrequent occurrence unless you prevent the pressure. The diseased condition is likely to extend into the bone. This patient has not been able to be on his feet since the opera- tion, which was performed a year and a half ago. He does not yet consent to an amputation at a higher point on the limb. 1 am satisfied that nothing short of that will absolutely relieve him. He desires to have these sinuses healed. They lead down to car- ious bone. It will therefore be necessary to open down upon the dead bone and remove it. We make the incision along the course of the sinus to the bone, elevate the soft parts from the bone as I am doing by means of the periostom. We will remove all of the carious bone, and will take off quite a piece of bone to prevent tension from the cicat- ricial tissue. I am confident that this will not cure the man. If not, he will be willing next time to try something better. We will cut out the entire track of the sinus which leads down to the denuded bone. These cavities will be thoroughly scrubbed and packed with iodoform gauze, secondary sutures will be applied which will be tied after removing the gauze packing four or five days from now. Contusion of Back. A., 282 Fifth Ave., age 26, American, farmer. About two weeks ago this gentleman fell about nineteen feet striking on his shoulders. He struck on some planks, and there seems to be great trouble in the lumbar region. Of course this is a sprain of the baek; it may be a stretching of fibres or a tear- ing of the sheaths of the muscles. If it were the latter, there INJURY TO SPINE. 331 would be extravasation of blood and a discoloration of the skin, ecchymosis, would be manifest. There is nothing of the kind present in this case. I imagine that there has been some concus- sion of the spinal chord, and if that be true he will complain of pain from the nerves that are given off from that point. In answer to my question he now tells me that he does have pain in the leg; this goes to prove the fact that there has been some in- jury to the cord. Treatment: The best thing that we can do for him is to apply a plaster-of-Paris jacket and in this way take the strain from the muscles and secure permanent rest for the parts. Injury to Spine. Ruby; Welton, Iowa, age 5, American. Family history and previous history good. This little patient fell from a baby carriage about a year ago. The mother noticed that the child was a little round shouldered, but did not notice the prominence of the spine in the region of the third dorsal vertebra until within the last few weeks. The child complains of pain in the chest. You notice the marked antero-posterior curvature of the spine, and the accompanying attitude taken by the child. A plumb line let fall from the third dorsal vertebra would pass behind the buttock. There are marked compensatory curves forward in the cervical and lower in the dorsal regions to make up for this abrupt curve backward in the upper dorsal region. There is undoubtedly a softening of the body, of the third dorsal vertebrae. Not infrequently, tuber- culosis of the bodies of vertebra—Pott's disease—follows an injury similar to the one this patient has sustained, but in the absence of a tubercular family history and in the presence of such excellent general health the condition present must be attributed to the injury itself and not to a supervening tuber- culosis. You can readily understand why the pain is in the chest; the curve is so high in the dorsal region. The cervical region is not implicated, excepting in the normal compensatory curve, and the curvature of the spine in the dorsal region is not low enough to interfere with the abdomen. A cast in this case would be of very little service, except as a support. The child looks so well that 332 TUBERCULOSIS OF SPINE. I am inclined to believe that if she were put to bed for a year or six months the disease would come to an end, as it is not particu- larly active now, and nature seems to have begun to establish some fixation of the joints. Butter, cream, milk and cod liver oil should be given in as large quantities as the child can toler- ate. In that way there will be an end to the disease in the bodies of the vertebrae. It is a case that will improve rapidly, but there will be a permanent deformity. There is no means with which we are acquainted by which the deformity can be restored. Pott's Disease of the Spine. Arthur; Kensington, 111., age 2^ years, American. Watch this little fellow walk; see how he holds his head. The head is held back in this peculiar position in order to get in a line with the vertebral column. You have noticed the peculiar prominence found in the dorsal region and see that it is due to a curvature of the vertebrae backward in that region, very plainly shown. The body of a vertebrae being the seat of a tubercular inflammation has become so much softened that it is no longer able to bear the weight of the body. The approximation of the body of the vertebrae above to that below, cause the displacement and consequent prominence of the spinous process. The little fellow is very well in every other way and gets around much better than the majority of such patients do. I do not know that I can explain this, except that it is due to an effort on the part of nature to cure the disease, and that the defect in the body of the affected vertebrae has been covered by new bone as the disease has progressed. Owing to the fact that the child has so little difficulty in getting about and that his health otherwise is good, I am not inclined to confine him with a cast or other apparatus. Unless the disease should, later, manifest a disposition to rapidly increase I am inclined to believe that it would not be of any ser- vice to him. I should give the child plenty of good food, such as milk and butter, all kinds of fats and ale and beer, if he will take them, and let him run about out of doors. We have here a disease developed in the bodies of the verte- brae, which is caused, the same as in the lungs, by the bacillus of tuberculosis. The spinal column has become curved posteriorly TUBERCULOSIS OF SPINE. 333 and the child involuntarily carries its head back on its shoulders in this manner, making a compensatory cervical curve to bring the head in a line with the column. We will advise the treatment already indicated. If there is any kind of change in the spine indicating a rapid degeneration of the vertebrae, then a cast carefully applied may be of advantage. And perhaps an apparatus would be applied with it to carry the weight of the head. Blanche E., 2928 Honore St., age 7 yrs., American. You have heard how well this little girl's mother described the symptoms of the case. It is so well marked that I need not go into the minutiae of it, for you have all made a diagnosis before this, but I desire to impress upon you the information that the mother gives. She described the pain in the stomach and extend- ing down upon the hips and groin. Soon after this she noticed that the child had a peculiar walk; it walked as if it were stiff, and it did not have the usual grace of movement. You notice that the child picks the scissors up for me much better than such patients usually do. A little earlier the child would have walked up directly over the scissors and made a ladder of its limbs in both getting down and up. The mother says that this is not the case. You notice the extreme antero-posterior curve of the vertebrae. No doubt the bodies of the vertebrae have softened, become absorbed to the degree which you see, and nature, after eliminating the destroyed bone, has firmly united what remained of the bones into one piece. The child is thus enabled to pick up objects from the floor without using her legs as a ladder. If we examine the skeleton postmortem in cases of tuberculosis, or Pott's disease of the spine we find the diseased part strengthened in the same way that the architect strengthens the arches in buildings. There is nothing that I can suggest that will relieve this de- formity. I am quite sure that the disease is already limited by nature. Frequently, before the disease reaches this stage, there is infection with pus microbes, and we have abscesses formed, such as psoas, lumbar, etc., according to the fascia which restricts it. The patient has worn a plaster-of-Paris jacket, and all the good has been accomplished that is possible from its use. So we will not advise the use of any further apparatus. We will, how- ever, advise the mother to be careful, and prevent, as far as pos- sible, all jarring of the child's body by falls and the like. The remedial agents will be good, wholesome food, as milk with its 334 LATERAL CURVATURE OF SPINE. due portion of cream, and medicines that will enrich the blood— Syrup of the iodide of iron, Hypophosphites, and small doses of Cod-liver oil. I think the mistake in giving Cod-liver oil is in giving too much, more than can be assimilated. A teaspoonful three times a day is, as a rule, as much as can be assimilated by a child. It may be given in a wine-glassful of beer, or in com- bination with the extract of malt. Or if you or your patients have consciencious scruples against using beer, you can give it in the foam of beer. It is best administered an hour after meals. Lateral Curvature of the Spine. August K., New Hampton, Iowa, Age 8, American. (Q.) Well, my boy, are you sick? (A.) No, Sir. (Q.) Did you fall and hurt yourself in this way? (A.) No, Sir. All that the parents noticed in this case was that the two shoulders were not the same in outline. You notice that the boy has very good use of his arms. Will you tell us, please, what the trouble is? (Student.) The right shoulder stands out more prominently than the left. (Q.) As he bends over and I make the course of the spine distinct by irritating the skin over the spinous processes, what do you see? (A.) A lateral curvature to the left. Looking along the spine from the neck to the sacrum, you notice a marked sinuosity of the column. There is a lateral curvature of the spine with the convexity toward the elevated scapula. Often in feeble girls a deviation in the spinal column from the normal is not detected until a dress is being fitted; then it is noticed that one scapula is more prominent, it stands out more from the ribs than the other. In such cases the convexity of the spinal column always points toward the protruding scapula. The scapula ap- pears as though something were growing under it. This is due to the fact that there is an increased curvature in the ribs, and the scapula is carried out by this increased curvature. (Q.) What would you do for this patient? (A.) I would put him through the list of gymnastic exercises. If faithfully and religiously carried out for one hour a day, in three months the deformity will be corrected. It is not necessary for me to repeat that I believe that all systems of braces or plaster casts are inju- rious and should not be used in these cases. LATERAL CURVATURE OF SPINE. 335 I will illustrate this method of treatment by asking the patient to go through the list of exercises formulated by Dr. Bernard Roth so that you may appreciate the different steps. In place of a narrow table it is just as well to use an ordinary ironing board placed on two chairs. 1. Lying on back, arms by the sides of the body, hands supi- nated, slow, full inspiration by the nose; slow expiration by the mouth (repeated four times). 2. Similar exercise with the arms extended upwards by the sides of the head (repeat four times). 3. Same position as 1, head rotation on axis to right and left alternately; also lateral flexion of the head to right and left alternately (four times). 4. Lying on back, slow simultaneous circumduction of both shoulder joints from before backwards, elbows and wrists extended (twelve times). 5. Same position as 1, hip circumduction both ways slowly, knees kept extended (ten times). 6. Lying on back, simultaneous extension of arms upwards, outwards and downwards from a position with the elbows flexed and close to the trunk (four times). 7. Lying prone; hip-circumduction both ways; knee kept ex- tended (ten times). 8. Sitting on couch with back at an angle of 450, ankle circum- duction down, in, up, out, the toes being directed inwards the whole time (twenty times); abduction (surgeon resisting), (eight times). This may be omitted if there is no tendency to flat-foot. 9. Lying on back, arms extended upwards by the sides of the head, slow flexion of both arms (surgeon resisting by grasping the hands), followed by extension (patient resisting), (six to eight times). The patient's knees flexed over the end of couch or table to fix the trunk. 10. Patient sitting astride a narrow table or chair without back, with arms down and hands supinated, trunk-flexion at the lumbar vertebrae (patient resisting slightly), followed by trunk extension (surgeon resisting by his hands against the back of patients head), (six times.) 11. Patient with arms extended upwards, leans against a vertical post or door fitted with pegs on each side, which he grasps; the surgeon gently pulls the patient's pelvis forward by his hands on the sacrum (patient resisting), and the patient then moves back the pelvis to the post or door (surgeon resisting), (six to eight 336 SPINA BIFIDA. times.) At no time are the patient's heels to be raised from the floor. Also pelvis-rotation on its axis to right and left alternate- ly (surgeon resisting with his hands on each side of the pelvis), (six to eight times). 12. Lying on back with head and neck projecting beyond the end of the table, arms by the sides of the body, hands supinated; the head is gently flexed by the surgeon's hand on the occiput (patient resisting), followed by head extension (surgeon resisting), (eight times.) Spina Bifida Bessie, Shewanee, Wis., Age 3 months, American. You have a little patient before you to-day, gentlemen, with a tumor at the lower end of the back, in the middle and about at the base of the sacrum. It is situated over the last lumbar ver- tebra. The baby is a bright, fat, chubby looking little fellow, apparently healthy in every other respect. Now that the dress- ing is removed, you see that we have a tumor of a bluish color on the surface, with exceedingly thin walls. It is much broader at its widest part than it is at the base and it contains fluid. Its walls are made up principally from the sheaths of the spinal cord. The base of the sac is made up of the integment of the body, the tumor is congenital, growing a little larger all the time, and the walls are becoming more attenuated, until they are so that they may rupture at any time. It is a condition which follows a want of developement of the spinal column. The laminae and spinous processes are wanting, allowing the pro- trusion of the membranes of the cord. Spina bifidae are divided into three varieties: The meningocele proper, meningo-myel- ocele and syringo mylocelle cases in which the cystwall is as attenuated as in this patient are always fatal if allowed to remain uncared for. There are different methods of treatment that have been advised; as, for instance, the injection of certain fluids which have for their object the irritation of the walls of the sac and finally an agglutination of the walls and the closing of the opening. There are other methods but all of them are quite un- satisfactory. Of late I have operated upon three different patients suffering from spina bifida with the result of curing two of them absolutely. SPINA BIFIDA. 337 Duringthe operation the patient is held in an inverted position in order to prevent the cerebrospinal fluid from escaping too rapidly. This might result in a sudden congestion of the cerebrospinal system and almost instant death. Now I have opened the sac, I purpose now to separate the lining membrane of the sac wall. You see by a little patience and perseverance I have succeeded in separating all of the lining membrane of the sac entirely free from its walls. This is the protruding membrane of the cord. We will ligate it and thereby close the opening, then we will close the wound with the "stairway" stitches of fine catgut. You are not required to remove very much of the external covering, for you see that we have only enough to bring it firmly together and as it contracts it will strengthen the part. These stitches should be applied so as not to penetrate the external skin. This row of stitches that I am applying now are entirely separate and distinct from the others and are merely for the purpose of closing the external line. You can readily understand now why we did not cut away any of the redundant skin. I do not see any reason why an operation of this kind should not succeed nor why it is not as reasonable as any similar opera- tion for the removal of a sac about any portion of the brain. In the method of injecting some irritating fluid a plastic exudate is sometimes thrown out and causes an agglutination of the walls, closing in that way the opening. Success has sometimes followed where the opening into the spinal column was very small, and could be shut off at the time of injection by pressure. Where thetumor ispedunculatedand the opening issmall thespina bifidae may be shut off from the spinal canal by means of the rubber band. It may then be injected. The fluid commonly used is the one introduced for this treatment by Prof. Brainard, viz., iodine. This mode of treatment, however, has gone out of vogue because it failed in most of the cases. In many cases this treatment re- sulted in an inflammation that could not be controlled. You can readily see how this result might follow. I believe that the thing to do is to attack these troubles decidedly by a procedure similar to that which I have made use of in this case. So far as our experience is concerned the results are favorable: two cases, as I have said, resulted in absolute cures. The case that died was unfavorable for two reasons. There was a very large opening in the dorsal region that would admit the end of a finger, the laminae and spinous processes of two vertebrae were wanting. And after tying the ligatures and closingthewound, 338 INJURY TO WRIST not satisfied with the security and did a very wrong thing by passing a catgut suture through the base of the tumor to close the opening more securely. I am very sorry that I did this, for the child did very well for a week and then infection took place beginning at the stitch referred to. The wound became inflamed and resulted in a septic meningitis causing the death of the child. You will approach these cases with a good deal of anxiety as to the results. The parts seem to be more easily infected than other parts of the body and the strictest observance of cleanli- ness must be maintained. I wish especially to direct your atten- tion to these facts, that you may take all the necessary precautions to prevent infection. Nothing then remains to be done but to apply external dressings of iodoform, iodoform gauze and borated cotton. The great object is to keep the wound abso- lutely clean. You see that it is in a difficult part of the body to keep clean, yet I think with a great amount of care it can be done. ' Sprained Wrist. John S., 2266 Archer Ave., age 30, American, carpenter. This is quite an interesting case. Four years ago this man lifted a heavy weight and flung it aside producing extreme abduc- tionsothathe sprained the ligaments of the wristontheradial side, disabling him for work for two weeks. He is a carpenter, and when he does any extra amount of work his wrist swells and gives him trouble. The persistency of these troubles gives the origin to the ex- pression, "A sprain is worse than a break." I am satisfied that this has reached a condition where absolute and positive rest is an ad- vantage. I find no line of fracture, and the trouble is principally on the radial side. I will advise the application of a light cast of silicate of sodium for this patient, extending up to the elbow and down to the tips of the fingers, to be left on for two weeks. This will relieve it for this time, but not permanently. For I am sure that the first time he goes to work and uses this arm in heavy work, the pain will return. In such cases as this you will not tell the patient that the joint will get well and be as sound as it was before the injury; it will get better, but it is doubtful if it ever becomes as strong as it was before the injury. Do not promise our patients too much. ANKYLOSIS OF ELBOW JOINT. 339 Ankylosis of Elbow Joint. Mrs. W., Clear Lake, Dakota, age 18, American, housewife. We have in this case a complete bony ankylosis of the elbow- joint at an angle of about 90 degrees. There is not a hair's breadth of movement in it. Six years ago the patient had an at- tack of scarlet fever, following which was an abscess of the joint which led to this ankylosis. Not infrequently you will have such abscesses following exanthematic diseases, and you must be ready to meet them.' I am satisfied that no different result could have been obtained in this case, for the inflammation has been so great that the articular surfaces of the joint were completely destroyed. The ankylosed arm is not so large as the other. Very likely the trouble was an osteomylitis in the lower portion of the humerus by which the epiphysial cartilage from which the bone grew in length was destroyed. Hence this bone grew in length from but one epyphysial cartilage while its fellow grew from two. It looks like a very useful arm. The patient wishes to know if we can restore the motion, if not, she does not care to have it changed. By making a resection we might be able to secure motion, but the patient would be running a risk, and therefore, I do not feel like advising her to have the operation performed. It is very likely that I should get a good result, but possibly I might not. The patient's joint is ankylosed in the best possible position to make the arm useful. She can carry the arm in such a manner that the deformity will not be noticed, consequently operative in- terference is not indicated by the conditions present. Oswald, H., 905 Dana Ave., age 41, German, iron worker. In October last this man received a fall and sustained a partial dislocation of both bones of the fore-arm outward and backward. Making rotation, I find the head of the radius in this position, and the olecranon process in this position, both showing a displace- ment outward and backward. Internally I can feel the trochlear surface of the humerus. These facts make the diagnosis positive. The patient is unable to flex the arm to a right angle. In all such cases of ankylosis, it is well to consult the patient as to his occupation. Here is a man whose occupation would be ruined if 340 ELBOW INJURIES. his arm were ankylosed in the flexed position. But with it ex- tended he is able to carry on his business of blacksmithing. So of course he would rather have the joint in the extended posi- tion as it now is than in the usual position of flexion. Ankylosis of Elbow. This is the little boy with the bent elbow. We have it at a right angle, and it remains at that point. I thought for a while that it would be well to loosen the tendon of the triceps muscle, but I am inclined to believe that the result in good would not balance the damage of the wound. I am sure the joint will always be stiff. The last time we operated we produced quite an echymosis as you see. There is a slight amount of motion, and it is worth while to anaesthetize the boy and try to make the motion complete. There has been an exudate that has filled the fossa, which makes it a very difficult case to treat. We have now increased the amount of motion as you see. If he gets even that amount of motion it will be a great help. It would be very easy to tear off the tissues if I were to exert much force. I know many of you are sympathizing with me for fear I will. But we have to risk something in surgery or we will not be successful. The mother wants the child to be able to button his collar. You remember that when the boy came to us the arm was in a straight line. He can button his collar now. We will apply the plaster-of-Paris cast and will hold the arm flexed up to this point for a week. Contusion of Elbow. This man, about two months ago, was playing with a child, twelve years old, fell on the kitchen floor and struck his elbow, from which time he has had pain upon motion. Theelbowisslightly reddened and swollen, and painful on pressure. It is an interest- ing case; small injuries have bad results frequently. There is no evidence whatever of a fracture or a dislocation. It is merely a concussion resulting in a subacute inflammation of the ligaments ANCHYLOSIS OF SHOULDER. 341 limiting the usefulness of his arm. It has been tender, just at the surface which he struck at the time of his fall, ever since. The treatment should consist in the use of passive motion, daily and hourly. At the same time mild, warm fomentations should be applied over the surface. Infection may take place through the circulation, either with bacilli of tuberculosis or with pus microbes. In the former case intra-articular injections of a 10 per cent, solution of iodoform in glycerine would be likely to result favorably. In the latter case the joint should be opened and drained freely and dressed with moist antiseptic dressing. Anchylosis of Shoulder. Emma E., Warren Ave., age, 38, American, housewife. Well, madam, of what do you complain? I have some trouble with my shoulder. Can you use your arm? I can use it a little better than I could. About four months ago this lady had an axillary abscess which was evacuated spontaneously. Since that time she has had a good deal of pain on the surface of the scap- ula. We have a contraction of the tendons resulting from the inflammation, and the arm is bound down to a certain extent by cicatricial tissue which has formed in the axilla. Treatment—What the patient needs is to have the limb put through these passive movements. I am sure she will regain the use of her arm. I am not sure that her shoulder will be as good as it was before the inflammation, but she will gain a great deal by these motions. Anchylosis of Jaw after Abscess. M. G., Hildreth, 111., age 4^ years, American. This is a very interesting case. The father tells me that two years ago he noticed a swelling in the region of the temporo- maxillary joint which increased to the size of his fist, broke and 342 ANCHYLOSIS OF TEMPOROMAXILLORY JOINT. evacuated a large quantity of pus at the superior margin of the eye; hence we have a deep seated abscess which burrowed until it came to the surface just above the eye. A secondary abscess followed, broke and emptied itself in this same way. After this second discharge they noticed that the child could only partially open her mouth. The joint is almost completely fixed on one side. We have as a result of the abscesses a partial fixation of the muscles of the jaw, especially the temporal muscle. By placing my fingers on the ramus of the jaw and then moving, it, I do not find any bands of cicatricial tissue extending across from one jaw to the other. Consequently the disease must be confined to the articulation itself, or in connection with the muscles. The first thing to do in this case is to anaesthetize the child, and by a series of wedges try to open the mouth. Here we have a myositis resulting in a fixation of the muscle. I have here a wedge-shaped screw—Archimedes' screw—by the use of which I think it will be possible to forcibly separate the jaws. What can we do next if this fails? Perhaps the next thing to do, would be to divide the tissues subcutaneously and keep up passive motion. If this should not succeed, or if there were a complete fixation in the joint we could do a species of osteotomy and make a false joint. This could be done by removing the coronoid process and a por- tion of the condyloid process, taking away the upper half of the ramus of the jaw. By one or the or another of these means I am sure that the child can be relieved. It is a case, however, that can not be cured at once, but will require a considerable time for its relief. I am inclined to believe that the forcible extension of the jaw will be a satisfactory treatment in the case. Some of you remember the case of a man whom we cured of an ankylosis by the removal of the upper half of the ramus of the jaw, and who said when he came before you to show the result of the operation, as he put out his tongue, "That is the first time that I have seen my tongue in seventeen years." ANCHYLOSIS OF VERTEBRAE. 343 Painful Contraction of Muscles of the Back Following Rheumatism Connected with Anchylosis of Vertebral Joints. Dr. W. E. P., Elk Creek, Wis., age 34, American, physician. This patient, a doctor, attributes his trouble to rheumatism, resulting in deformity noticeable in the cervical and upper dorsal vertebrae. He has an antero-posterior curve, that is, the verte- brae are curved abnormally forward. He is able to move his head but very little, especially laterally, without great pain, referred to the muscles rather than to the joints. He has tingling sen- sations in the arms. The arms, hands and feet are swollen to some extent. The patient comes to-day for advise as to what is the best thing to do for his relief. I find that not only is there a bending forward of the vertebrae, but there is a peculiar condi- tion of the trapezius muscle extending as far forward, also as the sterno-cleido-mastoid muscle. The muscle in this area is of a board-like hardness. It might seem, at first glance, that the trouble is "Pott's Disease" of the spine. But I am satisfied that it is not of that nature, but it is due to an inflammatory condition of the joints of the vertebrae. Occasionally after a long period of an inflammatory disease of this nature the joints of the verte- brae are absolutely glued together and instead of having seven bones you practically have but one. We have such a specimen in the museum which will be a very interesting one in connection with this case. There is a little motion here but it is limited by the muscle, just as nature always limits the motion in such cases. Another case of such limitation is seen in fixation of the joint in hip-joint disease. If this were Pott's disease you know the bodies of the vertebrae would be affected. It is the exception in that disease for the hard, com- pact arch to be affected. As a result of the softening of the bodies of the affected verte- brae there is invariably a convexity of the spinal column back- ward at the point of infection. Again, in tuberculosis of the spine you have the other general systemic conditions incident to the disease. This man's appearance argues against tuberculosis, and he tells me that his health has been good with this exception. 344 ANCHYLOSIS OF HIP. And now as to the relief. I have no doubt that he has tried to be about his business as duty called him and the very act of be- ing about has prevented absolute rest and has increased the inflammation. It is necessary to provide for absolute and posi- tive rest. You know how very difficult it is to hold the head quiet. It is impossible to hold it still for half a minute before the photographer's camera without a head rest. Hence this ap- parent fixation of the muscle by nature. I am satisfied that the patient will be relieved by some apparatus that will take the weight of the head off the inflamed joints. This will relieve the tension of the muscles. I know of nothing that will do this so completely and perfectly as the jury-mast attached to a plaster-of-Paris jacket. Anchylosis of Hip Due to Tr\uma. A. G., 165 Clark St., age 16, American, elevator boy. Eighteen months ago, this lad was thrown from a buggy and he is now unable to flex his thigh. Allow me to impress upon you the importance of these little symptoms, whether they are from trauma or disease. You always have a guide to assist you in diagnosis in the anterior superior spinous process of the ilium. As the boy lies on the table, and I flex the well limb, you notice that there is no motion communicated to the anterior superior spinous process of the ileum. On the other side, I am able to flex the limb but a very slight degree, before you see motion communicated to the spinous process. The case is evidently one of traumatic synovitis leading to a limitation of motion in the joint, and is a trouble which I am sure we will have difficulty in relieving. Sometimes traumatic synovitis is very difficult to overcome. Consequently you will warn your patient and friends of the danger attending such trouble. What can be done for this case? The thing to do is to anaes- thetize the patient and forcibly break down the adhesions which have formed, then to apply Bucks' extension to keep the joint surfaces separated if possible, and to keep the limb in the ex- tended position. Hot fomentations should be applied for the purpose of allaying the pain. After a week, passive motion should be introduced and practiced daily. FLOATING CARTILAGE, 345 Remember, however, what I have said in regard to the disease when tubercular in character, not to use force to any degree, for fear of starting anew a latent tuberculosis, or giving rise to general tuberculosis by giving the bacilli access to the general circulation through ruptured veins. Floating Cartilage in Knee Joint. S. M., Pleasantville, la., Age 28, American, farmer. Family history and previous history good. What is your trouble, sir? I have some trouble with my knee. Have you hurt it in any way? It was broken below the knee when I was four years old. Has it troubled you ever since? It has been stiff ever since. Have you hurt it lately? I sprained it five weeks ago. How did you happen to do it? I do not know how it was done. Where were you when it was done? I was walking on sod ground, and suddenly could not move it and fell down. Did you feel any pain when it was done? It happened so suddenly that I cannot remember. Was the ground rough? The ground was pretty smooth. Where does it hurt most? At the front and side. Did you lay up for a few days? I did not lay up. You have heard the history of the case: This man thinks he has sprained his knee. Without any known cause he suddenly became lame about five weeks ago, and the inability to extend the knee has since remained. And now I am unable to straighten it. It is on account of contraction of the flexor muscles of the thigh. Usually continued pressure will straighten the leg. Let your muscles be perfectly relaxed. Here is the possible beginning of tuberculous degeneration. The pain is referred to the inner part of the knee. He gives me the symptoms of a foreign body in the knee, a loose piece of cartilage. A person may be walking along and suddenly become unable to use the knee. After resting a few minutes, making attempts at motion, the function is restored; usually one cannot find these pieces until the patients come across them themselves, then the diagnosis is confirmed. Now there is something in this man's knee, in the neighborhood of the joint, because he keeps the leg in this position. If the patient were anaesthetized it would be straightened without difficulty. I feel that the flexor muscles are tense, and this is the reason the 346 FLOATING CARTILAGE. leg is in this position. The thing to do is to put the joint at rest. This treatment will relieve him temporarily at least, no matter what the trouble is. So as a means to the end, we will advise the application of a plaster-of-Paris cast, extending well down on the leg and to the upper third of the thigh. It will be better to an- aesthetize him, then the muscles will relax and the cast can be made to fit perfectly in all parts. He will wear the cast four weeks, and I am sure he will not feel any inconvenience from it. Note.—The cast was applied, and after two days of rest the patient went to his home in Iowa. The limb is in a good position, just sufficiently flexed at the knee to make walking easy. He is to wear the cast for three months, then apply a flannel bandage from the foot up to prevent oedema consequent to removal of the cast. Traumatic Inflammation of Knee. B. F., Crown Point, Ind., Age 48, American, traveling salesman. Three months ago this gentleman was struck on the leg by a bale of hay. This was followed by an inflammation and effusion into the knee joint. The knee has been more swollen and more painful than you see it now. The disposition is that of a con- firmed ankylosis of the knee as a result of the traumatic injury. There is a little predisposition to fixation of joints especially if they are wounded in any way. This is almost the first thing that happens after a joint is affected. Nature attempts to put the joint to rest. This patient has a disposition toward perma- nent flexion of the leg. The landmarks of the knee are gone. The leg is smooth above and at the sides of the patella. I have no doubt that the patient has been rubbing this with various remedies, but unless it is put to rest,the degeneration will become so great that there will be a dislocation of the tibia backward. Treatment: The patient should be anaesthetized and the leg straightened, then a plaster-of-Paris cast should be applied. In straightening the knee you should be very careful for there is a risk in connection with it. Sometimes the elasticity of the parts in the popliteal space is lost. More than one surgeon has ruptured the popliteal artery, and that means amputation of the thigh immediately. All of the tissues have been ruptured from without, inward. When I make these attempts at extension I can CONTUSION OF KNEE. 347 readily feel the adhesions giving way. Now if we should un- fortunately have ankylosis of the knee the best position that it can be left in is not complete extension, but a slight amount of flexion. It will then be more useful than if it were perfectly straight. Of course, there will be a disposition of the muscles to contract and flex the leg, but the plaster cast will prevent this. Contusion of Knee. John, 65 Gologhe St., Age 29, Canadian, sailor. Here we have a contusion of the knee joint. I find no par- ticular difficulty with the tissues of the joint. The tissues are elastic; there is no noticeable thickening or hardening. The patella is freely movable. I find nothing abnormal about the joint, except its stiffness. This is due to the tension of the liga- mentum patella on the inner side of the condyle. This stiffness is partially due to the tincture of iodine which he has applied over the surface of the joint. There is nothing to be done for the case surgically. I should advise him not to use the iodine, but to use instead something to soothe it, as a hot fomentation of water and alcohol, and to put the limb through its motions after the acute irritation has subsided. Sprained Ankle. Fred S., Western Ave., age 38, German, tailor. Twelve weeks ago, this man fell four feet spraining his ankle. He says he cannot bear his weight upon it. I find that I can put the foot through all of the movements. The patient has kept the foot quiet too long, and has lost confidence in himself. Let me see you walk. Get right up on your foot, it will hold you. You observe that the patient limps, using two crutches. We will take one crutch from him and then the other and you will see that he gets along very well, showing that he had lost confidence in the strength of the limb. He should have massage and a shower bath every night. Put it through complete circumduction and use it. He will then get well in two weeks. You remember that 348 CONTUSION OF ANKLE. there is a time when rest ceases to be a good and does injury. You will have to learn to recognize such cases from experience. When you are able to put the foot through the motions that I have applied to this man's foot, and find no swelling nor adhes- ions from an injury occuring so long ago, you may know that rest is no longer likely to benefit the patient. G. H., Plattville, Wis., age 32, American, photographer. This young man sprained his foot fourteen years ago. Not many years ago a noted surgeon of London made a number of post-mortem examinations following injuries of the ankle-joint. The results were something of a revelation to the profession regarding sprains and injuries about the ankle-joint. It was found that instead of the ligaments being torn from their attachments a little plate of bone was separated from the shaft, these small fragments of bone, that the joint remained for years in this weakened condition. You notice that the landmarks have not been destroyed, and there is no evidence of infiltration about, nor effusion into the joint. One peculiarity to be seen is that the foot stands out a little to one side of the leg. A line drawn through the center of the foot will run off to one side instead of going through the center of the tibia. The external malleolus stands out a little too promi- nently* A measurement shows that there has been a separation of the two malleoli from each other. There has been a separa- tion of the bones, therefore, and a tearing of the interosseous ligament which always complicates the injury very much. Now, the patient is concerned in what will relieve him. He will not be relieved by using the limb in its present position. I should anaesthetize him, bend the foot up to a right angle with the leg and apply a plaster-of-Paris cast, in this way securing elongation of the tendo-Achilis. The reason why the patient can- not walk any better is because the foot has become fixed in the talipes equinus position. We advise the application of the cast, as I have suggested, and let him wear it a month. The foot will be put through passive motions and be subjected to massage, and to douching with hot and cold water for the purpose of stimulating the weakened joint. EVERSION OF THE GREAT TOE. 349 Eversion of the Great Toe. We have a very interesting case of an eversion of the great toe and of the development of a bursa on the head of the metatarsal bone of that toe. This condition is sometimes called policis val- gus, i. e., an outward deviation of the great toe. This deformity and its relief was first well described by Frank Hamilton, the famous fracture surgeon. His method of treatment is to make a sufficiently large incision along the inner side of the metatarso- phalangeal articulation, to expose the head of the metatarsal bone and remove it. We will proceed to do this. I have done the operation a number of times and have found no difficulty fol- lowing it. There is also a destruction of the joint in this case, and this is certainly the operation to do in the case. The joint is entirely destroyed; evidently the bursa has broken down after becoming infected. The degenerated tissue looks very much as if it were tuberculous. The great destruction makes it necessary to do a greater operation than is usually required. I shall use the chisel in dividing the bone. Usually the bone is so heavy that it requires a very heavy pair of bone forceps to divide'it, and frequently the bone is crushed instead of being divided. At least we shall partially divide it with a chisel and complete it with the forceps. Usually where the joint is not destroyed, as in this case, the wound is perfectly clean, the edges are smooth, and it is a very pretty operation. This is of the nature of a bunion, but is more painful than the ordinary bunion, and is more apt to suppurate. The only means of relief is some operation of this kind. There is a shoe made with a special internal border to which the great toe is fastened by means of a plaster, but this method does not accomplish its object, because there is always a change in the mechanism of the joint. By the method which we have just employed we get a good inner border to the foot. I have treated patients who had the deformity in both feet, and after curing the greater deformity, the relief was so great that they returned to have the less deformity of the other foot treated in the same way. In this case it will be necessary to resort to thorough dis- infection of the wound, and to use drainage in order to pre- vent sepsis. In cases in which the bursa is not in an inflamed 350 DISLOCATION OF ELBOW. condition, the wound can be entirely closed and expected to heal primarily. It is important to dress the great toe with a pad be- tween it and the next for months in order to insure a correct position permanently. Old Dislocation of the Elbow. This little patient on the table comes here with a dislocation of both bones of the arm upward and backward, five months old. The humerus projects forward and causes this prominence on the front of the fore arm at its upper part, by feeling of it, the irregularities can be easily determined. The fore arm being ex- tended the patient has no power of motion in the joints. I told the parents that I could not do anything without a surgical operation, and probably the most I could do would be to bring the fore arm into a position at right angles with the arm. This accident happened about five months ago. This is a long time, and there is always present a large amount of exudation and cicatricial tissue which bind the bones together the more firmly the longer the time since the accident, and the probability is that no force will be of any service. We will make an effort. Now I know that this is an upward and backward dislocation, for when I followed the ulna in an upward direction until I come to the olecranon process, I feel a sudden depression. I know that this is the olecranon process from its shape and from feeling the ten- don of the triceps muscle attached to it, and becoming tense with every effort at flexion. When I make supination and pro- nation I can feel the rotation of the head of the radius in its abnormal position. We had the accident a few days ago of fracturing the humerus in trying to reduce an old dislocation of the shoulder, and I should not be surprised if we had one today. Now I have succeeded in nearly reducing this. I have the radius in position; here is the surface of the condyle, I have no doubt but that the cavity of the coronoid fossa is partially obliterated, and hence the difficulty of slipping the process into it. I am tempted to cut this tendon of the triceps muscle. Of course, if I apply extra force to the forearm in its present position, it would be very easy to break the olecranon process, so we will fix the arm in the position of a right angle by means of a plaster-of-Paris cast. OLD DISLOCA TION OF SHOULDER. 351 Here is the internal condyle, and here the outer condyle, and lean rotate the arm without any trouble. The olecranon process stands out midway between the condyles in its normal position. We will apply hot fermentations to the joint to prevent traumatic inflammation. After two weeks we will begin to make passive motion every day, maintaining the arm in the position of flexion at an angle less than a right angle while at rest. In case the joint should remain per- manently stiff this is by far the most fortunate position. It will require great patience and endurance to secure motion in this joint, and even then one cannot make a positively favorable prognosis. Old Dislocation of Shoulder. Michael B., Danville, 111., Englishman, wheelwright, age 42. This patient presents himself with a six weeks old dislocation of the shoulder-joint. It is very seldom that you will see a dis- location as far forward as this. The most common dislocations are those downward into the axilla, and those forward under the coracoid process of the scapula. We have, as well, the subclavi- cular dislocation in which the head of the bone is thrown to the inner side of the coracoid process and lies beneath the clavicle. This dislocation has existed six weeks, and has been subjected to several trials at reduction before coming here, so that I do not feel at all certain that I shall succeed in reducing it, and I shall make no very powerful efforts at reducing it. I have told you several times why you must use great care, and abstain from all power- ful efforts in the reduction of these old dislocations because of the great liability of adhesions and the subsequent damage to important structures in the axilla. We shall, therefore, use a limited amount of force, and if we do not succeed we will bring the patient in again and make an open operation, and replace the bone. I can illustrate very nicely in this subject Dugas' test for dis location of the shoulder. You take the hand of the injured side- and carry it to the opposite shoulder, and if the elbow can be made to touch the chest while the arm is in position, there is no dislocation; but if the elbow stands out from the chest, there is a dislocation of the shoulder. This is a very easy test to remem- ber, and it is a very sure one as well. I should feel very bad if I should tear off the bracial vein or artery in loosening these adhesions. 352 OLD DISLOCATION OF SHOULDER. I have succeeded in making a true downward dislocation out of it. It seems as if we should be able now to reduce it, but I am quite sure that we shall not be able to reduce it by manipulation. We shall reduce it at another time by making an incision and exposing the glenoid cavity. A week later concerning the same, someone says: "It is always the unexpected which happens." This was not true in regard to what happened in this case of the old dislocation of the shoulder last week. You remember that when I brought the patient in, I told you that I should not resort to any prolonged efforts or to severe violence, but, if unable to reduce it by ordinary manipu- lation, I should resort to an operation. I mentioned the dangers of an old dislocation of six weeks standing, as in this case. The head of the humerus lies so close to the large vessels of the axil- lary space that adhesions are apt to form increasing very much the likelihood of a rupture of those vessels. We made some man- ipulations in our attempts at reduction, you remember, by rotation, extension, circumduction and some of the usual movements in- tended to reduce such dislocations. Following these movements a small tumor began to appear in the axillary space, warning me to cease my manipulative procedure, reserve the patient until the next clinic and replace the bone at the time after uncovering it by an incision. In a few minutes an assistant came in telling me the tumor was increasing in size. I told him to make pressure on the subclavan artery, and we went on with the clinic. When I went out after the clinic, I found a "pure air" tumor, as it is called because of its coming on so rapidly. It filled the entire loose tissue of the axilla to such an extent that the arm was lifted from the side of the chest, consequently it contained an immense amount of fluid. Recognizing the nature of the accident, we made an effort to secure the injured vessel. We knew that the operation would be a difficult one, requiring a large incision and that it would not be safe to clean out the axillary space and search for the rent in the vessel -in the usual way, as it would probably be too high up in the space. Accordingly the hemor rhage was suppressed by compressing the subclavin artery against the rib, and the pectoralis major and minor muscles were divided by a free incision. The artery was found to be the axillary torn about its middle and the ends were retracted. The ends of the artery were ligated and salt solution and stimulants injected, but the patient died twenty four hours later from shock. Now, here is a lesson in this case, and one which will lead you OLD DISLOCA TION OF SHOULDER. 353 to handle these cases of old dislocations with great care. This accident has befallen almost every surgeon who has tried to re- duce such dislocations. I have reduced many old dislocations using more force than I did in this case, resorting to the move- ments of adduction, extension and rotation without harm. I have always been successful in cases of two months standing and more recent ones, in a few cases of six months duration and have repeatedly failed as have many others. If you will read the his- tories found in medical literature you will find many cases on record of the tearing of the brachial artery or the axillary vessels, also tearing of all of the tissues down to the bone, in the power- ful efforts to reduce the dislocations. That accident once happened to Prof. Lister. He was so im- pressed that he decided in his own mind never to resort to mani- pulation, after a certain length of time, but to make the open in- cision which would expose the joint and enable him to cut away all of the muscular attachments of the bone, and in this way re- duce the dislocation without difficulty. He has pursued this plan in three cases—one single and one double—and the results are very satisfactory. As a deduction from these operations we may say that your manipulations in these cases should be very care- fully made, and also very slight in force. If the reduction can- not be made by easy manipulations when the patient is asleep, do not resort to force, but to an open operative procedure. I am satisfied that the case before you was peculiar in char- acter, and more likely to injury than is usually the case. After the axilla was opened and examined, it was found that a compli- cation existed in the form of a fracture through the greater tuber- osity of the humerus. The edges of the fractured bone were rough, containing sharp spiculae which, no doubt, had been brought in contact with the artery during the attempted reduction, and did the injury. You will ever be on the alert, therefore, after an attempt at a reduction of an old dislocation. If the tumor appears in the axilla, you will know by its character that it could come from nothing but the rupture of a large vessel. When the accident does occur, then there is but one thing to do, and that is to un- cover the axillary space and secure the injured vessel. There is but one incision which will thoroughly and quickly do this, and that is the anterior opening through the pectoralis major and minor muscles. 354 CONGENITAL DISLOCATION OF THE HIP. Congenital Dislocation of the Hip. Meta B., 540 Blue Island Ave., Age, 6, American. This is a congenital dislocation of the hip-joint. Here are the heads of the femora very near the crests of the ilia. They are not in the acetabulum. Perhaps there is no acetabulum. There is a prominent curving forward of the vertabrae in the lumbar region to compensate the dislocation and to bring the line of gravity between the feet. You all notice the prominence formed by the head of the bone in its abnormal position on the dorsal surface of the ilium, a condition present, in upward or backward dislocation of the hip joint. We can reduce them you see with- out difficulty by simple rotation, but they will not remain in position if any weight comes on them. The weight of the body is not supported by the acetabulum but by the ligaments of the joint and the surrounding soft tissues. This gives rise to severe lameness, the child becomes exhausted easily when walking and suffers some pain. All kinds of treatment have been futile. Among other methods of treatment,the child was placed on its back in bed and extension applied, but as soon as the extension was removed, the deformity returned. The child has been tinder treatment almost ever since its birth. We purpose to-day to relieve the deformity by fixing the head of the bone in the acetabular cavity. I shall first proceed in the operation in identically the same manner that I should, were I going to resect the upper end of the femur. After the incision is made, the great trochanter exposed and the muscular attach- ments detached, the acetabular cavity, or what should be that cavity will be examined. The probability is that we shall find no cavity, but in its stead a smooth surface covered with con- nective tissue. I shall then make an incision along the lower border of the acetabular cavity and with the elevator raise the periosteum. If the cavity is large enough to contain the bone, it will be replaced, if not, the cavity will be enlarged to the proper size by the use of the chisel. The head of the bone will be placed in the acetabular cavity and the flap brought over the head of the bone in this position. CONGENITAL DISLOCATION OF HIP. 355 I have now succeeded in getting the head of the bone beneath the anterior surface of the capsule, after having a little difficulty. I am now sewing the remains of the connective tissue which I separated from the bottom of the acetabular cavity to the remnant of tissue around the trochanter major, forming in this way a capsule for the head of the bone. We will close the wound in different layers so as to approxi- mate the tissues as accurately as possible during the fixation of the limb. We will have Buck's extension applied at once, in just the same manner as we apply it for the treatment of hip-joint disease. Fractures. Gentlemen:—Today I shall call your attention to the sign of fracture termed crepitus. It consists of the sound and the sen- sation communicated to the examining hand, produced by the rubbing together of the roughened, irregular surfaces of the ends of the broken bone. When clear and unmistakable, it is a definite and pathognomonic sign of fracture. Occasionally, other patho- logical conditions give rise to sounds resembling it in a degree, hence it is usual to mention them as a warning against possible mistakes. For instance, the soft rubbing sensation communi- cated to the fingers upon the reduction of the displacements found in separations of the piphyses is said to resemble crepitus; also the cracking sensation and creaking noise caused by the rubbing of tendons in their sheaths, or inflamed joint surfaces when either are roughened by exudations of inflammation, have been mistaken for crepitus. It is scarcely possible that the sensa- tion caused by the presence of emphysema, or air in the cellular tissue, could be mistaken for crepitus; assertions to this effect have been made. Notwithstanding the excellence of this sign as a proof of the solution of continuity in bone, all fractures do not display its presence. An impacted fracture, the variety in which the end of one fragment is driven into and firmly fixed in the end of the other fragment, cannot have crepitus as a sign. Foreign bodies between the ends of the bone prevent the occurrence of crepitus because the broken ends cannot be brought in contact with each other, as when the sharp end of a fragment is driven deeply into muscular tissue, or dense fascia, and cannot be dis- engaged. 356 ERA CTURES. A practical deduction from this last condition is, that one should always be suspicious of the presence of this complication when crepitus is not found as a sign in any fracture unless ab- sence is dependent upon impaction is very evident and demon- strative. Overriding of the fragments. It enables the attendant to warn the patient and friends of the probability of that unhappy complication termed ununited fracture. Whenever the presence of intervening soft tissues between the ends of a fractured bone is suspected from the absence of crepitus, the patient should be anaesthetized and manipulation continued until the roughened ends meet and give the characteristic sign. Allow me to impress upon you,as forcibly as possible,the necessity of special care and acuteness in the elucidation of this as well as all other signs of fracture in cases, in which the injury is in close proximity to a joint. As a rule in such cases, the land marks used as guides to determine misplacements and deformities are rapidly rendered obscure and often entirely obliterated by rapidly occuring swell- ing and effusion in the loose tissues about joints, so that the evi- dences so easily obtained in other situations become particularly difficult to determine. In all cases of fracture, the rule is a good one which justifies us in the use of an anaesthetic in clearing up the slightest doubt, if any exist. Every means should be adopted that will enable the surgeon to establish a positive and complete diagnosis of the actual condition present, as a result of the injury. The next and last on the list of signs which have been given to you as evidence of the existence of fracture, is Ecchymosis; a discoloration of the tissues in and about the neighborhood of the fracture. It is among the last to appear and is dependent upon the effusion of blood into the tissues, the coloring matter from which stains them. It is a common accompaniment of the in- juries producing a fracture, sometimes a very prominent one; for not infrequently the discoloration implicates the entire segment or more of an extremity, and the color is so dark that the patient often and sometimes the doctor mistakes it for an evidence of mortification. In cases in which, notwithstanding every effort is made to de- termine the existence of a fracture by careful consideration of all the signs mentioned, there still remains a doubt, the late ap- pearance of ecchymosis at the seat of the injury, spreading along the length of the bone injured, is confirmatory evidence of frac- ture. The blood in such a case comes from the several vessels of the bone itself and has taken some time, several days per- FRACTURES. 357 haps, to make its way through the interstices of the deeper tissues to the surface. Under such circumstances, taken in con- junction with other symptoms it may become a reliable sign of fracture. Now gentlemen, you have before you a sufficiently complete list of the signs of fractures and we have given to each one a due consideration. It is absolutely essential that you become perfectly familiar, automatically familiar, with the whole and each part so that you will involuntarily bring them to mind whenever a fracture comes under your care. Remember that no single sign is at all times indicative of fracture, nor the absence of the most pathognomonic positive evidence of no fracture. The most reliable among them are preternatural mobility and crepitus. Still the testimony of all is the only basis for satis- factory diagnosis. Some additional remarks must now be made upon the variety of fracture termed epiphysial separation. The signs are similar to those of ordinary fracture with some especial complications and suggestions. It has already been intimated to you that in this injury crepitation is different from what is present in com- mon fracture. The sound and sensation are subdued and soft instead of harsh and grating. As the injury is always in close proximity to a joint the sign resembles those indicative of dis- location very closely. There is this difference, in dislocation the deformity when once overcome remains permanently over- come. There is no disposition to its recurrence when the efforts of reduction have ceased. In separation of the epiphysis, on the other hand, the deformity instantly and constantly recurs as soon as the efforts made to overcome it are discontinued. Epiphysial separation occurs early in life, that is, before ossification of the skeleton is complete, hence the age of the patient is an import- ant item in the diagnosis. The accident occurs oftenest, perhaps, between the ages of five and sixteen. Another item to be re- membered and of significant importance is the situation of the fracture—its close proximity to the joint being dependent upon the normal site of the epiphysial line. The points to be remem- bered as indicating the presence of an epiphysial separation are, first, the special kind of crepitation; second, its resemblance to a dislocation; third, the situation of the injury; fourth, the age of the patient. „ Having finished the description of the signs indicative of the 358 FRACTURES. occurrence of fractures, we now proceed to the consideration of the general treatment. There are two general indications which must be carried out in the treatment of all fractures and these are expressed accur- ately by the two words Replace and Retain. The first, replace, means to overcome all deformity by manipu- lating the ends into such position as will make that position absolutely normal or as near the natural condition as it is possi- ble to bring them. In common language it means to " set " the fracture. Whether the fracture is " set" or not is always an item of anxiety to the patient and the patient's friends. It is almost the first of their questions that the attendant will be called upon to answer satisfactorily. To relieve this anxiety and because of the quieting influence upon both which follows a satisfactory answer to the question, it is always best to give the answer at the earliest possible moment. Naturally the best time at which to replace or " set " a fracture is just as soon as possible after the accident occurs. For the reason already given and as well because the parts are less dis- torted by swelling and effusion so that irregularities in position or direction can be more readily detected and corrected, because the element of muscular spasm or contraction is at a minimum and hence offers less resistance to the efforts at reduction be- cause the depressed condition of the patient assists replacement by eliminating in a degree voluntary movements on the patient's part, finally because an early restoration of the broken fragments to as nearly a normal condition as possible has a great influence in diminishing subsequent irritation, consequent pain as well as local and general disturbance. Fractures are replaced or " set " by means of extension and counter extension, by manipulation, and by position. By exten- sion and counter-extension is meant the application of force in the longitudinal axis of the broken bone, and in directions away from the site of the fracture. The counter extension may be weight of the patient's body, still it is usually furnished by an assistant holding the upper fragment firmly and securely, or, as well, drawing it towards the trunk. Extension is made by force applied in the same axis to the lower fragment drawing it away from the trunk. The amount of force applied is in proportion to the strength of the opposing muscular contraction, its object is to overcome entirely, if possi- ble, the deformity of shortening. This means of replacement is ERA CTURES. 359 mainly applicable to injuries of the long bones, or in fractures of the spinal column. The application of the force in the use of this method should always be regular, even and moderate. By steady, continous ex- tension and counter extension muscular contraction is often entirely overcome and fragments fall readily into proper position. The time during which it must be kept up before accomplishing the object for which it is practised, varies of course with the power of the muscles which are to be overcome and the degree of irritation resulting from the local damage and caused by sharp ends of the fragments. Manipulation means the use of the surgeon's fingers at the site of the fracture for the purpose of correcting lateral and angular displacement after shortening is overcome by the means already mentioned. The fragments are moulded into accurate position. The hands in this way being enabled to detect all deviations abnormal in character and to correct them. While practicing these means of replacement the surgeon is made familiar with all the peculiarities of the fracture such as the degree of displace- ment. The condition and position of the fragments, the direct- ion of the fracture in relation to the bone's axis, the special tend- ency to displacement and the character of the force necessary to be applied in maintaining a proper position during repair. The application of position as an aid in the replacement of fractures is often necessary and the assistance to be obtained by its use should always be borne in mind. In some fractures in which a powerful muscle lies behind the broken bone and in which the tendency of displacement is always forward and in a marked degree, extension and counter extension, however possi- ble, has no influence towards overcoming the deformity, in fact, the latter seems readily to be increased by its use. Neither does manipulation appear to give any aid. In these cases if the seg- ment of the extremity in which the fracture exists, is freely flexed so as to relax the tense flexor muscles, the use of either of the other methods, quickly relieves the deformity. Illustrations will be found in fractures of the tibia with great anterior angular de- formity and in Colles' fracture in which complete separation often renders the reduction noticeably easy of execution. Under special conditions of deformity with inability to render the con- tractible force of muscles inoperative by any of the means men- tioned, it becomes necessary to resort to subcutaneous division of the tendon of the offending muscle. Tenotomy is justifiable 360 FRACTURES. under such circumstances rather than to allow the deformity to persist and it is usually a harmless procedure, entailing no subse- quent loss of power to the patient and in no way complicating the restoration of the injured member to perfect usefulness. When done, of course every preparation should be made for an aseptic operation. It is exactly the same procedure that is so frequently done for the relief of contracted tendons in the care of club foot. Still, before resorting to any use of the knife in cases in which muscular spasm or contraction prevents replacement, it is well to bring the patient thoroughly under the influence of an anaes- thetic. Anaesthesia is of two fold benefit, it not only does away with all resistance to replacement from muscular action, thus obliterating the principal cause of deformity and allowing the easy and successful application of the means of replacement already considered; but it also enables the surgeon to make a complete diagnosis, to learn thoroughly all about the special peculiarities of the fracture. In no other condition can the sur- geon so satisfactorily examine and care for a fracture, besides it saves the patient from all suffering and no resistence is offered to any manipulations. Are there any reasons against its use in all cases? The following have been urged: First the danger of death to the patient from the anaesthetic itself. Anaesthesia always carries with it some danger to life, but the great care and watchfulness all practice in its administration together with the many means we now possess of overcoming its effect when the first manifestations of danger show, reduces its harmful effects to the minimum degree so that the danger from this source is practically very slight. Second, during the stage of excitement produced by the anaesthetic in many patients, there is much like- lihood of the uncontrollable movement of the patient, causing great harm at the site of the fracture, by the sharp ends of the fragments, a simple could be easily converted into a compound fracture, arterial or venous trunks torn open, nerves destroyed or muscles badly lacerated. This liability constitutes a real danger during the administra- tion of an anaesthetic in cases of fracture and when it is given, every means possible to prevent any such occurrence should be carefully adopted by the surgeon, by securing absolute quietude to the injured part. The majority of patients will come under its influence without any demonstrations that will produce damage. The rule followed by myself is to invariably administer the FRACTURES. 361 anaesthetic, first in all cases in which there is the least particle of doubt in my mind as to the nature and condition of the fracture after an examination with ordinary inspection and painless manip- ulation of the part injured—second in cases in which the displace- ment cannot be readily and early overcome. The popular im- pression that if a fracture is perfectly "set" in the beginning, the progression to satisfactory recovery is correspondingly certain and easy, is not to be treated lightly. There is an element of truth in it, for successful replacement means subsequent rapid abeyance of irritation—the ends of the fragments in close con- tact with each other and all the other conditions necessary for rapid disappearance by absorption of the debris of the injury and equally rapid and regular deposition of the elements of repair and perfect ossification. There is scarcely any doubt that the closer the ends of the broken bone are brought together the sooner union will take place and that union will be firmer, also will be accompanied with less deposit of callus and corres- pondingly less permanent deformity. No attempts whatever at replacement should be made until after the clothing covering the neighborhood of the injury has been removed. Accept a caution as to the manner of removing the clothing. It should be accomplished with gentleness and freedom from pain to the patient, or disturbance of the fracture itself. Neither should attempts at replacement be made until after a study of the situation and conditions of the fracture have allowed the surgeon's mind to come to some conclusion with reference to the kind of dressing which it will be necessary to apply. To pre- vent the recurrence of the displacements this examination should enable him to place the dressings ready at hand for application, quite as soon as the replacement is satisfactorily accomplished. It is very easy to understand how all these preparations will save the patient much pain, prevent unnecessary disturbance of the fracture and provide for a regular and methodical treatment of the injury. By retention is meant the adoption of such measures and the application of such apparatus as are necessary to maintain qui- etude and perfect position in the fragments during the time necessary to secure complete ossification and restoration of im- paired function. The necessity for the use of retentive apparatus arises from the fact that the reproduction of the original deformity of the 362 FRACTURES. fracture is an ever present danger because the forces which pro- duced it reassert their power just as soon as the means employed for the reduction is discontinued. It is to be borne in mind that every plan of procedure adopted, that all means of treatment instituted have their object first and last in the comfort of the patient, both local and general. It is therefore an imperative necessity that the surgeon be sure that each and every appliance made use of shall not in any way, add to the discomfort of the patient or increase the damage at the seat of the fracture already done by the injury. Especially should the surgeon be assiduously watchful to pre- vent the harmful effects of pressure or constriction. Remember- ing at all times that even in health the skin quickly rebels against the evil effects of pressure and that the blood vessels speedily loose their function under the influence of constriction. The liability to harm is increased in a manifold degree when these hurtful agents are allowed to act upon tissues in which the vitality is already greatly diminished by the same injury that produced the fracture. It is far better that the injured parts should be left entirely free of all appliances than that any harm should result from their use. However it arises, my experience has demonstrated the fact that the opinion is a common one among many people that when dressings are once applied to a fracture they must not be dis- turbed in any way by the patient. Hence it is not an uncommon thing to find patients suffering untold agony and yet patiently awaiting the arrival of the doctor to relieve them from the pressure caused by a rapidly swelling member rendering a ban- dage too tight. The best rule to follow is to warn every patient to cut all bandages provided the pain persists, certainly if it con- stantly increases after the dressings are applied and to merely keep the injured parts as quiet as possible until a re- arrangement can be made at the next visit. It would seem impossible for the most experienced surgeon to estimate to a nicety just how much swelling will occur or how great the loss of vitality in the tissues in any given case of fracture may be. So it is far the best plan to provide the means of safety in case harm is likely to arise from either cause by giving directions to loosen the dress- ings. These instructions apply especially to the first dressings used in the treatment of any fracture. It is my conviction that first dressings should always be of a temporary nature loosely ap- plied and easily removed. It is not an imperative necessity that FRACTURES. 363 great force should be used to keep the ends in close apposition early in the treatment of a fracture for there is ample time to mould and manipulate them into position after the irritation in the surrounding soft parts has begun to subside. Be ever watch- ful and diligent not to do harm. The appliances made use of for the retention of fractures are as follows viz: Bandages, starch, plaster-of-Paris, sillcale of sodium and special apparatus. First, bandages may be made and are usually made from ordi- nary unbleached muslin; the selvage should never be left on. Some surgeons make use of flannel for bandages. The most common and useful width is three inches. They should be rolled very firm. The elasticity of the flannel bandage is immensely in- creased for some purposes by having it cut on the bias as it is termed. The size of the bandage mentioned is very satisfactory in its application to all fractures of the extremities and the bones of the skull. In fractures of the fingers the bandage should be no more than one inch wide. Those of the trunk re- quire a wider roller, say six to eight inches. Bandages are used for the purpose of retaining splints and other appliances in con- tact with the injured parts and should always be applied evenly and smoothly so that the force exerted through them shall be evenly distributed. When the part is of different thickness in different positions of its extent this smoothness of application is accomplished by making use of the single or double spiral through reverse turns as illustrated. The application of a bandage next to the skin in the early treatment of fractures is fraught with great danger and never should be used. When so used it is called the initial bandage. This initial bandage may be used, and is of great service in the later history of many fractures in overcoming oedama, resulting from interrupted circulation, from a weakened condition of the vessel walls after prolonged pressure from splints or from the dependent position of the extremities during the first attempts at use. It is useful also for the purpose of equalizing pressure in cases in which splints are applied only to the upper segment of an extremity, as for instance in many fractures of the humerus. Under this circumstance the initial bandage may be applied to the uninjured fore arm and prevents swelling of the arm likely to follow the pressure of the splints upon the arm. The bandage should extend from the base of the fingers to the elbow. This method of equalizing pressure should be remembered and prac 364 FRACTURES. ticed whenever constriction on the extremities is necessary in any position of their extent above the wrist or ankle. The scultetus bandage is very useful and easily applied in cases in which for any reason it is best to avoid lifting the injured part and to relieve or increase the pressure with the least possible amount of disturbance. It is made by cutting an ordinary roller into strips sufficiently long to more than encircle the limb after all strips have been put into place. These straps are placed in succession so that each one overlaps its neighbor one- half the width of the bandage, they are fastened together by a single thread sewed through all of them down the center. This makes a many tailed bandage. The ends of one side are drawn beneath the injured limb until the thread which unites them is opposite the middle of the limb; the ends are then drawn into position over the top of the limb commencing with the highest strip. As each successive strip overlaps its neighbor, the bandage becomes firm and self-sustain- ing after the first and last strip is fastened with a pin. Fracture of the Skull. John M., 19 Western Ave., age 58, American, carpenter. Two years ago this man received a blow on the top of the head, about four inches in front of the occipital protuberance and a little to one side of the median line. He was rendered insensible for some time. As he holds his head down you can see quite a depression which illustrates very beautifully what we mean by a punctate "stellate" or "circumscribed" fracture of the skull which is likely to occur from a blow from the corner of a brick, the edge of a hammer or any other hard substance having blunt but well defined edges. You notice that the fracture is some distance away from the motor area of the brain, and hence the impingement of the bone proper does not make any pressure on those areas, consequently the patient has no special interference with the motion of the extremities. However, he has had severe attacks of headache, nausea, vomiting, general debility and a numbness of the right arm and fingers of the right hand. All these symptoms go to show that there is a connection be- FRACTURES. 365 ween the injury and the symptoms. They are not so well marked as they were in the young man before you at last clinic who had reached the stage of epileptic convulsions. Nothing of the kind is present here. You have here, then, a stellatate, circumscribed fracture in which an operation should be. done immediately for its relief, even though the symtoms are not severe at the time. This is the conclusion that we have reached lately. Formerly, it was thought an operation was not the thing unless the symptoms of compres- sion were present—slow, heavy respiration, puffy cheeks, and patient insensible to all manner of irritation—a "living dead man" as it were. But the profession have now gotten to the point where they believe that if a patient has received a wound of this nature, that he should be subjected to an operation, and the depressed portions of the bone elevated, not especially because of the present symptoms, but because of the after results, such as epilepsy. I am inclined, therefore, to advise this patient to have the bone elevated. We do not consider the operation of trephining under aseptic precautions a dangerous procedure, and under those pre- cautions there is no reaction. We will advise the patient to come into the hospital and have the bone elevated. Case 3—Mr. George S., 304 Washington Boulevard, age 39, American, bookkeeper. Now this is a very interesting case because the sequelae which follow, depressed fractures of the skull not properly treated are so terrible. In early childhood this man received an injury on the head, near the parietal eminence. He recovered, and was apparently well until about two years ago, when he received another blow in the same place. Since the second injury he has been gradually loosing his mind as well as his general health. You can see this punctate fracture. I will say that every fracture like this should be exposed early, and the depressed bone elevated. If this had been done in this case I think it is very probable that the man would not be in this condition now. The loss of his mental power has gradually increased until now he does not know what he is doing. We propose to uncover this spot on the head and trephine, in order, if possible, to lift up that part of the skull which is depressed. First, you should have the patient thoroughly prepared by carefully shaving and scrubbing the entire scalp, then make a wide horse-shoe incision, and turn back the flap con- 366 ERA CTURES. taining all tissues down to the bone. New I have gotten down to the root of the fracture, and find that the skin adheres to the bone, requiring a little force to separate it. You notice the manner in which I make the flaps. This is sometimes called the trap-door flap, for it falls down something like a trap-door. The soft parts are dissected off, and you can see the scar very plainly indeed. The incision should be made directly through the tissues, and all parts of the scar made bare, then the skull is opened with this circular saw which I hold in my hand. It is called a trephine. It has a pin in the center as you see, which, by a series of rota- tions, is fixed in the bone. This enables you to make the trephine cut a groove at any desired spot. This point will, of course, go through the bone more quickly than the saw, so that after you have made the saw take hold you must remove the point to pre- vent its going through the bone and projecting into the brain. The saw is conical in shape, narrower at the cutting edge, so as to allow of a considerable amount of force, and at the same time prevent its suddenly going into the cavity. By going on care- fully and measuring the distance sawed accurately, you will be able to make the opening without causing much hemorrhage. You will have a little hemorrhage when you reach the diploe, which indicates, you know, that you are through the outer table of the skull. You know that the inner table of the skull is very thin. There is not a great deal of danger of hemorrhage from the membranes, but it is understood that you will rupture as few of the small vessels as possible in breaking up the adhesion of the membranes. I try to embrace the main portions of the depres- sion in the trephine, and in consequence of the depression the inner table is uneven, hence more care must be exercised so that when these adhesions extend through there shall not be a sudden tearing of the membranes. We have trephined the skull in this arena on three separate occasions in which it required the full depth of the trephine to penetrate the bone on account of hypertrophy, then we were compelled to pry out the button instead of pulling it out with the trephine. There is a very thin paper scale of bone on one side that the saw did not cut, which I will break off. By examining it you will see how close you can come to the brain without doing injury. By the aid of the trephine I have been able to lift out the depressed portion of the skull. We have a very slight hemorrhage from the rupture of the small vessels from the dura mater which have penetrated the cicatrix. As far as I can see the membranes are perfectly healthy. They FRACTURES. 367 do not bulge into the opening as they would if there were pus or fluid behind them. They are light in color and I see the pul- sation of the brain. We think that all has been done for this young man that can be done. Nothing will be done to this wound but to sponge it out, suture the flaps in place and protect the wound well by iodoform gauze and borated cotton dressing. The space will soon fill up with a blood clot and form a natural protection to the parts. The flaps of the scalp fall readily into position and it requires but a little time for adhesion to take place in this vascular tissue. You notice that I did not apply the stitches very closely because adhesion takes place quite as'well, and it allows the escape of any serum that may form. I feel as if I would rather have a good blood clot below the scalp to hold it in position. Of course I cannot say as to what the results will be in this case, he is in such a bad condition mentally and physically, but with great care exercised during the operation its successful termination and the careful subsequent attention which he will receive, it is reasonable to suppose that he will get well. With the care that is given there is very little danger in doing the operation. Fracture of Vertebr/e. Mr. W. The patient we bring before you is a man who fell from a height of about eighteen feet, four days ago, and we find the present condition of affairs. Have you any pain? No. Did you have any? I had a great deal at first in my back. What were you doing when you fell? Holding rivets in building a tank. And you fell about eighteen feet. How did you come to fall? I slipped and struck on a board before reaching the ground. Do you know what part of the body struck? A point between the shoulders. What happened after you fell ? I had no power to move the legs. You have no trouble about your head or your shoulders anywhere? No. Can you lift this leg? No. Can you lift the other one? No. What am I doing now? (Prof. Parkes illustrated here the absence of all sensation in all parts below the fourth rib by a series of pinches not felt by the patient.) You see demonstrated the absolute loss of motion and sensation as high as the fourth rib. It is the same on both sides. Now let us see you breathe. If you are accustomed to see a 368 ERA CTURES. naked person taking a long breath you will notice a very different movement during the act of respiration from what is present in this man. It is apparantly almost entirely ab- dominal, but the abdominal walls are moved purely by the con- tracting of the diaphragm. The action of the diaphragm pushes the abdominal walls out, and they fall in when it is relaxed. Now let us see what is the nature of the accident that would produce these symptoms. An injury to the spinal cord by which its function is destroyed would do it. Let us look at the spinal column by turning the man on his side slowly and carefully, mov- ing the entire body at once. First, I notice a fullness, a distinct round prominence between the shoulders, but he tells me that he has always been round shouldered, still this prominence is abrupt, stands out from the general bend. In the neighborhood of the cervical region of the spinal column, I make a series of depres- sions to detect where the soreness is and find none. Now tell me when it hurts you. There! does that hurt you? Just here about the middle of the posterior border of the scapula he complains of pain on pressure. Now if you look at the spine above and below this point I think you will be able to see easily a prominence which you could not find anywhere else, and it is tender at this point, especially when I make lateral pressure. I get something else, a harsh, grating sensation, as if two broken bones were rubbed together, the sign of fracture termed crepitus. Hence we know this man has a fracture and displacement of the fourth dorsal vertebra. The displacement causes a compression of the cord at a level with the fourth intercostal nerve and that limits the point at which sensation and motion end in this case. These injuries explain exactly to you all the symp- toms you find present already elicited by our inquiries. Your ana- tomical knowledge tells you of nerves which are given off here. He has motion and sensation above the injured vertebrae, but neither below it. Can you pass your water? I cannot. Have your bowels moved? Yes. Did they give you anything to make them move? They did. He has had several doses of magne- sium sulphate. This is a very interesting case for you to study and remember. You will meet with them frequently. They will be among the most important cases that you will have to treat because the sequelae are so terrible and the ending so univers- ally fatal. There is only one condition possible, where these symptoms are present, from which the patient will recover, and that is where there is a laceration of some blood vessels or con- tusion of the spinal chord, in which case the symptoms are some- FRACTURES. 369 times only transient, lasting until the pressure upon the spinal chord has been relieved by the absorption of the blood clot. In this patient the paralysis and loss of sensation came on immedi- ately after receiving the injury, which indicates that it is probably due to an injury of the cord, or to compression by a displaced bone, and not to pressure from a clot of blood due to laceration of some blood vessel. Of course the vitality of the parts below the injury is very much impaired, and you will expect to have disturbances of the bladder and rectum. When you come to introduce the catheter you will remember that the urethral canal has lost its sensibility. It is always best to use the soft catheter to relieve the bladder of its contents, never be without one. Be careful not to introduce into the blad- der any septic materials, be sure that your hands and your cathe- ter and the meatus are aseptic. Be sure that you do not bring on cystitis, it will come soon enough. You must use the catheter often enough to prevent over-distention. It must be left in until you are sure that there is no residual urine in the bladder. If the urine becomes a little cloudy, then you must resort to anti- septic solutions as washes. Irrigate the bladder with a saturated solution of boric acid in warm water. Then it must be remembered that the abdominal walls are par- alyzed and that you must stimulate the bowels. You can do this by the use of the sulphate of magnesium or other cathartics. The greatest trouble which you will have is from the effect of pressure on the patient's body from contact with the bed. A constant pressure of the clothing and of his weight on the bed produces sloughing. If you subject your own body to pressure at any one point continuously for five minutes there will be pro- duced a redness and if continued this would lead on to sloughing or gangrene even with the sensation of the parts perfectly normal. Special attention must be given to the patient to prevent the occurrence of these bed-sores. This is accomplished in the easiest manner by means of a water bed. with which the pressure is equal on all parts, the patient sinks into it and the pressure is changed constantly. If you cannot get a water bed, then you must resort to Cushions and pads as other means of comfort to the patient, together with frequent changes of position. A frac- ture like this to the dorsal region of the spinal column is more likely to get well than if it were in the cervical region. While a frac- ture in the lumbar region or sacral region is still more favorable. Now, is there anything to be done for the patient? Yes. Spe- 370 FRACTURES. cial care is to be given him, particularly with reference to move- ments of his body. In removing the patient from the place of injury to his home or to the hospital or in changing his position in bed, be very careful not to twist the spinal column. Be very careful to move all of the parts of the body at the same time. Extension and counter extension will sometimes remove the pressure and cause relief and should always be tried. This method has in some cases taken off the pressure and restored fractured bones to their normal position. If the application of this method replaces the fracture and relieves the symptoms at once, you will of course make some application to the patient's body, to retain it in this position. The best means is a plaster-of-Paris jacket, made out of a blanket. The plaster-of-Paris will fit every eleva- tion and depression of the body, will be comfortable to the patient and will prevent movement. If by all these efforts you fail, is there any operation which is justifiable? Of late surgeons have begun to believe that they are justified in cutting down the seat of fracture and removing all loosened fragments or portions of bone which seem to produce any harmful pressure. This is done by means of the chisel or trephine after making a long cen- tral incision down to the spinous processes and uncovering the laminae and pushing aside the muscles with the periostom. Usually the laminae and corresponding spinous processes of sev- eral vertebrae will be removed in order to uncover the area of cord involved in the compression. This operation was performed a few days later. A continued fracture was found. The laminae and spinous processes of the two vertebrae were removed. There was an improvement of the area of sensation and motion to a distance of six inches below the original line. There has also been an improvement in the action of the bowels and bladder. Treatment is being continued by means of an extension aparatus. The difficulty in these cases consists in the fact that the pro- cedure merely removes the cause of counter pressure, but does not relieve the direct pressure which is produced by the cord being acutely bent over the lower portion of the fractured body of the vertebrae, and held in that position by the weight of the body above the seat of fracture. In many cases also the injury has been so severe as to destroy the continuity of the cord hence no operation can relieve them. FRACTURES. 371 Fracture of the Rib. Wm. O. 75 W. Monroe St., Age 38, Irish, Machinist. Two weeks ago this patient received a severe blow from a fist upon his breast. Since that time he has suffered severely espec- ially while coughing. Making pressure upon the seventh rib while I direct the patient to take a long breath. I get a little preternatural motion and a little grating. We have here a broken rib. In order to immobilize this fracture we shall shave off the hair and apply an adhesive plaster bandage, six inches in width and extending from a point six inches beyond the spine around the injured side and six inches beyond the sternum. This will be left in place for about six weeks. It will limit the motion of the chest wall and consequently control the pain. At the end of six weeks there will be perfect union of the fragments and the patient will have been entirely relieved by this simple treatment. Separation Between Eighth Rib and Costal Cartilage. Selma N., 9 S. Curtiss St., Age 19 Swede, House-maid. You saw this patient recently. She has a great deal of pain and distress during the act of respiration, dependent upon the separation of the eighth rib from its costal cartilage. This con- dition has existed for several years having been caused by a fall upon a hard object. What I purpose to do is to uncover the rib, perforate the adjacent parts of the rib and cartilage with a drill! introduce a cat-gut suture and bring the parts accurately to- gether. Of course, it is necessary for us to proceed very carefully here for it would be a very easy matter to enter the peritoneal cavity. I now elevate the end of the rib into the opening of the wound. I think that I can pass a strong needle directly through the rib and the cartilage. You can see that it is not such a difficult operation to uncover a rib for resection. I have now passed the needle armed with a 372 FRACTURES. good strong thread through the rib and cartilage and have securely united them, I am now sewing up the wound with a series of sutures from the bottom. It will be dressed in the usual way. Epiphysial Fracture of the Upper End of the Humerus. This boy, ten years of age, fell from a fence five weeks ago and sustained an injury to his arm, as is shown by this unusually well marked projection, about two inches below the acromion process on the anterior surface of the arm. In examining the character of the damage done by violence applied to any portion of the extremities, you must always com- pare the injured part with the corresponding point of the un- injured extremity; for in that you have an unerring guide to re- fresh your minds as to the normal condition and will be able, with some degree of certainty, to detect displacements in the in- jured member, Now, as the injury in the case before us is close to the shoulder joint, let us first ascertain if there has been any harm done to the joint itself on the injured side, by carefully comparing the salient landmarks of these two shoulders. In this case the condition can be determined with the utmost degree of certainty, because such a length of time has elapsed since the injury that all swelling from effusion of blood or serum has dis- appeared from the neighborhood of the injury. Feeling first along the extent of the clavicles, it is found, both by touch and by sight, that they are exactly the same on the two sides. Next, a thorough examination of the length of the spi- nous processes of the scapula fails to show any deviation from the normal condition. Therefore we can unhesitatingl) assert that there has been no injury done to these bones. So, also, the acromion processes of both sides are easily manipulated by the fingers, and ascertained to be free from any deviation in contour and from the existence of any abnormal motion. Now, hiding the seat of the deformity from view with my fingers, we compare the general aspect of the two shoulders, and find that there is no difference whatever between them; they possess the same round- ness, evenness and smoothness of contour on all their surfaces. Next, we put the extremity through the motions permissible at the shoulder-joint, and find that there is some limitation to the FRACTURES. 373 full degree of motion on the injured side. Still, it does move freely and easily in all directions within this limited range of motion. We examine the axillary space, and find that it contains nothing abnormal. From these facts we conclude positively that in this case there is no injury whatever of the joint itself. Next, we examine the humerus, and find, first, that its direction is changed as compared with the uninjured bone, that its lower end projects too far backward, and, upon inspection of the upper end, we easily discover this unusual prominence just below the shoulder-joint, and also ascertain that it is directly continuous and in a line with the shaft below, Hence there has been in this case a solution of continuity, or fracture, at the upper end of the humerus, followed by the forward displacement of the upper end of the lower fragment. It has been displaced so far forward that it stands entirely away from the direction of the short frag- ment still attached to the head of the bone; the broken surfaces are absolutely separated from each other. Now, I ask you to remember the boy's age, a very important fact to bear in mind in determining, in children, the diagnosis of an injury to the long bones close to their extremities. Your knowledge of the development of the long bones brings to your mind immediately the recollection that just here is a weak point. It is produced by the epiphysis, or rather the line of cartilaginous deposits between the epiphysis and diaphysis, which remains un- ossified until about the eighteenth year, in order to provide for the increase of the bone in length. So that, in all these cases, if you bear in mind and can determine the presence of the well- known signs of fracture, such as swelling pain and ecchymosis, loss of contour, deviation in direction, proximity to a joint, prompt recurrence of the deformity after perhaps easy reduction, and crepitation, you will scarcely ever fail to recognize the ex- istence of an epiphysial fracture, such as was certainly produced in this case from the fall which this boy suffered five weeks ago. This is certainly true so far as this case is concerned, now that the obstacles to the recognition of the normal landmarks have entirely disappeared with the total absorption of all effusion. When the point is greatly swollen and the subcutaneous tissue overfilled with such effusion of blood and serum as would obtain immediately after the injury, the determination of the exact nature of the injury might be attended with the greatest difficulty and uncertainty, in fact, might have been absolutely impossible. This case also gives an excellent illustration of angular de- 374 ERA CTURES. formity, forward in this instance and extreme in degree It also demonstrates that firm and solid union will take place between broken bones, even if the broken ends are not anywhere in con- tact with each other, provided one of the broken ends is held in contact with some portion of the shaft of the other fragment- Notice, again, that, notwithstanding the presence of this de- formity, the boy has a very useful and movable joint. The ex- tent of range of motion is limited somewhat, but with use will in- crease from day to day until it is restored quite to the normal condition. Is any operation advisable in this case to overcome the de- formity? I think not, unless it be the rather simple one of ex- posing the upper end of the lower fragment and chiselling away this projection, mainly to prevent ulceration of the skin covering it, which seems imminent. The dressings necessary to apply in a recent case of epiphseal separation or fracture of the upper end of the humerus are simple, and I will illustrate their application on this boy's uninjured arm. Take a strip of adhesive plaster two inches wide and a little longer than is sufficient to reach entirely around the patient's body; make a loop in one end of it considerably larger than the circumference of the patient's arm at the seat of the injury- This loop can be made permanent by a safety-pin or, better, by sewing it. It is now carried over the extremity and over the humerus until it leaches just to the upper end of the lower frag- ment. The deformity is then reduced by pressure backward at this point with one hand, while the opposite hand at the elbow makes extension and at the same time draws the elbow forward. While the arm is held in this position, with the deformity re- duced, the plaster is carried around the patients body over its posterior surface and held in contact with its surface until ad- herent. The elbow is then fastened in its forward position by a second strip of plaster carried around the elbow and over the opposite shoulder in front of the body, and the hand and forearm are supported in a sling. You can readily understand the mechanism of this arrange- ment: the loop of the plaster around the upper end of the hum- erus, when fixed by its attachment to the body, is the fulcrum, the long humerus, is the lever which reduces the deformity, and the second strip of plaster holds the lever steadily in position. The loops of plaster surrounding the arm should always be much larger than the circumference of the latter, in order to avoid im- FRACTURES. 375 peding the return circulation. This dressing is very simple, is easily applied, the necessary materials are readily obtained, and it is thoroughly effectual. It should be examined, as every other dressing for fracture should be, from time to time, to ascertain whether it properly fulfills the requirements of the case. I have always found it proper to introduce between the arm and the side of the chest a single thickness of muslin, to prevent excoriation from retained secretions. The dressings should be retained in perfect position for at least four weeks. Fracture of Neck of Humerus. Dina F., 1461 State St., age 60, Russian, housewife. This lady fell down about two months ago and hurt her shoul- der, and she is supposed to have a dislocation. There is but little deformity as far as the contour is concerned. There is a little en- largement which is unnatural. When I rotate the arm I find that this moves, so it is connected with the shaft of the bone. As I move the arm backward and forward I find that the prominence moves, and when I place my fingeron it I feel a depression which tells me that my finger rests on the head of the humerus. You notice the shoulder joint is wider from before backward than it should be, showing that therehas been a separation of the continu- ity of the bone sufficient to increase the width of the bone opposite the tuberosity. Of course an injury of the kind cannot occur without injury to the muscles and a tearing of the capsular liga- ment. There is a falling forward of the humerus, and it lies in front of the acromion process. I am sure that in this case we have a fracture extending into the shoulder joint. The motion in the joint is very good, and I do not know that I can suggest anything more to be done than the use of massage, and active and passive motion. Fracture of Internal Condyle. Theo. S., 222 DeKoven St., age 38, American, laborer. This man says that he hurt his arm five weeks ago by falling and striking his arm and shoulder on the walk. He cannot make 376 FRACTURES. complete extension, and cannot flex the arm beyond a right angle. He says that it catches him in the elbow. I find the radius in its normal position, and the other landmarks in their proper places. There is a very slight protuberance on the inner side of the injured elbow. It is made up principally of the internal condyle, but when I hold the arm up in this manner and rotate it I get a soft grating sensation. The indications are that there has been a slight fracture with slight displacement of the internal condyle. It may be that there has been a fracture in to the joint separating the external condyle. He makes very fair flexion and extension and I am satisfied that if he were asleep we could make more motion. He has been using his arm to much in his daily labor. The thing to do is to give the arm rest, and apply hot fomenta- tions. If he cannot stop working, then the best thing is to put him to sleep, and put the arm through motions, then let him put it through passive motions every day, and put on large fomenta- tions covered with some impervious dressing. He should also bathe the arm with warm water and alcohol, and there is not much doubt but that the motion will be restored. Ununited Fracture of the Arm. Mrs. C, 488 Halsted St., age 45, German, housewife. Fourteen years ago this woman had this arm broken, and we have an excellent example of an ununited fracture. And it proves again what I told you so many times that the cause of the non-union is the existence of a foreign body between the ends of the bone. Notice the large amount of flesh between the ends of the bone here. The patient has quite a number of scars marking the situation of sinuses along the clavicle and shoulder, and a few are to be seen on the neck. The commencement of this trouble was an osteomyelitis which weakened the bone. Just how much of this is constitutional, we cannot say, but I am inclined to believe that the most of it is. The clavicle is the most common seat of specific manifestation in bones, therefore, believing that the trouble is specific, we will advise her to take large doses of Pottassium Iodide and report to us. If she will take it three months out of the year, I am sure that she will be very much benefited. ERA CTURES. 377 Colles' Fracture. This woman received a fall. In trying to support herself, the arm was thrown forward, and the weight of the body came on it, producing the injury which you see. I have not examined the injury yet and cannot say what the nature of the trouble is, but judging from the history of the case and the location of the in- jury, together with the age of the patient, of course I suspect what the trouble is. You know the bone becomes very brittle as age advances and is therefore liable to fracture. The lower end of the radius you know makes up the complete articular portion of the wrist-joint and the weight of the body coming on the hand, in falling, very often communicates the force to the radius and fractures it a half inch or an inch above its articular extremity, producing what we technically term a Colles' fracture. The name Colles' fracture was given to it from Colles of Dublin, who first called special atten- tion to this kind of fracture. As I hold the arm up in this manner you can see some of the deformities; the riding of the lower fragment on the dorsum of the bone causing a projection at this point; just in front of this there is a depression. All of this gives to the hand and wrist somewhat the appearance of a silver fork, hence it is sometimes called the "silver fork" deformity. If we turn the hand over, we find the corresponding prominence and depression existing on that side. Again we have the usual symp- tom of pain. The patient did not hear any sound accompanying the injury Besides the deformity already mentioned, there is a foreshortening of the radical side of the fore-arm, from the over- riding of the ends of the bone. We also have preternatural mo- bility. When I seize the radius just above the point of injury, and with the other hand grasp the lower end of the bone as closely to the carpus as possible and make this motion, I not only get preternatural mobility, but also the rubbing of the rough ends of the bone crepitation. All of the other signs, of pain, redness and swelling are also present. We therefore have present a Colles' fracture, with all of the symptoms. Usually the lower end of the upper fragment is impacted into the upper end of the lower fragment. This with the riding of 378 ERA CTURES. the ends by each other makes it extremely difficult to retain the short lower fragment in the normal relation with the upper frag- ment. The fracture is termed Colles' fracture when the lower fragment is an inch and a half or less in length. Not infrequently when the weight of the patient is great, you have additional com- plication by having the ulna fractured and its end driven through the skin, producing a compound fracture. A common sequela which causes the patient a good deal of trouble is an inflammation in connection with the flexor and ex- tensor tendons lying in the grooves at the lower end of the radius, limiting motion and giving the patient more trouble than the fracture itself. Therefore, I have come to the conclusion that it is well to pay attention to the inflammation primarily, rather than to give your whole attention to the bone, I might mention a ease of Colles' fracture which was in the hospital not long since. It was a case of a young man who got a " header " from a bicycle and nearly broke his head, resulting in breaking his arm. For four weeks he was uncontrollable on account of delirium, tearing off the various dressings that were applied until a plaster-of-Paris dressing was made, and at the end of four weeks there was nothing of it left, yet the patient had a good result, in fact about the best that I have seen, So you will give attention to the soft parts and not try to hold the fragments in place by forcible com- pression. There are a good many methods of treating Colles' fracture, but I think the best method is the one which we shall illustrate to you. I find the "pistol" splint on the patient. Formerly, all fractures of this kind were treated in this way. Now the "pistol" splint is not found necessary. I only use the internal and external splints. You will remember that you are not to use splints on any portion of the body without thoroughly padding them. I have called your attention to this so much, yet not two weeks ago I was called in consultation with a graduate of this institution, a very intelligent and good man, to a case of fracture. When I arrived I found a splint used without any padding whatever. The splint made blisters wherever it touched. Under no circumstances use a splint without covering it thickly with cotton batting. You can almost always find it, if not use three or four thicknesses of flannel. It will prevent injury to the skin, deeper tissues and circulation, and the splints will hold the fragments in position precisely as well. The splints are held in position by means of roller bandages FRACTURES. 379 carefully applied with uniform pressure just tightly enough to maintain the position of the splints. The arm should be examined once a day until the swelling has entirely disappeared and then less frequently. You can expect firm union of this fracture in six weeks. After the second week active and passive motion should be made in the wrist joint, to prevent stiffness. Fracture of the Radius. Case i.—Frank H., 54 S. Carpenter St., Age 36, Irish, Laborer. This man received a fall this morning, at which time he threw his hand forward, and the weight of the body came upon it, pro- ducing some injury to the wrist, or to its immediate neighbor- hood. Comparing the two hands, you can see a well-marked prominence over the posterior surface of the wrist on the injured side, extending upon the arm. There is not the peculiar de- formity resembling the silver fork which is so often found in injuries in this situation. This prominence is soft, elastic and compressible, calling your attention to the fact that it is made up of effusion of blood and serum, and is not caused by displaced fragments of bone. This being the case we shall have to resort toother means to determine whether or not the continuity of the bone has been destroyed. The radius is covered with muscles in its upper part, but the lower portion of the bone can be readily felt. I seize the carpus and the lower portion of the radius, and making motion in this manner, I find that there is a little pre- ternatural mobility produced, and at the same time I get a peculiar sensation transmitted to the fingers, which is called crepitus. We therefore, have a fracture of the lower end of the radius, oblique in character extending upward and backward. There are a number of signs of fracture to which your attention has been called. However, they will not always be present, and sometimes, when present, they are not well-marked. So you will not be positive in your opinion that there is not a fracture, simply because you do not find all of the signs present indicating a frac- ture. You have an example in this case of the absence of the peculiar and remarkable deformity which, all but invariably, follows a fracture in this portion of the arm. Ecchymosis is also 380 ERA CTURES. wanting, but there is pain, swelling, preternatural mobility and crepitis. These signs are quite sufficient to fix the fact in your minds that a fracture is present. All that is necessary to do in this case is to apply the Moore's splint. It consists of a roller about two inches wide and an inch thick applied to the inner side of the ulna, at its lower end, and then an adhesive plaster about two inches wide is applied very tightly around the wrist over this roller. The object of the roller is to prevent the interference with the return circulation by the pressure of the plaster on the vessels. After the deformity is corrected, and the plaster is applied, the pressure is sufficient to retain the fragments in their proper posi- tion. About six hours after the application of the adhesive plaster it should be cut across at a point opposite the roller in order to prevent the occurrence of cedema. The arm should be carried in a sling which extends from the wrist to the elbow, and the hand should be permitted to hang free. This will have the same effect that was formerly obtained from the use of the pistol splint. The patient is advised to use his fingers at once, and passive motion of the wrist is made after the first week. The dressing is removed after three weeks and another one applied less tightly, which is permanently removed two weeks later. Passive and active motion is now employed freely, in order to prevent stiffness of the joint. Fracture of Styloid Process of Ulna. Ira H., Center St., Graceland, age 18, Swedish, marble pol- isher. An enlargement exists on the inner side of this man's wrist, re- sulting from an injury which occurred several months ago. It is very tender. There has been a fracture of the styloid process of the ulna, and perhaps a dislocation which was treated for sprain by the use of tincture of iodine and liniments. The fracture is the same in character as the fracture on the radial side known as Colles' fracture, and should have been treated in a similar manner. There is no effusion into the joint. When I first saw this wrist I thought there might be a tuberculosis of the joint, but I find noth- ing of the kind. It has only the peculiarities to which I have ERA CTURES. 381 called your attention, and it will always be a weakened joint. There is nothing that we can do for it surgically. It will always sprain easily, and I should advise him to wear a brace made of heavy leather in the day time to prevent severe straining of the ligaments during work. Fracture of Both Bones of Fore-arm. Noble S., 437 State St., American, carpenter. This young man has had a fracture of both bones of the fore- arm. Four months has passed since the accident occur red,, which consisted in a fall from a building. The arm was dressed in a plaster-of-Paris splint. You can see how easy it is to follow up the radius to the seat of fracture, and then the ulna in the same way. The bones are united at an unfortunate angle. The angle is a little outward and backward. He tells us that the arm is weak, that it is not nearly so strong as it was before the break. The fracture is of comparatively recent occurrence, and I have no doubt but that it will grow stronger with time, and make him a very good, serviceable arm as it is; but if he desires to have it straightened we will do this for him, of course. He will determine what he will have done to it. Now here is a case in confirmation of what I have told you in regard to the use of plaster- of-Paris casts in the treatment of fractures. You can not always know what is going on inside of a cast. Sometimes your patients do not complain of the accompanying pain. Not long ago I saw a case of Colles' fracture which had been treated with a fixed dressing of plaster-of-Paris, and when the cast was taken off it was found that both bones had perforated the flesh from the occurrence of pressure necrosis. So it should be a rule if you use plaster-of-Paris in the treatment of recent fractures, to cutopen the cast within twenty-four hours after its application by making a longitudinal incision preferably before the plaster has completely hardened, and to inspect the extremity. In case there is evi- dence of pressure the cast should be removed and another applied. 382 FRACTURES. Fracture of External Condyle of Humerus. This patient comes with a history of having fallen upon the sidewalk a week ago striking his elbow. You notice the ex- treme amount of ecchymosis on the inside of the arm. It looks almost like gangrene. You must learn to recognize this redness, this change in the color of the skin, as meaning nothing except that there has occurred a laceration of blood vessels. I am able to extend his arm almost as easily as on the opposite side. He tells me he has been examined by another physician who finds no fracture. There is limitation of motion in the direction of flexion not in extension. Some individuals cannot extend the arm en- tirely. Some can carry the arm a little beyond full extension It is only by comparing the two arms and inquiring as to whether the patient has had an injury before that we can determine this in any given case. As I flex the arm it is all right until it reaches the right angle but beyond that he objects, and I find resistance to further flexion. I estimate between my thumbs the situation of the alecranon process between the external and internal condyle. There is no dislocation, as they are in line with each other. It is rather easy to determine in this case. The upper point of tender- ness is over the external condyle. I can press on the internal condyle without causing pain, but pressure on the external con- dyle gives rise to severe pain. I am satisfied this man has an in- jury to the lower end of the humerus, limited in character. This displacement of the external condyle hurts the man pretty severely. By that action I force the external condyle down into its line and hence restore the joint surface of the lower end of the humerus. It is only necessary to put on an anterior angular splint. The old fashioned Fisk splint is a good one. It consists of two splints, one on the outside and one on the inside. We have a fracture through the external condyle, which always implicates the elbow joint. In these cases, always warn your patient of stiffness of the joint which may possibly occur in spite of the utmost care and the greatest skill in their treatment, We will dress this man's arm in the manner I have mentioned and use the heavy paste board in making a splint. It will be wet thoroughly so that when it dries it will answer every purpose of a heavier piece of FRACTURES. 383 board. I should prefer to put on the board splints. We have many of the signs of fracture in this case which you should bear in mind—the swelling, limitation of motion, the tender point. This one sign of the tender point will very frequently enable you to distinguish a fracture. I can make a great deal of pressure on the internal condyle, but not on the external without giving rise to severe pain. After three weeks we will begin to employ passive motion each day in order to prevent stiffness if possible. In case stiffness connot be avoided it is best to maintain the arm in a flexed position, because this renders it more useful than when extended. Fracture of Femur. This young fellow had a horse fall upon him yesterday and he has as a result some injury to his thigh. He was conscious at all times during the accident but did not hear any break of the bone. He thought, however, that his thigh was broken, because he was unable to get up and he was conscious of the force which produced the injury. When he came in, the limb assumed a much more extreme position abnormally than you now see. Now you see that the toes are turned out, eversion of the foot, and there is a bow in the thigh in comparison with the other. These are sometimes due to spasm and shortening of the muscles of the thigh, always found if there is a fracture of the femur. If we measure from the anterior superior spine of the ilium to the in- ternal malleolus we will find another sign of the fracture, and as you see we get an inch and a half of shortening. Another sign which is always present is preternatural mobility, motion in a position where it should not be found. Usually the sound made by the snapping of the bone is heard by the patient. By rubbing the two ends of the bone together we get another sign, that of crepitation. So that we have a fracture of the thigh in this patient. It is a simple fracture, simple because the skin is not wounded; there is no communication between the air and the seat of the break in the bone. If there were such a communica- tion with the air it would be a compound fracture. Again it is a single fracture. Were it broken in many places it would be a multiple fracture. It is not comminuted as the bone is not broken 384 ERA CTURES. in pieces. We have the sign of swelling now, and in a few days will perhaps have the sign of ecchymosis. I have no doubt that the bone was broken not by direct, but by indirect violence. Finally we have the sign of pain. You must be as familliar with all these signs as you are with your A. B. C's. The treatment above all others for a fracture of the thigh is the one which you see made use of in this case. We take a piece of adhesive plaster four or five inches wide, a little wider at the upper than at the lower end, and carry it up to the seat of the fracture and apply it to the inner side of the limb. This is brought down to within four or five inches of the malleolus. It adheres intimately to the skin and gives a good broad support. A sim- ilar strip is placed on the outer side of the limb. The plaster is doubled back upon itself to a short distance above the malleolus to prevent the adhesive surface from coming in contact with the ankle-joint. A stirrup is fastened at the bottom of the foot for the double purpose of preventing the plaster from impinging on the malleoli and at the same sime to furnish an attachment for an extension cord which runs over a pully and to which is attached the necessary extension weights. And it is necessary to apply enough weight to overcome the muscular contraction. You know that if the boy is left on a flat surface like this there would be a constant tendency for the body to move in the direc- tion of the extension. This difficulty is obviated by elevating the foot of the bed a little and by fastening the body to the bed by means of a wide bandage. A piece of a sheet will answer the purpose, but a stronger material is better. Two holes are cut in it for the arms and it is placed around the body and fastened to the bed. In this way the body is down hill and you have good, effective extension and counter extension by which the surfaces of the bone are pulled apart. The limb is shortened simply be- cause of the powerful contraction of the muscles which pull the ends of the bone by each other. The continued extension and counter extension gradually tire out the muscles, so that the ends of the bone may be brought back to their normal position. This is the best and most reliable method of controlling fractures of the thigh. In order to prevent the occurrence of lateral displacement of the fragments and rotation of the foot outward, a bag six or eight inches in diameter will be laid along the entire length of the ex- tremity on either side. From four to eight narrow coaptation FRACTURES. 385 splints may be applied about the seat of the fracture but it is doubtful whether they are of any real value. This case then affords you an example of a simple fracture of the thigh with all of the signs, of swelling, pain, loss of contour, preternatural motion, crepitation and loss of function. Ecchy- mosis is wanting. The patient is a young, vigorous man, noted for his muscular activity. I expect to show you next a fracture of the thigh on an old person who received a slight blow from falling down. When she came under our care she had complete eversion of the foot, loss of contour, swelling, pain, crepitation and loss of function, being unable to raise the heel from the bed. There was a decided shortening and the arc described by the trochanter major in rotating the femur was diminished. The upper border of the trochanter major is above Nelaton's line y inch. No disposition to carry the ball of the injured foot to the dorsum of the uninjured foot exists nor to eversion of the thigh. These symptoms indicate, in a patient of this age, a fracture of the neck of the femur. I desired to show you this patient for it is a case that you will frequently meet. She came into the hospital at 9 or 10 o'clock saying that she had a dislocation of the hip-joint. In the first place the age is against the probability of a dislocation. In the majority of cases of this character in patients above fifty years of age, the trouble is a fracture of the neck of the femur. But it would not do, of course, to say that it could be a dislocation. I saw an old man ninety years of age who was struck from be- hind by a runaway team. The pole of the wagon striking him on the sacrum communicated force sufficient to throw the head of the bone out of the acetabular cavity. In diagnosing these cases you will frequently not find all of the signs present. At one time ecchymosis will be wanting, at an- other some other sign will be absent. The degree of pain varies very greatly in different cases. When the fracture is smoothly transverse there is not the in- jury done to the soft parts that there is if the fracture is a long oblique one, and consequently much less pain follows, and there is less likelihood of the occurrence of ecchymosis. 386 FRACTURES. Fracture of Neck of Femur. Mrs. L. D., 170 E. Madison St., American, housewife, age 62. I wish you to notice first the age of this patient. She is sixty- two years old. She received an injury to the hip by falling on the pavement. We will take the measurements of the two limbs. Measuring from the anterior superior spinous process of the ilium to the lower margin of the external malleolus on the injured side we get a distance of thirty-three inches; on the sound side thirty-four and a halt inches. A difference of one and one-half inches. Measuring from the umbilicus to the external malleolus on the injured side, I find a distance of thirty-six inches; on the unin- jured side thirty-eight inches. Again, measuring from the top of the sternum, I get fifty-one inches on the injured side, and fifty-three inches on the uninjured side. So we get two measurements with a difference of two inches, and one with less. On bending the knees and flexing the thighs you see a difference of about two inches between the projection forward of the free surfaces of the patellae. There is then a decided shortening of the limb injured. Turning now to the position of the foot itself on the injured side, you notice that there is complete eversion of the toes. WTe will see what the position of the trochanter major is. Drawing a line from the anterior superior spinous process of the ilium to the tuberosity of the ischium, you notice that the trochanter major, in- stead of being immediately below this line, is to be felt three- quarters of an inch above the line. The upper surface of the trochanter major then extends above Nelaton's line. Now, we desire to make a differential diagnosis between a dis- location of the head of the femur and a fracture of the neck. First we take into consideration the age of the patient. Fractures usually take place at the neck of the femur at this time in life: dislocations are uncommon. It is not a dislocation backward on the surface of the ilium, for I cannot feel the head of the bone in that abnormal position. Besides, the trochanter major would ex- tend an inch or an inch and a quarter above Nelaton's line, and there would be no power of motion in the joint. The patient is FRACTURES. 3S7 able to flex the thigh to a certain extent. Again it is not a dislo- cation backward on the ilium because the position of the foot in that case is just the opposite to what we have here, and the pa- tient carries the ball of the injured foot on the dorsum of the sound foot. It is not a dislocation anteriorly on the pubes, for I find the pubes free from the bone which would be present if the disloca- tion were present. In this dislocation there would be a lengthen- ing of the limb and a fixed adduction. I do not believe that it is a dislocation backward and downward into the obturator for foramen, for there is no flexion of the thigh and the head of the bone cannot be felt in that abnormal position. Therefore all of the signs of dislocation are absent; and owing to the age of the patient, the shortening of the limb, the eversion of the foot, and the movement of the joint, I am forced to believe that we have here a fracture of the neck of the femur. We do not have here a preternatural mobility, as in the earlier stages of the fracture, but there is a certain amount of immobility and loss of functions. We know, therefore, that union has taken place with shortening. The condition of the limb is as good as is usually the case in such accidents. If you get a repair of such a fracture with a shortening of an inch or an inch and a half only, the pelvis will tip to one side sufficiently to prevent a noticeable limp. In this case it will require only a slight lift on the shoe to prevent limping. It will be treated in the same way as the pre- vious case by Buck's extension. As soon as the limb is put in the proper position, like this, the long external splint, extending from the axilla to the foot, is applied and is fastened at the body, thigh and leg. This splint is to prevent disposition toward ever- sion and is applied after the extension is made, not before. The cross piece is placed at the bottom to keep the foot on position and to protect it. A very important item in these cases is a proper bed. Scarcely any house has a suitable bed. You can make a bunk yourself out of boards which will be suitable for any case and in any house. It should be six feet and a half long, three feet wide and two feet high. The foot of the bed will be elevated a little and the patient will have nothing under the shoulders, but will have a pillow under the head, the weight of the extension in children should be 1-6 of the weight of the body. It may be necessary for the first few days to put on double that weight on as high as 20 lbs. 388 FRACTURES. You frequently hear doctors saying that they do not like this method. If they do not have success with it, it is because they do not carry it out. Ununited Fracture of Tibia and Fibula. Anton, 699 17th. St., age 23, Polish, carpenter. Family history—Mother has consumption. Previous history good. What is the trouble, sir? You broke your leg. When did you break it? January 22. How did you break it? You fell down two steps and one foot went through. You would not think that a strong man would break his leg by falling two steps, but it takes only a slight force when the weight of the body is thrown on the leg, while in a disadvantageous position. You say this occurred in January. Where have you been all this time? In the County Hospital. How long have you been there? Nine weeks. This was a compound fracture of both bones of the leg. He conies to us with evidences of a sinus leading down to a foreign body, and gives us the history of a compound fracture. Remember always that these granulations are very vascular and bleed freely. By the use of the probe I find here quite a frag- ment of bone which will need removal. If he will come into the hospital we will take care of him. He has been walking on this leg, but it is an ununited fracture. Usually ununited fractures do not unite while there is a piece of dead bone between the ends of the fragment. This is a case of delayed union in bone. I am inclined to believe that the fragments were not separated by soft tissue when he went into the County Hospital, for those gentle- men would have detected and removed this as they do their work well. It may be that it was a long time after his injury that this man reached the hospital. Treatment.—The thing to do is to open the sinus and detach the dead bone from its surrounding tissues and remove it as soon as possible. There is a deformity of a bowing backward of the leg at the seat of the injury. It is a very common one, and is dependent on the weight of the limb itself. You will remember FRACTURES. 389 this and will prevent the deformity by the use of splints to retain it in a proper position. You must not be satisfied with having it set in a line, but you must look at it laterally as well and see that there is no bend antero-posteriorly. We use the sinus with the probe in it as our guide and cut directly down through every- thing to the surface of the bone. Here is the same old story which you have seen illustrated so many times. This case has been operated upon for ununited fracture and the operator made use of silver wire to hold the bones together. Not a year goes by but what I have to untwist a lot of wire which acted as a foreign body in bone. I do not see why surgeons use wire. If they will unite the bones without any foreign body between them and hold them in place with splints nature will make a union. I have obtained a small fragment of dead bone placed between the ends of the fragments illustrating what I have said that the majority of ununited fractures depend not on the manner in which they are treated but in almost every instance depend upon the fact that a foreign body exists between the ends of the ununited bone. The foreign body may be a piece of wire, a piece of dead bone, fibres of muscular tissue or fascia. I have no doubt but the lower portion of these bones are separated by either a layer of muscular tissue or a layer of fascia. It is of very common occurrence for the bone to be needle-like in character and for the force to continue often after the severance of the continuity of the bone and thrust the ends of the fragments through the flesh. Frequently it is impossible to disengage them and you have the muscular fibres between the bones acting as a foreign body. You can see in the track of this wire, an unhealthy sinus running down behind the bone. Of course the wiring of them together was a useless thing to do. Now I have exposed a large fragment of dead bone equal in diameter to that of the tibia. As long as this fragment was here this man's leg could not get well. It will be necessary to split this fragment in order to remove it because it is very tightly wedged in by the callus above and below. One of the most difficult things you will try to do is to break a piece of dead bone. I will make this opening in the callus as narrow as I can in order not to weaken the bone. You see that this frag- ment is on the posterior surface and that accounts for the diffi- culty of its removal. It is hardly necessary for me to say that it would have been very much easier to have gotten out this frag- ment at the time of the injury than now and it could have been removed without giving rise to shortening. One other difficulty 390 FRACTURES. is the peculiar shape of the fragment. It is very necessary that all parts should be thoroughly cleansed of the septic granulations; we will remove them by means of a sharp curette. The cavity will be thoroughly washed and then packed with iodoform gauze. This will be rewarded with a rapid healing. If this is not done it will be very likely to show the results and cause a great deal of trouble. The Same Patient Six Weeks Later. Now, here is our very interesting case of compound commin- uted fracture of both bones of the leg. You remember that this man was before us some time ago, and we opened the wound freely and removed a large fragment of bone equal in diameter to that of the tibia, and also smaller fragments, as well as three large wire sutures. We operated upon him about six weeks ago. Within two weeks after the operation he walked upon the leg. There had been no union for seven months before the operation. There are two lessons to be learned from this case. First: When you have a compound comminuted fracture, examine the parts under the skin. If there is no opening large enough to in- troduce your finger, make it large enough and find out the condi- tion of the fragments. Remove all loose fragments. Second: In regard to the use of wires, I must say that I have no confi- dence in their use at all, whether they are used primarily or sec- ondarily. Invariably, if their is any tension upon the wire it will cut its way out; it does injury by becoming a foreign body. My experience is that nature is able to take care of a compound as well as a simple fracture. And I am satisfied that you get as good results from the use of the antiseptic cat-gut as from the use of anything. Ununited Fracture of Thigh. The next case is one of ununited fracture of the thigh. The patient received a gun shot wound through the thigh about a year ago, resulting in the fracture of the femur. The soft parts healed promptly and kindly, but there has been no disposition toward union of the bone. The limb has been perfectly treated FRACTURES. 391 by fixation and by the use of splints. I can obtain no signs of roughness between the ends of the bone, so I expect to find an opening down upon the ends of the bone that they are covered with connective tissue, and there is probably also muscular tissue between the ends. There are many different methods of securing union in these cases The simplest is that of putting the patient to sleep, as is neces- sary, and rubbing the ends of the bone together vigorously. Again, irritation is brought about by passing a needle in between the ends of the bone. The next is the subcutaneous method of introducing an instrument into the seat of fracture, and scarify- ing the ends of the bone in all directions, and break up all of the connective tissue between. The next method is that by the use of Dr. Brainard's bone drill. The drill is used in making various openings in the end of one bone through the opening in the integ- ument. Finally you can cut directly down on the seat ot the fracture, remove the offending foreign body, and unite the ends of the bone by means of cat-gut sutures, silver wire, ivory pegs, or in any such aseptic manner; or you may approximate the ends of the bone and hold them in place without first uniting them. The use of the suture material which cannot be absorbed, for the purpose of uniting bone, is becoming abandoned more and more, because the fragments can be held in apposition a sufficient length of time by the use of cat-gut sutures or by the use of splintsto secure union. If non-absorbablesubstancesare used they are very likely to require removal at some future time. Scarcely a year passes that we are not called upon in this clinic to remove silver wires which were employed in uniting fractures a long time before. I shall make an incision on the outer side of the thigh and ex- pose the seat of fracture and, if possible, chisel off the ends of the bone. Of course it will require quite a large incision to en- able me to do the work. I now have exposed the upper end of the lower fragment. You remember that I expressed it as my opinion that in the majority of cases of non-union in the bones some foreign body was inserted between the ends of the frag- ments. We have a very beautiful specimen of what we call pseudarthrosis. Here is a membrane which is analagous to the synovial membrane. It is as nearly synovial membrane as it is possible to have outside of the true joints. I find the condition which I told you I expected to find. There is a space of three 392 FRACTURES. fourths of an inch between the ends of the bone. They never could unite in this condition. You can see the wide space be- tween the fragments of the bone occupied by a portion of the vastus externus muscle. The patient has been walking on this limb for about three months, and partially the result of this, the ends of the fragment ride by each other a distance of two inches. I have uncovered the ends of the fragments and shall chisel away a sufficient amount of the end of each fragment in order to bring the ends of the fragments in line and at the same time approxi- mate large bone surfaces. It is an utter impossibility to make ex- tension on the limb sufficiently to bring the fragments into proper apposition without first shortening them. I shall remove only the half of the lower fragment. This operation is a very difficult one. It is not only difficult but it is a dangerous opera- tion as well. You know that we have running near the bone the femoral artery and its branches and in an injury of this kind the relative position of these parts are so changed that you do not know just where you will find them. I remember a case of fracture of the thigh where the surgeon attempted to bring about union in this way. The upper fragment was treated without meeting with any accident But unfortunately in treating the lower fragment the femoral artery was injured so that in the course of twenty-four hours a severe hemorrhage came on pro- ducing a very bad result. You will keep close to the bone con- stantly and the tissues are pushed to one side; in this way you will avoid the vessels and you will be able to bring together new surfaces of bone tissue. You see that this wound has been sewed up perfectly tight. I do this because I have perfect confidence in the operation. It has been closed by means of three layers of sutures. The first layer united the periosteum, the second the muscular tissue and the third the integument. The sutures will have a tendency to stop hemorrhage. We will now apply a large cast of plaster-of- Paris including the thigh, the leg and if possible the hip as well. This will hold it better than anything else and we will place the thigh in a semi-flexed position similar to that of the double in- clined plane, but not so complete. In the beginning of the term you remember, we had a case of non-union of the femur before us, in which the fracture was very oblique, extending upward and in- ward. The upper end of the lower fragment was a mere splinter, extending as far up as the great trochanter, so that the femur was broken through and split